todd snyder, dds, faacd, fiadfe, asda

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Accredited Fellow, American Academy of Cosmetic Dentistry

Fellow, International Academy for Dental Facial Esthetics

Member of The American Society For Dental Aesthetics

Former Faculty, UCLA Center For Esthetic Dentistry

Speaker, Catapult Education

www.LEGION.dentist

Todd Snyder, DDS, FAACD, FIADFE, ASDALaguna Niguel, CA / Las Vegas, NV

Aesthetic Dental Designs®

[email protected]

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IDENTIFY THE PROBLEM

WHAT ARE COMMON OCCLUSAL PROBLEMS

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CENTRIC OCCLUSION DENTISTRYOR MIP

Red Blood Cells 2 – 5um

200-500nm

Human Hair 60 –120um

6,000 – 12,000nm

?

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SHIMSTOCK & ARTICULATING PAPER

What do you use…..

.…and why?

SHIMSTOCK & ARTICULATING PAPER

• Parkell Accufilm II is 21µm for dentistry

• Great Lakes articulating ribbon 12µm

• 8µm Almore Shimstock foil

• 8µm articulating paper??

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What do you use…..

.…and why?

8µm articulating paper

Available in blue

And red too!

Mark the bite before prepping teeth!!

TROLLDENTAL-4.5ΜM ARTICULATING PAPER

WWW.TROLLDENTALUSA.COM

DIRECTA DENTAL

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• Verify bite• Shimstock

• Over Impression

• Preparation

• Bite Registration• Dead soft Delar Wax

• Firm, Hard Bite Reg

• Shimstock

• Facebow

• Full Arch Impression

• Provisional

• Lab Articulation

Indirect Restorations & Bite Registrations

PDL & OCCLUSAL RECORDSThe range of PDL width: 0.15mm ~ 0.38mm

• Average PDL width by age:

o 11 ~ 16 years old: 0.21mm

o 32 ~ 52 years old: 0.18mm

o 51 ~ 67 years old: 0.15mma

• The PDL width decreases with age.

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

• Tooth with more function has bigger PDL space

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Occlusal Testing Hold

Drag

No Hold (None)

SHIMSTOCK

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

pulled out

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

out slowly

• No Hold• There is no resistance what so ever when pulled between

occluding teeth.

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BUILT IN ERRORS!Thickness??Rotation?? Rocking??

Function & Failures

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• Closed Bite Trays (most common)

• Lack of rigidity may cause distortion

• Spring back after impression potential

• No cross arch stabilization

• Thin spots or perforations can cause distortion

• Impression material shrinks towards bulk

• Unable to recreate excursive movements

• Potential for errors & adjustments extremely high

Impression Trays

QUAD TRAY EXTREME (CLINICIAN’S CHOICE)& BITE REGISTRATION

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PEER REVIEWED

The Catapult Group rated the Quad-Tray Xtreme as better than, just as good, or tied with other available closed bite trays.

QUADRANT & DISPOSABLE ARTICULATORS

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Bite Registration & Occlusal IndexingTIP

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LITHIUM DISILLICATE (EMAX)

• Simple

• Fast

• In Occlusion

• Minimal or No Adjustment

CEMENTATION

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REASONS WHY OCCLUSION IS SO IMPORTANT

1. You are changing bite pressure by not having adequate occlusal pressure

2. You can cause more damage to other teeth from occlusal forces

3. You can cause tooth movement and shifting in the dentition due to pressure.

4. You can cause a jaw positional change that upsets the TMj.

Disposable Articulators

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Semi Adjustable

not on Hinge Axis

Semi Adjustable

not on Hinge Axis

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TRY-IN / NO ADJUSTMENTS…

• A few steps makes a big difference

• Patients notice the difference.

• Do you want to be like everyone else?

