Minimally Invasive Bioactive 2020

Daniel H Ward DDSPunjabi Dental

9/26/2021Less is More

Daniel H Ward DDS

Less is More ‐ Incorporating Minimally Invasive and Bioactive Materials into Your Practice 2020

3

•Emergency Treatment Only

•Limited aerosols

•No anesthetic

•Fear of the Unknown

Dental First Aid Kit

•Fuji IX


•Fuji IX

•Fuji Automix LC


•Fuji IX

•Fuji Automix LC

•G-aenial Universal Injectable



Re‐open for Business

New Protocols●Pre-appointment Questionnaire ●In-Car Check-in●Temperature Check●Closed Reception Area● Fewer In-Office Patients ●Pre-Procedure Rinse●Extended Disinfection●Plexiglass Front Desk Shields●PPE

Impact on Patient & Doctor Finances

Pent‐Up Demand for Aesthetic Treatment

Goal is to Share New Products & Techniques

for Superior Care

Products for a Post‐Covid World30 Products for a Post‐Covid World



Technology

•Laser Fluorescence Caries Detection

•Diagnodent

•655 nm laser

•Decay fluoresces

•Numeric display & audible sound

•>30 decay

•Great for patient education & confirmation

MID Diagnostics

Diagnodent

•Stained Grooves •Place tip in occlusal pits

Diagnodent

•Lite Touch Erbium YAG Laser

Hard Tissue Laser

•Tooth Preparation

Hard Tissue Laser



•High Viscosity Flowable Composite

•Low Wear

•Excellent handling

•Polishes nicely

•Bioactivity

Beautifil Flow Plus X

Set Glass Ionomer MaterialSurface Modified Pre-Reactive

Glass Ionomer Filler

•Restored w High Viscosity Flowable

Finished Restoration

•Near infra‐red trans‐illumination

•CariVu

•Near infra‐red trans‐illumination

•Need proprietary software

•Works with Dexis

MID Diagnostics

•Radiographic View

•Uncertain radiographic findings

MID Diagnostics

•Clinical View

CariVu

•Device around tooth

CariVu



•CariVu Image

CariVu

•Initial Excavation

CariVu

•Prep and Liner

CariVu

•Finished Restoration

CariVu

15 Year Old

“My Mom Doesn’t Like My Smile”

RED Proportion Template

Minimally Invasive Dentistry



Multiple Step Layering Techniques

Buildup dentin replacement with opaque darker hybrid –typically A3-A3.5




Buildup remaining form with shade similar to desired final color with hybrid (typically A1-A2)



Add special effects to simulate imperfections within tooth structure




Add special effects to simulate imperfections within tooth structure

Add translucent incisal hybrid or microfill


● Darker to Lighter

● Opaque to Translucent

● High Chroma to Low Chroma

● Larger Particle to Smaller Particle

● Low Polishability to High Polishablity



Add dentin shade

•Aura Dentin 6

•Miris

Add General Purpose Shade

•Aura MC 3

•TPH Spectra

•Coltene Brilliant

Add Characterization

Important-Junction must be invisible

Add decalcification, brown, gray zones

(incisal blue)

Add Facial Surface•Aura Enamel

•G-aenial

•Beautifil II

•Esthelite Sigma Quick

•Harmonize Enamel

Optrasculpt Pad

➡Non-Stick foam pad attachments (Ethylene Vinyl Acetate)

➡Two pad sizes for contouring of direct veneers and large-surface class III and IV restorations

➡Reference scale to measure the width of the anterior teeth (RED Proportion)

Gross contouring of facial surface

Incisal edge

Quick Contouring

•No metal in the center

•Very Flexible

•Double Sided

•Available in Unit Dose

859-014

Coarse, fine diamonds, finishing carbides

Enhance to blend margin, develop facial surface contour

Astropol to finish

Diacomp Feather Lite to polish

Astropol

Shaping, Finishing and Polishing

Enhance

7901

Diacomp Feather Lite

201.3VF



Pre-Operative

Finished Restorations

Direct Contouring Techniques

Technique by Dr Paul Belevedere

and Dr. Doug Lambert

Mold Margin Perfect Matrix

Margin Perfect Matrix

Pre-Shaped matrix

Place and cut excess ends of matrix

Hold instrument against band

Use Heliobond to adhere to gingiva

MPM in place sealed against gingival

margin

Etch

Thoroughly wash and dry

Place bonding agent and light cure

Apply composite and adapt to sides



Trim with diamonds then finishing carbide

burs

Use brush to push composite into

corners

Finish and polish restoration

Shape, finish and polish restoration

Restore opposite tooth

Technique by Dr Paul Belevedere

and Dr. Doug Lambert

• GrandioSO• Mosaic• Brilliant Ever Glow• Venus Pearl• Spectra TPH ST• SimpliShade• Tetric Evo-Ceram• G-aenial Sculpt• Filtek Supreme Ultra• Beautifil II• Esthelite Sigma Quick- Omnichroma

Universal CompositesT

ranslu

cency

Difference in Opacity• GrandioSO• Mosaic• Brilliant Ever Glow• Venus Pearl• Spectra TPH ST• SimpliShade• Tetric Evo-Ceram• G-aenial Sculpt• Filtek Supreme Ultra• Beautifil II• Esthelite Sigma Quick- Omnichroma

SimpliShade

Universal Composites

Light, Medium, DarkLight, Medium, Dark

3 Shades Match Well

Universal Composites



Anterior Restorations

Anterior Restorations

••Patient said placed 5 years ago Patient said placed 5 years ago

Large Posterior Large Posterior Composites LayeringComposites Layering

Open Margin Cracked Enamel

(white line)

Effects of Polymerization Shrinkage STRESS

Fractured Cusp

Bulk Fill CompositesBulk Fill Composites

● Modes of Action– Initiators more light sensitive– Greater translucency allows better light transmission– Delayed gel state formation– Increased elasticity