KEY TO ADJUSTMENTS

• Full Arch Impressions

• Facebow

• Bite Registration

• Semi Adjustable Articulator

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ASAP INDIRECT + POLISHERS(CLINICIAN’S CHOICE)

CERAMIC ADJUSTMENT

• Jiffy Ceramic Polishers (Ultradent)

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OCCLUSAL RECORD/BITE REGISTRATION

Fast Setting Rigid PVS

Or

Wax

MODEL ARTICULATION & EQUILIBRATION

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INCISAL PINS

Selection Process

◦ Open Bite Trays

Plastic-full or quadrant

Metal-full or quadrant

Custom Trays

Non-perforated or perforated (metal or plastic)

Rigidity can eliminate tray distortion and rebound

Spring back after impression is possible with plastic

Cross arch stabilization

Ideal occlusal stops for proper model articulation

Able to recreate excursive movements if mounted on a semi or fully adjustable articulator.

Potential for errors & adjustments are low

IMPRESSION TRAYS

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STOCK TRAY SIZES

Impression Trays

DIFFICULT FOR IDEAL FIT

Impression Trays

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IMPRESSION TRAYS

• Custom trays create more ideal placement

• Thinner material creates less distortion

• USE TRAY ADHESIVES for all open bite trays, not just custom trays.

• Only negative is time

Selection Process

Custom Tray

HEATWAVE TRAYS BY CLINICIAN’S CHOICE

• 4 upper & lower trays

• 60 sec. @ 158°F

• Fast, efficient

• Virtually custom

• 30% less impression material used

Impression TraysTIP

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Impression Trays

HeatWave by Clinician’s Choice

Impression Trays

HeatWave by Clinician’s Choice

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THERMO CLONE

TISSUE MANAGEMENT…

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Types of Moisture

Saliva

Crevicular Fluid

Bleeding

Fluid/Tissue Management

Superoxol Epinephrine

Ferric Sulfate

ViscoStat 20%

Astringent 15.5%

Aluminum Chloride Viscostat Clear 25%

Expa-syl

Hemostasyl

Aluminum Sulfate

Tissue Goo 25%

Various Cords

Enhancing Moisture Control


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Lasers (Diodes) Fast

Hemostasis

No crevicular fluid

No cord

Better healing

Enhancing Moisture Control


A soft tissue laser incision at 1000x magnification

Laser cut

Superficial coagulation

Heat dissipation with little/no edema

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Aesthetic Contouring

Aesthetic Contouring

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Time??

ROI??

Aesthetic Contouring & Provisional

Laser Tissue re-contouring, Provisional & Impression

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Gemini Dual Wavelength

Customize Teeth

Checking Occlusion is the Key to Aesthetics

Interferences

Case Example: #1A

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Checking Occlusion is the Key to Aesthetics

WHAT, WHY, HOW, APPLY

What is the perceived problem?

WHAT IS THE ACTUAL PROBLEM?

WHAT

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Can we find the true cause of the problem?

WHY

◼ Aesthetics

◼ Occlusion

◼ Excursives

◼ Restorations

◼ Wear

◼ Solutions

HOW DO WE FIX THE PROBLEM? What

options are available to fix the problem?

HOW

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APPLY

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Case Example: #1B

Case Example: #1C

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Case Example: #5

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Silginat - Kettenbach

Counter FIT- Clinician’s Choice

Status Blue - DMG

Alginate Alternatives

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Silginat - Kettenbach

Counter FIT- Clinician’s Choice

Status Blue - DMG

Alginate Alternatives

Wear Facets & Interferences

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Mounted and Equilibrated

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Custom Incisal Guide Table

GC Pattern Resin

Duralay

Sil-Tech (Ivoclar) -

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http://www.gcamerica.com/lab/products/PATTERN_RESIN_LS/

http://reliancedental.net/main_products

https://us.shop.ivoclarvivadent.com/en-us/shop/products/more-products/laboratory-silicone/laboratory-silicone-putty/sil-tech-plus-putty-1

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CLING 2 (CLINICIAN’S CHOICE)

• is a zinc-oxide non-eugenol, automix temporary cement with a unique polycarboxylate resin

• The addition of polycarboxylate optimizes adhesion, soothes the tooth, and provides an excellent seal, while allowing the material to be easily removed from the tooth preparations when desired.

30 second working time, 60-90 second set time

Good adhesion, easy removal

Low film thickness

Excellent marginal seal

Biocompatible – protects the gingival tissue

Resists forces of mastication

2 year shelf life

PROVISIONAL CEMENT• Utilize an accurate preliminary over impression

• Maintain over impression

• Check contacts and occlusion

• Place temp cement only on margins

•Do not fill temp with cement

•Or vent holes

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PROVISIONAL CEMENT

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CHANGE!

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

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

• Material properties must become more resilient to increased wear and

pressure demands.

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

jaw positioning, and/or adhesive techniques and materials.

• A different approach to typical Restorative Dentistry

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

Cosmetic Provisionals (Bead Line Technique)

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Scribe a 0.5mm-1mm groove into tissue & a little on tooth


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Provisionals-Visalys (Kettenbach)

-Inspire (Clinician’s Choice)

-Luxatemp Ultra (DMG)

-Pro V (Bisco)

-TempSmart (GC America)

-ExperTemp (Ultradent)


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No Polish Necessary if you use a good model


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Minimally Invasive Veneers…. Why? Benefits??

Waxup

Mockup

Preparation

Provisional

Bonding to Enamel

Material Options

Minimal Prep Case: 3

Beadline Provisional Mockup

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Cling 2 (Clinician’s Choice) for all my full crowns & bridges, retentive

inlays & onlays.

MY FAVORITE TEMPORARY CEMENTS

ClearTemp LC (Ultradent)

For either veneers or thin

anterior cosmetic restorations

Mockup

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Depth Cuts

Photos for Laboratory Technician

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Provisional Restorations

Final Restorations

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Provisionals Mimic The Final Restorations

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Bite Registration Demonstration Video w/ HandoutO-Bite:

PVS bite registrations

Strong material

Easy to cut

Good rigidity

Fast

LuxaBite:

BisAcryl material

Higher accuracy

More rigid

Use for bigger cases

POSTERIOR INTERFERENCE (PREMATURITY)• Centric Occlusion

• Natural growth patterns

• Orthodontics

• Dental work

• Trauma

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JOINT REPOSITIONED AND

STABILIZED (CRSTABILIZED)• Splint Therapy

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Example-Centric Occlusion

▪ Anteriorly positioned condyles

▪ Occlusion is not ideal Appears to have canine guidance

Weak centric stops and limited number

▪ Patient okay for a few months

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

Centric Relation

▪ Joint in proper position

▪ Occluding only on second molars

▪ Restorative dentistry & orthodontics (aligners too)

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Normal Disc Reducing Non-ReducingNormal

Remodeling DJDRemodeling

Adolescent

Facial GrowthDecreasedInterruptedNormal

Bones

Disc

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Aesthetic Opportunities:

Developing Beautiful Smiles

Case #24 (Complex Occlusion)

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TMJ Signs & Symptoms

• Wear facets

• Pot holes

• Abfractions

• Gingival recession

• Mobility

• Occlusal & Incisal wear

• Linea Alba

• Tongue scalloping (Crenations)

◼ Muscle hypertrophy◼ Muscle tension/tenderness◼ Muscle rigidity◼ Limited opening◼ Guarding on CR closure◼ TMJ noise◼ Head and Neck aches◼ Tooth sensitivity◼ Ear problems, ringing, buzzing,

fullness

Developing Beautiful Smiles

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

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Cause & Effect Diagnosis• Functional Wear on Anteriors

• Masticatory Muscle Pain

• Headaches

• Jaw Relationship / TMJ Disorder

• Obstructive Sleep Apnea (OSA)