● Advantages– Quicker, easier– Deeper depth of cure– Decreased polymerization shrinkage STRESS– Fewer air voids between layers– Gives dentist confidence to tackle larger restorations

•Excellent with smaller preparations

•Difficult access-2nd or 3rd molars

•Challenging anxious patients

•Cusp-buildup technique

•Increased translucency

•Results are surprisingly good

Bulk Fill Flowable CompositesBulk Fill Flowable Composites

•Designed to be the entire restoration

•Use Spherical particles

•Filled >50% by volume

•Good wear resistance

•High flexural strength

•Good polishability

GG‐‐aenial Universalaenial UniversalBulk InjectableBulk Injectable



•Designed to be the entire restoration

•Use Spherical particles

•Filled >50% by volume

•Good wear resistance

•High flexural strength

•Good polishability

BeautifulBeautiful‐‐Bulk Bulk FlowableFlowable

● Improved flowability of composites● Improved marginal adaptation● 5mm depth of cure● Delayed gel state decrease stress● Increased sculptability● Designed for large posterior use

ADVANTAGESADVANTAGESSonic Energy Assisted Light PolymerizationSonic Energy Assisted Light Polymerization

Sonic Fill 3Sonic Fill 3

Chipping

Fracture Discoloration

Marginal Debonding Sensitivity

Secondary Decay

Incomplete PolymerizationIncomplete PolymerizationRESULTSRESULTS

Same Brand Light‐Different Units

NOT ALL CURING LIGHTS NOT ALL CURING LIGHTS ARE CREATED EQUALARE CREATED EQUAL

Different Brand Curing Lights

www.bluelightanalytics.com/checkUP

Each Curing Light AnalyzedEach Curing Light Analyzed

Light OutputLight Output

WavelengthsWavelengths

CollimationCollimation



Each Curing Light AnalyzedEach Curing Light Analyzed

Angle of Light TipAngle of Light Tip

HeatHeat

Ergonomics & Ease of UseErgonomics & Ease of Use

Databases Created by BluelightDatabases Created by Bluelight•• Each Curing Light CharacteristicsEach Curing Light Characteristics•• Each Popular Composite & ShadeEach Popular Composite & Shade

Composite Dataset

(Technical Info for 800+ Materials)

LCU Spectral Dataset

(700+ LCU @ 25K+ clinics)

InIn‐‐Office ProceduresOffice Procedures

•• Test Output of All Curing LightsTest Output of All Curing Lights•• Enter Light, Composite & ShadeEnter Light, Composite & Shade

5m m

5mm

Interproximal Contacts

Composite Direct Placement Composite Direct Placement ChallengesChallenges

Christensen JJ. Duplicating the form and function of posterior teeth with Class II resin-based composite. Gen Dent. 2012;60:104-108.

Composites Should NOT be Viewed as Short-Term Crown Buildups

Tofflemire vs. Sectional Tofflemire vs. Sectional MatricesMatrices

Tofflemire System

➢ Thin contact at the marginal ridge

➢Non‐anatomical

➢ Foodtrapbelowcontact

➢ Increasedlikelihoodof:fracture,recurrentcariesandperiodontaldisease.

SectionalMatrices

✓Broad contacts at the proper height of contour

✓Anatomicallyshapedcontacts

✓TightContacts

✓Propercontactsthatflossproperlyforbettergingivalhealth



Sectional MatrixSectional Matrix

TrioDent/Palodent

Universal V3 Ring Narrow V3 Ring

Challenge:

Adjacent Class II Composite Restorations

Place contoured

band, wedge & V-Ring

Selective etching

Wash thoroughly

Apply bonding agent

Fill box 2/3’s full

Compress w 1P

Finish buildup

Cure ContacEZ

Re-contour diamond/finishing

carbides

Finishing strips

Place V-Ring on adjacent tooth

Burnish desired contact area

Selective etching

Place Universal bonding agent

Light Cure

Peel back band

Cure from both sides at

gingiva

Place Composite as

before

Light Cure



Finish and polish

Adjust occlusion


RetainersRetainers

Garrison Composi-tite 3-D Fusion

Short Ring Tall Ring Wide Ring


BandsBands

Garrison Composi-tite 3-D FusionTweezers


BandsBands



WedgesWedges


Fusion WedgesTweezers

Adjacent Class II Composite Restorations

Restore center tooth using Toffelmire

Adjust mesial & distal so gingiva is visible

Preparations Maxillary Right quadrant



Quadrant restored

Place band & retainer

Maxillary arch restored

Place Toffelmire band & retainer on center

tooth

Preparations Maxillary Left quadrant

● Improves occlusal anatomy● Easy to Use● “Connect the Dots”● Proper angulations for proper shape● Safe sided to protect unshaped enamel

Occlusinator ProOcclusinator Pro Occlusinator ProOcclusinator ProSculpting BursSculpting Burs

50 Micron Diamond

“Acorn Shaped”

15 Micron Diamond

“Christmas Tree Shaped”

Diamond- FREE

safe edge/safe zone

Occlusinator ProOcclusinator ProTechnique Step 1Technique Step 1

Drop the Acorn bur into the natural pits, and then move up between the cusps to define occlusal anatomy

Occlusinator ProOcclusinator ProTechniqueTechnique‐‐Step 2Step 2

Polish with the Christmas tree bur



Occlusinator ProOcclusinator ProShaped ToothShaped Tooth

•Total Etch Technique

•Self Etch Technique

•Selective Etch Technique

Improved Dentin Bonding

Total-Etch Technique

Challenges-Technique Sensitivity

Under-etched enamel Over-etched dentinProper moisture-affects bond strengthsMoisture ContaminationProper Evaporation of solventIncompletely filled dentinal tubulesPost-Operative Sensitivity

Air only syringe

Air/water syringe

Evaporating the solvent with dry air

Post-Operative Sensitivity

• Chlorhexidine

•HEMA

Anti-Microbial



Benefits

• Superior antimicrobial activity

• Enhances bond strength • Antimicrobial activity

• Inhibits enzymatic degradation

• Enhanced dentin bond strength

• Reduced micro-leakage

• No soft tissue burning

• Economical

Benefits

Desensitization Prior to Bridge Seating

Under Composite If you would like to try:

Text “Advantage” to:

72345



Self-Etch Technique

Challenges-Material Weaknesses

Decreased bond strength & marginal gap formation w/ un-etched enamel

Bond incompatibility to self-cure & dual-cure resins

Hydrolytic degradationEnzymatic collagen attack

Self etching Primer

Solution: “Etching prepared enamel w phosphoric acid promoted better marginal integrity with self-etching bonding agents.”

Marginal Gap Prevention

Souza-Junior EJ, Prieto LT, Araújo CT, Paulillo LA. Selective enamel etching: effect on marginal adaptation of self-etch LED-cured bond systems in aged Class I composite restorations. Oper Dent. 2012;37:195-204.

Solution: Use a self-cure or dual cured dentin bonding agent

Suh BI, Feng L, Pashley DH, Tay FR. Factors contributing to the incompatibility between simplified-step adhesives and chemically-cured or dual -cured composites. Part III. Effect of acidic resin monomers. J Adhes Dent 2003;5:267-282.

Bond Incompatibility with Self and Dual Cured Resins

Solution: Use MDP containing bonding agents which become hydrophobic upon polymerization due to high amount of cross-linkage.

“MDP-containing adhesives form nano-layering at the adhesive interface. Stable MDP-Ca salt deposition along with nano-layering may explain the high stability of MDP-based bonding.”

Yoshida Y, Yoshihara K, Nagaoka N, Hayakawa S, Tori Y, Ogawa T, Osaka A, Van Meerbeek B. Self-assembled nano-layering at the adhesive interface. J Dent Res 2012;9:376-381.

Hydrolytic Degradation

MMP-Matrix Metalloproteases

● MMPs are naturally occurring proteases involved in dentin formation and trapped during odontogenesis

● Not bacteria but proteolytic enzymes found within dentin capable of degrading collagen within newly created adhesive hybrid layers

● Low pH causes dentin to release these inherent MMPs which attack exposed collagen fibrils

Osorio R, Yamauti M. Osorio E., et al. Effect of dentin etching on metalloproteinase-mediated collagen degradation. Eur J Oral Sci 2011;119:79-85.

Enzymatic Collagen Attack



MMP-Matrix Metalloproteases

Carrilho et al., JDR 2007;

In-vivo 12 m w/PBNT (Acetone)

Immediate (MPa)Control 29.3 (9.2)CHX 32.7 (7.6)

w/CHX in 12 m

14 mo (MPa)Control 19.0 (5.2)CHX 32.2 (7.2)

Potential MMP Inhibitors

Long Term Dentin Bond Stability

● Chlorhexidine (CHX)

● Hemaseal & Cide

● Benzalkonium Chloride

● MDPB (12-methacryloxydodecalpyridinium bromide)

● GLUMA

Perdigao J, Resi A, Loguercio AD. Dentin Adhesion and MMPs: A Comprehensive Review. J Esthet Restor Dent 2012: 25:219-241.

Disinfect to prevent MMPs

Use Etchant containing 1% Benzalkonium Chloride

TE-Apply 2% Chlorhexidine after acid etching for 30 sec

SE-Apply 2 coats 2% Chlorhexidine prior to application of primer

OR

Long Term Dentin Bond Stability Selective-Etch TechniqueChallenges with Self-

Etching Primers:

Improved Enamel Bonding

But…

Selective-Etch TechniqueChallenges with Self-

Etching Primers:

Poorer Dentin Bonding

THE SolutionSelf‐etch Selective‐etch Total‐etch

Universal Bonding Agents

Challenges-SOLVED



Total-etch, self-etch or selective-etch technique

Can be used for direct and indirect restorations

Bond to all indirect substrates-metal, ceramics, zirconia, porcelain and lithium disilicate.

Compatible with light-cured, self-cured and dual-cured composite and luting cements.

Universal Bonding AgentsAll-Bond UniversalTotal-etch, self-etch or selective-etch

Single bottle for direct and indirectrestorations

High bond strengths to metal, ceramics, zirconia, porcelain & lithium disilicate.

Compatible with light-cured, self-cured and dual-cured composite and luting cements since pH is 3.2

Becomes hydrophobic upon setting


Universal Bonding AgentsContain MDPContain MDP Contain MDP


Having an effect upon a living organism, tissue, or cell.

Biologically active.

Bioactive



121

ORAL ENVIRONMENT

2. ACP: Amorphous Calcium Phosphate – very high quantities

• Is pH driven. Healthy resting saliva has a pH 6.8. Demineralization starts at 5.5 pH.

• Saliva contains calcium and phosphate so it can build hydroxyapatite to keep teeth healthy.

• Hydroxyapatite is major component and essential ingredient of normal bone & teeth. It makes up bone mineral & the matrix of teeth. Hydroxyapatite gives bones and teeth their rigidity.

122

ORAL ENVIRONMENT


• If the mouth is constantly being challenged by acid attacks, saliva cannot keep the balance.