• Combination

Aesthetics & Occlusion

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

AIRWAY VOLUME

-50mm2 and below have an association with OSA


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TMJ EVAL/Diagnosis

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


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Orthotic: Superior Repositioning Appliance (SRA)

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Lucia Jigs and Leaf Gauges

Nociceptive Trigeminal Inhibition Tension

Suppression System (NTI-tss)

Jaw Position

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Day One A Few Weeks

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NTI type appliances

Jaw Position

NITE BITE

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

discomfort

• Fast fabrication

• Force distribution

• Minimal opening

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SRA FABRICATION:Try-in

Check Bite

Adjust Posterior

Shallow Ramp

Trim Trough

Occlusal Reline

Passive Centric & Hold

Mark Depth of Fossa

Trim Excess

Polish


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

• Understands they will wear 24/7

• Patient comes back for evaluation every 2-4 weeks

• Passive reline to achieve equal contacts

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


Orthotic: Superior Repositioning Appliance (SRA)

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Occlusal Analysis


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Aesthetics & Occlusion Impression Trays

HEATWAVE BY CLINICIAN’S CHOICE

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The Nuts & Bolts of Veneers

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Simplified Provisionals


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• Verify shape

• Display at rest

• Protrusive

• Excursives

CEMENTATION OPTIONS• Glass Ionomers

• Resin Modified Glass Ionomers

• Self Etch Resin Cements

• Bonding Agent w/ Resin Cement

• Calcium Aluminate

• TriSilicate Cement


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

• Moisture Tolerant

• Self Sealing

• Apatite Formation

• Insoluble

• Stronger with time

• Semi / Translucent

• Biocompatibility-Excellent

• Bioactivity-Apatite formation

• Sealing Quality-Excellent



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Pre-op

Post-op


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Review Patient with Problems-Sleep Study Questionnaire-Sleep Study?-Cone Beam CT (CBCT)

-TMJ Diagnosis (Beamreaders.com)-Airway Evaluation

-Superior Repositioning Appliance (SRA)-Reline as needed.

-Hinge Axis-Diagnostic Model Workup-Discuss Options with Patient


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1.

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2.

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-Clean Tooth

-Try-in with water soluble try-in paste, not water.

-Clean & Decontaminate

3.

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4.

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- Light-cured luting cement designed for cementation of porcelain veneers.

- Color stability.

- Corresponding try-in pastes (sold separately)

- Choice 2 is specifically formulated for color stability (Delta E <1.2**) resulting in high esthetics

-Highly filled resin cement enhances the overall strength of the restoration

-Low film thickness ensures veneers are completely seated

-Corresponding try-in pastes confirm shade selection prior to cementation

-Choice 2 cement will not change (shade shift) over time, a problem that can occur with dual-cured systems

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All Steps are the SAME, Except we are using a Dual Cured Resin Cement where there is

decreased exposure from curing light because of ceramic material or thickness.

1) Implant screw retained #7

2) Bisco All Bond Universal Adhesive & Duo-Link Universal #6, 8 & 10

3) Bisco All Bond Universal Adhesive & Choice 2 Veneer Cement #9 & #11

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- Dual Cured

- Quick Clean Up

- High Conversion

- Low Film Thickness

- Radiopaque

- Available in Universal (A2) & Milky White shades

• What is the working time of DUO-LINK UNIVERSAL?

Minimum 2 min. (includes mixing)

• What adhesive can I use with DUO-LINK UNIVERSAL?

Can be used with any – we recommend All-Bond Universal. Some manufacturer's adhesives are

too acidic to properly bond to self -& dual-cured resins. ALL BISCO manufactured adhesives

are compatible with self- & dual-cured cements. If you are using an adhesive from a different

manufacturer, please refer to their instructions for compatibility.

• Do I need to pre-treat the surfaces of my indirect restorations?

Yes. Silane should be used to prime the surface of glass ceramics. Z-PRIME™ Plus should be

used to prime the surface of metals, composites, and zirconia.

• Can I use this for all indirect restorations?