• Result is an environment that favors demineralization

TOOTH

Acid

Calcium

phosphate

Demineralization Remineralization

Google Image Word Search

• Under acidic attack release ions-F, Ca, PO4, Na, Sr, Si, Al, Na, B

• Restorative and Base material

• Pulp capping material

• Cements

• Others

Bioactive

•Self-curing: Acid/Base setting reaction

•Ionic Bonding to tooth Calcium

•NO polymerization shrinkage stress

•More highly filled-reduced wear(compared to RMGI)

•Expansion/contraction similar to tooth

•High Fluoride Release-Bioactive

(The Original Bioactive Dental Material)Glass Ionomer Restoratives

Patient on multiple meds

Glass Ionomer Cervical Caries

Remove decay-place matricesTreat dentin with PAA

Place, shape and wait 2:30


Shape w very fine diamonds & waterPlace matrix and surface sealant



Class V root caries


Repair around crown margins


Internal Cracks

Glass Ionomer Crown Buildup

Class II

Glass Ionomer Pediatrics

Glass Ionomer Sealants

Partially erupted vulnerable tooth

Able to seal before decayed

Long term fluoride affect -Rarely decay

Place


Partially erupted vulnerable tooth Etch with

phosphoric acid



5 Years Later


Place surface sealant Light cure

Glass Ionomer Closed Sandwich

Gain access to decay using a high

speed

Use slow speed and then spoon excavator

STOP if you feel you will expose pulp

Hilton TJ. Keys to Clinical Success with Pulp Capping: A Review of the Literature. Op Dent 2009;34:615-625.


Condition enamel only with phosphoric acid for 10 seconds and

wash


Place glass ionomerbase

Place Universal Dentin bonding agent Allow to set

Re-prep if needed


Place composite and light cureFinish and Polish

Glass Ionomer Open Sandwich

Preparation with dentin cervical

margin

Etch enamel with phosphoric acid -20 sec

Condition dentin with polyacrylic acid-10 sec

Wash thoroughly




Place glass ionomerbase

Allow to set, then reshape and wash &

dry if needed

Place Universal Bonding Agent


Buildup tooth with composite

Shape with fine diamonds and

finishing carbides

Finish and Polish


Straight -contoured Restoration

mesial view

Glass Ionomer

Composite

Bonding Agent

Posterior Glass Ionomer•Long-term provisional restoration

•High-caries risk patients

•Deep sub-gingival molar interproximal restorations

•Thin buccal walls

•Cracked teeth

•Transitional restoration before a crown

Equia Forte

•Stronger

•More Opaque

High caries risk patient

Posterior Glass Ionomer

High caries risk patient




EQUIA Forte HT

•High Translucency

•Higher Fluoride Release

•Higher Compressive Strength

•Long-term Interim Restorations

EQUIA Forte HTSurface-treated FAS glass

High reactive, fine FAS glass

Polyacrylic acid powder High Molecular Weight:Low Molecular Weight

Dentist-Multiple Radiographic Caries



GI Placement Before and After


SummarySummary

● 5-10% of teeth restored

● High caries situations

● Thin buccal or lingual walls

● Deep internal cracks

● Deep subgingival Class II near pulp

● Decalcified chalky margins

● Long Term Interim Restorations

● Invaluable Adjunctive Material


Fuji II LC

Resin‐Modified Glass Ionomer

Fuji Automix LC



•Dual-curing: Acid/Base & Polymerization Reaction

•Ionic & Micromechanical Bonding

•Shrinkage stress if cured prior to set

•Higher tensile, bond strength and wear

•More Translucency

•Fluoride Release-Bioactive

RMGI Properties(compared to “pure” glass ionomer)

RMGI Liner

No dentin conditioner needed due to self-etch primer component

RMGI Base RMGI Base

Place RMGI & light cure

Re-prepare if necessary

Etch tooth and base with phosphoric acid

Place composite

RMGI Class V‐Paste/paste

Place retraction cord

Prepare tooth with undercuts

Etch enamel only with phosphoric acid*

RMGI Class V‐Paste/paste

Bulk placement

Light cure

Hold gingiva down with instrument & shape with fine

diamonds and finishing carbide with water

Apply surface sealant or gently polish with slow

speed coated abrasives



RMGI‐Crown Buildup

Place tip and express material

Light cure & then allow to fully self-cure

Quick preparation & removal of provisional

RMGI‐Crown Buildup

Seated Zirconia CrownCompleted preparation

Bulk placement & light cure

RMGI‐Sandwich Technique

Decayed toothExcavate

thoroughly

Finished & Surface sealant applied

RMGI‐Sandwich Technique

Reshape base-curved floor Placement prior

to curing

Ca & F Releasing Resins

•Releases and recharges Ca, P & Fl

•Self-adhesive bonding

•Dual-cured

•Contains MDP

•Good compressive strength

•Radiopaque

Therabase(Resin based liner/base)



•Hydrophilic Calcium Silicate Matrix which releases Fluoride & Calcium

Thera ProductsUnique Formulation

200 pt

•Hydrophilic Calcium Silicate Matrix which releases Fluoride & Calcium

Thera ProductsUnique Formulation

200 pt

•No phosphoric acid or bonding agent needed

•Express through mixing tip onto tooth

•Spread out and light cure

•Initial acidic pH for self-adhesion- changes to alkaline in minutes

•Reprepare, etch, bond & place composite

TherabaseEASY TO USE

200 pt

Deep decay

Therabase

Place TheraCal

TheraBase placed & cured

Therabase

Tooth reprepared, bonded, composite placed

Esthelite Sigma Quick

Oh Sh………

Direct Pulp Capping



Endodontic Root Canal Therapy?Endodontic Root Canal Therapy?

● Asymptomatic● Single small exposure● Able to achieve hemostasis

Perhaps not IF:Goals

• Mechanical Sealing of the Pulp• Stimulate hydroxyapatite formation• Dentin bridge formation

Direct Pulp Capping

TheraCal • (Resin Modified Calcium Silicate)

Direct Pulp Capping

• Light cured apatite forming MTA in a hydrophilic resin

• Material sets hard and adheres to dentin• Alkaline pH• Releases Ca++ ions

Ca+2

OH-

H2O

Ca+2

OH-

Direct Pulp Capping

STOP!

Control bleeding

Water, saline, chlorhexidine, sodium

hypochlorite

Place Theracal & cure

Finish Excavation

Direct Pulp Capping

Cover with RMGI or Therabase

Bond & place composite SummarySummary

● Best is to avoid

● IFF Asymptomatic

● IFF 1 small exposure

● IFF Able to control bleeding

● Irrigate with chlorhexidine

● MTA is effective

● Theracal-quicker, easier, less expensive

Direct Pulp Capping



•Used for Pulpotomies in Primary Teeth


•Releases and recharges Ca & Fl

•Dual-cured

•Contains MDP

•Radiopaque

TheraCal PTResin Modified Calcium Silicate

TheraCal PT(Compared to TheraCal)

•Dual-cured

•Higher strength

•Able to build up thicker base (>1mm)

•Liner or Base

•Gray color vs white

•More moisture tolerant-does not wash out

Fit SA•Releases and recharges Ca & Fl


•No mixing, single component

•Light-cured

•Releases Giomer Ions

•Radiopaque

(Resin based liner/base/restorative)

•Surface Pre-Reactive Glass Fillers

Giomer ProductsUnique Formulation

200 pt

Set Glass Ionomer Material Surface Modified Pre-Reactive Glass Ionomer Filler

Surface modified layer

Glass Ionomer phase

Glass Core

Set glass ionomer filler particlesMultifunctional glass core

High radiopacity

Excellent light transparency

Combination of 3 layer structures

Hardness is equal to Enamel

Excellent color shade match(Light diffusion and light transparency)

Maintain mechanical property


Glass ionomer phase

High mechanical property

Long-term stability

Fluoride release and recharge

Multi-ion release

Bio-activity

Giomer ProductsUnique Formulation

200 pt

•Surface Pre-Reactive Glass Fillers•Surface Pre-Reactive Glass Fillers

Giomer Ion Release

・ F（Fluoride Ion）Forms Fluoroapatite

Anti-bacterial effectRemineralization effect of decalcified areas

・Sr（Strontium Ion）Accelerates Bone formation & remineralization

Improve Acid Resistance

・AI（Aluminum Ion）Reduces hypersensitivity

・Si（Silicate Ion）Induce remineralization

・B（Borate Ion）Anti-bacteria effect

Bone formation

・Na（Sodium Ion）helps other ion’s function



•No phosphoric acid or bonding agent needed

•Self-adhesive bonding reduces sensitivity

•2 viscosities-F03 (low flow) F10 (runny)

•Express through tip onto tooth

•Leave for 20 seconds-then light cure

•Cover with composite or continue to buildup Transitions from acidic PH (needed for initial bonding) to alkaline PH in minutes* which promotes pu

Transitions from acidic PH (needed for initial bonding) to alkaline PH in minutes* which promotes pu

Fit SAEASY TO USE

Fit SAInstructions

✴Class I Restoration - F03✴Class III and Class IV Restorations - F03✴Class V Restoration - F03✴Lining of Large Restorations - F10 Transitions from acidic PH (needed for initial bonding) to alkaline PH in minutes* which promote

vitality2 Transitions from acidic PH (needed for initial bonding) to alkaline PH in minutes* which p

pulp vitality2

Fit SA

2 Viscosities

F03 (low flow) & F10 (runny)

IndicationsFit SA

Dr. Jack Griffin

F03 CLASS I (MAXILLARY)

F03 CLASS I (MANDIBULAR)

Fit SA

Dr. Jack Griffin

F03 CLASS V

Beautifil Flow Plus X •Releases and recharges Fl

•Can be used as liner, base or restoration

•Light-cured

•Releases Giomer Ions

•Excellent Polishability

•Radiopaque

(High Viscosity Flowable Composite)



Beautifil Flow Plus X Improvements


Glass ionomer phase

Multi-functional glass core

Newly developed Nano S-PRG filler800 nm (Sub-micron filler) 400 nm (Nano filler)

Gives Enhanced Polishability

✴Class I Restoration ✴Class II Restoration✴Class III and Class IV Restorations ✴Class V Restoration ✴Lining of Large Restorations ✴Excellent for hard-to-reach Restorations Transitions from acidic PH (needed for initial bonding) to alkaline PH in minutes* which promote

vitality2 Transitions from acidic PH (needed for initial bonding) to alkaline PH in minutes* which p

pulp vitality22 Viscosities

F00 (no flow) & F03 (low flow)

IndicationsBeautifil Flow Plus X

Beautifil Flow Plus X Instructions

(Resin cone technique)

Beautifil Flow Plus X



•Dual-cure or Self-cure

•Reduces detrimental MMP effects

•Good compressive strength

•Radiopaque

Activa Bioactive(Resin based liner/base/restorative/cement)

•Ionic Resin Matrix-allows ion exchange

•“Rubberized” Resins-tough, fracture resistant

•Reactive Ionomer Glass-fluoride release

•Works in a moist environment

•Contains NO Bis Phenol A

Activa Bioactive ProductsUnique Formulation



Releases Phosphates as pH lowers

ppm

Activa BioactiveIon Release

Releases Calcium as pH lowersRestoration Under Crown

Activa Bioactive Restorative


•Calcium phosphate soluble in monomer

•-Light cured

•Reduces detrimental MMP effects

•Good compressive strength & toughness

•Radiopaque

Activa Presto(High Viscosity Flowable Composite)