Yes, however we recommend the use of a light-cured resin cement such as Choice™ 2 for

veneer cementation to ensure shade stability.

FAQs

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A Universally Simple, Universally Strong adhesive resin

cement specially formulated for cementation of ALL* indirect

restorations.

• Universal - for all cementation procedures*

• Formulated to allow for quick and easy removal of excess cement

• Easily identified on radiographs for quick and effective diagnosis

• High degree of conversion in both light- and self-cured modes

ensures a strong, long lasting restoration

• Easy to use auto-mix, dual-syringe provides a consistent mix for

immediate delivery

• Ideal for all chairside and lab-fabricated restorations

• Available in Universal (A2) & Milky White shades

0

5

10

15

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30

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Duo-LinkUniversalMultilink NX3 XTR

Sh

ear

Bo

nd

Str

en

gth

(M

Pa)

Light-Cure SE Self-Cure SE

* It is recommended to use BISCO’s CHOICE™ 2 for veneer cementation.

SBS Competitive Comparison

Data on file. BISCO, Inc.

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• Do I need to decontaminate my zirconia crown after try-in?Yes, if you hope to achieve optimal and reliable resin adhesive cementation results.

Removing contaminants from the restoration will help to achieve better bond strengths.

After try-in, clean the internal surface of the zirconia surface with ZirClean and then

proceed with applying a primer to the bonded surface of the restoration Z-PRIME Plus.

• Can I use ZirClean on porcelain/glass ceramics?Yes, ZirClean will also clean porcelain and glass ceramics, however, if you are HF

etching after try in, your HF etch will serve the same purpose as ZirClean.

FAQs

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• Significantly enhances bond strengths

to zirconia, alumina and metal substrates

due to its unique combination of two active

monomers, MDP, a phosphate monomer,

and BPDM, a carboxylate monomer*

• Compatible with light-cured and dual-cured

resin luting cements

• Convenient, single bottle delivery

FAQs• After dispensing, how much time do I have to use the Z-PRIME Plus?

Z-PRIME Plus is a light sensitive material. Use Z-PRIME Plus immediately once it is dispensed in

the mixing well or protect from ambient light.

• If I apply the Z-PRIME Plus when I receive the case from the lab, how long can I wait to cement the restoration?Z-PRIME Plus is effective for up to 6 months after application to the restoration. You may applyZ-PRIME Plus immediately after receipt from the laboratory.

• Do I need to shake Z-PRIME Plus prior to use?

There is no need to shake the bottle, as Z-PRIME Plus is always homogeneous.

• Do I apply Z-PRIME Plus before or after I try in the restoration?

We recommend after try in. 1. Try in, 2. Clean, 3. Rinse, 4. Z-PRIME Plus 5. Cement

If you apply Z-PRIME Plus first, there is no need to use ZirClean.

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Zirconia Cementation Protocol

1. Try in the restoration

2. Decontaminate with ZirClean

3. Rinse

4. Apply Z-PRIME Plus

1. Try in the restoration

2. Sandblast

3. ZirClean

4. Rinse

5. Apply Z-PRIME Plus

SANDBLASTED BY LAB SANDBLASTED BY CLINICIAN

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Zirconia Cementation

Protocol

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Lecture Handout

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

Link will be emailed to you, check your spam/junk folder.

Digital Handouts

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20% OFF!Dr. Todd Snyder: 20SNYDER

1-800-247-3368 • www.bisco.com

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• Reduce Your Stress & Build A Better Life

• Attract Better Patients that Pay

• Business & Communication Skills

• Marketing & Advertising that Crush IT!

• Work Less & Make More!

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• Dominate the Internet

• Cosmetic & Restorative Dentistry

• New Materials, Techniques, Technology & more..

• Learn what dentists do wrong 99% of the time and then be the 1% that don’t!!

Unconventional Trainingwww.Legion.Dentist

DR. TODD [email protected]

Questions?

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todd snyder, dds, faacd, fiadfe, asda

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