•Liners

•Class V restorations

•Class I II III restorations

•Pediatric patients

•Geriatric patients

•Crown buildups

Activa PrestoUses

Class I

Activa Presto Activa Bioactive vs Presto

Hydrophilic

Rubberized Resins

Calcium /Phosphate Enriched Ionic

Resins

Release/Recharge Calcium, Phosphate,

Fluoride

No Bis-GMA or BPA Derivatives

Dual Cure

Contains Glass Ionomer

Injectable/Flowable

Bulk Fill

5 Shades

Light Cure

Contains ModifiedCalcium Phosphate

High viscosity Flowable

2mm Increments

8 Shades



Ca & F Releasing Preventive

200

RECALDENT (ACP-CPP)

ACP-CPP release dependent on pH of the oral environment•Acidic environment-releases more ACP•Stable environment-releases appropriate level

ACP: Amorphous Calcium Phosphate • Active carrier molecule

CPP: Casein Phosphopeptide • Delivery vehicle

• Binds to enamel, pellicle, plaque, and soft tissue

• Binds Calcium and Phosphate

• Milk Protein

201

RECALDENT (ACP-CPP)

ACP: Amorphous Calcium Phosphate • Carrier molecule

CPP: Casein Phosphopeptide• Do not use on patients with a

proven or suspected milk protein allergy or with sensitivity to benzoate preservatives

• Lactose content is less than 0.01%

202

RECALDENT (ACP-CPP)


Provides Ca and PO4

Promotes Remineralization

Prevents mineral lossInhibits

Demineralization

Neutralizes acid from bacteria

Neutralizes & Buffers

Mechanism of ActionMechanism of Action• Binds to enamel, pellicle, plaque, & soft tissue

RECALDENT (ACP-CPP)

Mechanism of ActionMechanism of Action

RECALDENT (ACP-CPP) PRODUCTS

MI Paste MI Paste Plus

MI VarnishMI Paste ONE GC Fuji TRIAGE Plus



MI PASTE

● Provides bio-available calcium and phosphate ● Buffers pH● Reduces tooth sensitivity● Aides remineralization● Reduces sensitivity after scaling or tooth whitening● Excellent for dry mouth syndrome● Treats white spot lesions

● After tooth whitening

● For pregnant mothers

● For children 6 & older

● During or after ortho

● Desensitization

● Poor Oral Hygiene

● Extra protection for teeth

MI PASTE USES

MI PASTE PLUS

● Addition of 0.2% NaF (900 ppm)● Provides bio-available calcium and phosphate ● Reduces tooth sensitivity● Aides remineralization● Fluoride increases anti-cariogenic effect● Excellent for dry mouth syndrome● Treats white spot lesions ● Suitable for patients 12 and older

●White spot lesions

● Desensitization

● During or after ortho-12 and older

● Medical compromised patients

● Xerostomia

● High Acid Environment

● High Caries Risk patients

● Extra Protection

MI PASTE PLUSUSES

MI PASTE & MI PASTE PLUS

APPLICATION■ Apply after toothbrushing

■ Rub paste onto tooth & leave for 3 minutes

■ May apply with trays for 3-5 minutes

■ No food or drink for 30 minutes

MI PASTE ONE

● Toothpaste with ACP-CPP, Fluoride & Potassium Nitrate ● Same benefits as MI Paste Plus● Very low in abrasives● Reduces tooth sensitivity● Aides remineralization● Good for tooth erosion and wear● Treats white spot lesions ● Ideal for High-Risk Patients



MI PASTE ONE

APPLICATION

Apply a small, pea-size amount of MI Paste® ONE to your

toothbrush.

For best results, brush for 2 minutes and do not rinse; do not eat or drink for 30 mins after brushing. Use twice

a day.

MI Paste® ONE MI Paste Plus®MI Paste®

pH 7.1 7.2 7.2CPP-ACP 10% 10% 10%

Ca2+

content 11.6mg/g 11.7mg/g 11.7mg/g

PO4 content 7.0mg/g 7.0mg/g 7.0mg/g

Fluoride 1,100 ppm NaF 900 ppm NaF -KNO3 5%Silica Yes - -

Surfactant Yes - -

Composition

MI VARNISH

● Ads benefits of bio-available calcium and phosphate to fluoride varnish

GC FUJI TRIAGE EP

● Ads benefits of bio-available calcium and phosphate to high fluoride releasing glass ionomer

● Inhibits biofilm formation● Helps prevent caries caused by acid and bacteria

AGEAPPROPRIATE

RESTORATIONS

• Xerostomia• Root exposures• Difficulty maintaining oral hygiene• Some unable to tolerate long

appointments• Difficulty coming to office

• Fixed Income

US Population is Aging



Multiple Medications

Aging Population Challenges‐Xerostomia


“40% of all prescription drugs have dry mouth listed in the PDR as a possible side effect”

Chalmers J. Personal Communication. 2006.Chalmers J. Personal Communication. 2006.


In a published study of 131 different prescribed medications the most common side effect cited was xerostomia.

Smith RG, Burtner AP. Oral sideSmith RG, Burtner AP. Oral side--effects of the most frequently prescribed drugs. Spec effects of the most frequently prescribed drugs. Spec Care Dent. 1994;14:96Care Dent. 1994;14:96--102. 102.


• Incidence increases with # of drugs taken• 50% of patients taking 4 or more

medications had Dry Mouth

Medical Transport

Aging Population Challenges‐Transportation

Long-Term Interim RestorationsUsing Glass Ionomer Restorative Materials



Tooth Excavation

Band w Opening

Before

After

Direct Bonded Provisional CrownUsing bis-Acryl resins

•Take alginate impression

•Pour up model

•Cut off crown

•Remove decay

•Place GI base

•Reprepare

•Fabricate vacuum formed matrix

•Seat with bis-acryl composite

•Trim and shape

•Adjust occlusion

•Bond



•Perio abcess

•Sub-gingival distal decay

Immediate Natural Tooth PonticUsing Resin Pre-Impregnated Glass Fibers

•Carefully extract tooth

•Suture

•Scale and root plane adjacent teeth

•Cut off root of extracted tooth

•Remove decay and restore with glass ionomer

•Tryin and prepare slots

•Shape root area to support tissue

•Cut lingual slot when trying inline with 2 adjacent teeth

•Fibers are thoroughly coated

•Fibers oriented in the same direction

•Fibers are easier to cut

Ever Stick Fibers

•Measure space and cut Ever Stick fibers

•Place tooth

•Etch and bond

•3 months later



•3 months later

Before

Happy patient says that I just “straightened” his crooked tooth

Visual Communication

•Digital Radiography•Digital Radiography


•Pre- Photos


•Computer Library Photos




Imaged Smile Design

•Interested in Smile Makeover •His Concerns

Imaged Smile Design

Imaged Smile Design

•Implant #10 & Crowns 9-11 •My Concerns

Imaged Smile Design

•RED Proportion Smile Design

Imaged Smile Design Imaged Smile Design

•Bridge 9-11 & Laminates 5-8, 12



Imaged Smile Design

•Cost

Imaged Smile Design

•Bridge 9-11 & Laminates 6-8

Imaged Smile Design

•Preparations

Imaged Smile Design

•Lab Prosthesis

Imaged Smile Design

•Finished Smile

•DSD App

•I Pad I Phone App

•Smile Frame

•Proportional

•Personality Library Shapes


•Digital Smile Design App



•Digital Photos

•Digital Impressions

•CBCT (optional)

•Email to DSD


•Digital Smile Design Service

•Photo aligned

•Smile designed

•3-D virtual model created according to smile view

•Email of files sent to Dr.

DSD Service

•Program integrates all 3 files

•Print 3-D model

•Create putty matrix

DSD Service

•In-Office Preparation

•Inject bis-acryl & seat

•Smile Simulation

•Shoot movies & show patient still photos

In-Office Mockup

•Patient Views Smile on Face

Universal Post & Sleeve

Small diameter post preserves apical root structure

Sleeve fits over post for added strength

2 Components

“My crown fell off”

Measuring depth of GP removal



Trying in post

Trying in post & sleeve

Bond post & sleeve

Completed preparation

Provisional crownSeated crown

Splendor SAP Fiber PostSplendor SAP Fiber Post Fractured Metal Post

Post carefully removed

Gates Glidden to preliminary depth

Radiograph confirmation

Post prep drill to length

Post tryin to length

Sleeve tryin



Pre-treating Post and Sleeve

Silane

Etch dentin 5 seconds

Rinse and irrigate with chlorhexidine

Lightly blow air

Blot with paper points

Place Bonding Agent

Place several coats and rub in for 30 seconds Self-Cured

Forcefully blow air

Blot with paper pointsCoat post first

Insert cement into canal

Dual-cured

Cement & Core buildup



Quickly insert post into canal

Coat top of post and quickly insert sleeve

Buildup core

Light Cure & Wait 3 minutes

Cutoff extra post length

Prepare tooth

Completed Preparation

Splendor SAP Fiber PostSplendor SAP Fiber Post

Radiograph

• Preparations-Even & Adequate Reduction

• Cementation Procedures different for each material

• Cement may affect Color

• Cannot adjust intaglio surface of crown

• Post-seating fractures or debonding

• REQUIRES HIGHER SKILLS & ATTENTION TO DETAIL

All-Ceramic RestorationChallengesChallenges

High Strength Monolithic Zirconia (tetragonal 3Y-TZP*)

• Posterior molars

• Grinders

• Blockout dark tooth

• Always decontaminate intaglio surface

• Conventional cementation-RMGI

• Bond w short or non-retentive preps*3 mole-percent yttrium-stabilized tetragonal

zirconia polycrystals

tetragonal



High Translucent Monolithic Zirconia (tetragonal 4-5Y-TZP*)

• Low stress molars, bicuspids,budget anteriors

• More translucent

• Decontaminate intaglio surface

• Conventional cement OK if >1mm prep RMGI

• Prefer self-adhesive resin

• Adhesive Resin Bond short or non-retentive preps

*4-5 mole-percent yttrium-stabilized tetragonal and cubic zirconia polycrystals

tetragonal cubic

All-Ceramic RestorationsLithium DiSilicate

• Anterior Teeth, Bicuspids & Selective Molars

• Layered Incisors and Canine

• Monolithic bicuspids

• Silanate intaglio surface

• Conventional cement OK if >1mm prep RMGI

• Prefer Adhesive Resin Bonded Cement

High Strength Zirconia-3-Y• Strongest

(1100 MPa)• More Opaque• Conventional

Cementation• Molars• Bridges• Lower lab bill• Failure-Loose

All-Ceramic Restorations Summary3-Y HS vs 5-Y HT Zirconia vs Lithium DiSilicate

Lithium DiSilicate• Strong (bonded)

(400 MPa)• Most Translucent• Bonding Best• Anteriors &

Premolars• Selective Molars • More Expensive• Failure-Fracture

High Translucent Zirconia-5-Y• Stronger (700 MPa)• More Translucent• Conventional or

Bonded Cementation

• Premolars & Selective Molars

• Budget anteriors• Failure-??

I don’t like the dark lines around my teethRecurrent decay

Case I

What type of Crowns?

Patient wants to mask dark color

Wants good esthetics

Porcelain fused to Zirconia

Excellent masking of dark color

Provides good esthetics & Ease of cementation



Anterior 6 prepared and temporizedGo home and see how you like

Anteriors Prepared What type of Cement?

Retentive Preparations

Ease of Seating Multiple Crowns simultaneously

Conventional RMGI Cement

Prefer Fluoride Release at Margins

Good Strength & Ease of Cementation

Zirconia Retentive Preparation

➢Zirclean➢Fuji Cem Evolve

Removes phosphate contamination on intaglio surface of crown

Conventional Cementation

Very low sensitivity, moisture friendly

RMGI Cement Properties

FujiCEM Evolve

•Adheres well to Zr, LiDS, Metal

•3-5 second tack cure, 4:30 set

•Moisture tolerant

•Very low post-op sensitivity

•High radiopacity

•Fluoride Release

Zir Clean•Removes salivary contaminants on intaglio surface of crown after tryin

•Dramatically increases bond strength to Zirconia

•Contains potassium hydroxide

•Creates a very basic pH

•Paint on and leave for 30 seconds

•Wash & dry thoroughly



•Zir Cleaner in crown 30 s -wash & dry

•Clean tooth & leave moist

•Place cement in crown & seat

•Remove flash 2 min after seating or tack cure 5 s

•Light cure after margins cleaned

•Check occlusion after 5 minutes

Technique Layered High Strength Zirconia

Provisionals Removed Max Crowns Seated

Layered High Strength Zirconia Crowns

Pre-Treatment All Crowns Seated

Case II

I saved money during CovidI want my teeth to be WHITE

Flood of Cosmetic Cases

Treatment Planned in 2011 w MDM

I’m Ready to Start Next Week!


Patient Most concerned about White Color

Wear is a concern



High Translucent Zirconia

Good Color Masking


Preparation Appointment

Preparation of Max Arch Provisionals Seated

What type of Cement?


Ease of Seating Multiple Crowns simultaneously

Self Adhesive Resin Cement

Prefer TheraCem


TheraCem•Self-Adhesive Resin Cement

•Dual-cured-68% conversion without light

•Calcium and Fluoride releasing and recharging

•Bonds well to zirconia (contains MDP)

•Sets in <5 minutes-Easy cleanup starts in 2 min

•Radiopaque

•Becomes alkaline

High Translucent Zirconia Preparation

➢Zirclean➢Z-Prime (not necessary if

using Theracem)

➢Chlorhexidine➢TheraCem

Removes phosphate contamination on intaglio surface of crown

Disinfects and reduces MMP bond degradation on dentin

Self-etching Adhesive Resin Bonding

Bonds zirconia to resin (iff primer does not contain MDP)

Self-adhesive resin cement



Z‐PRIME plus•Enhances bond between ZR or metal to Resin Cement

•Compatible with light-cured and dual-cured resin luting cements

•Contains MDP

•Apply after cleaning with ZirClean

•Paint on and wait 90 seconds

•Zir Cleaner in crown 30 s -wash & dry

•Chlorhexidine on tooth 30 s-leave moist-do not wash off

•Place cement in crown (no primer needed) & seat

•Remove flash 2 min after seating or tack cure 5 s

•Light cure after margins cleaned

•Check occlusion after 4 minutes

Technique

High Translucent Zirconia Crowns

Pre-Treatment Max Crowns Seated

Case III

I don’t feel like smilingIt’s hard to chew my food

Let’s Fix it the Right Way

Orthodontic Consult

Orthodontics

Brackets placed Ortho complete



Smile Design

RED Proportion Template MDM (Master Diagnostic Model)


Most Interested in Best Esthetics

Appreciates Beautiful Smile

Layered Lithium Disilicate

Best Appearance

Patient is Easy to Work with

Max Preparations

Desired Shade Prep Stump Shade

What type of Cement?


Want to select shade of cement

Adhesive Resin Cement

Prefer Duo-Link w Universal Primer to bond Lithium Disilicate

Superior Strength



Mandibular Crowns

Mandibular preparations Crowns on Model

Duo‐Link•Adhesive Resin Cement (requires a bonding agent)

•Dual-cured-high degree of conversion without light

•Very high bond strengths

•Begins to setup quickly to allow prompt cleanup

•Available in A2 and Milky White

•Can be used with Universal Bond or Universal Primer

Lithium DiSilicate Crowns

➢Phosphoric Acid➢Bis-Silane➢Chlorhexidine➢Universal Primer or

Universal Bond➢ Duo-Link Universal

Apply phosphoric acid on intaglio surface to acidify & clean surface

Disinfects and reduces MMP bond degradation on dentin

Adhesive Resin Bonding

Apply silane

Self-cured or light-cureddentin bonding agent Dual-Cured Adhesive Resin Cement

Prelim Technique•Apply phosphoric acid to intaglio of crown•Wash off and thoroughly dry•Mix BIS-Sliane & apply, Wait 2 minutes & Dry•Apply chlorhexidine to tooth for 30 sec-don’t rinse•Mix & Apply 2-bottle Universal Primer (self cure)•Agitate into tooth for 30 seconds•Lightly blow air to evaporate solvent for 20 seconds and thin out excess

•Apply phosphoric acid to intaglio of crown•Wash off and thoroughly dry•Mix BIS-Sliane & apply, Wait 2 minutes & Dry•Apply chlorhexidine to tooth for 30 sec-don’t rinse•Apply Universal Bond (light cured) onto crown•Agitate into tooth for 30 seconds •Lightly blow air to evaporate solvent for 20 seconds and thin out excess-CURE THOROUGHLY!

Prelim Technique Cement Technique•Express through mixing tip, dispose initial drops, insert into crown & thinly coat evenly•Seat quickly & firmly onto tooth•Hold down and use a small brush to remove excess•Use scaler & quickly remove gelled cement•Hold firmly and floss with knot tied pulling buccally•Use explorer to go over margins-floss again•Paint glycerin on margins & thoroughly light cure



Lithium Disilicate Crowns

Pre-Treatment Crowns Seated

Jenny Wohlberg Ceramist

All-Ceramic Results

High Strength Zirconia

High Translucent Zirconia

Lithium Disilicate

You Can Achieve Excellent

WITH SKILL & PLANNING!

E-Mail Questions to:[email protected] Daniel Ward DDS

Documents

Minimally Invasive Bioactive 2020