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BOSTON UNIVERSITY HANDOUT

HUGH FLAX DDS

ALL IMAGES AND CONTENT ARE COPYWRIGHTED

CONTEMPORARY COSMETIC DENTISTRYPREDICTABLE PRINCIPLES THAT “FACILITATE

AND REPLICATE” THE SMILES OF OUR PATIENTS

BY HUGH FLAX DDS, AAACD, MICOIATLANTA, GA

Henry M. Goldman School of Dental Medicine

FOR HANDOUT GO TO www.HughFlax.com

Catapult Group is an organization which consists of top clinicians and educators from throughout the United States and Canada. This group of like-minded yet diverse dentist’s goal is to bring quality education to the dental community via multiple venues including; live lecture, participation, web based, and written formats.

SUMMARYContemporary Cosmetic Dentistry-- Predictable Principles that “Facilitate and Replicate” the Smiles of our Patients • Cosmetic dentistry is no longer a novelty as it was in the 1980’s……it is serious business. Patient

expectations are growing so that you must learn to master the art and science not only in the front but the back of the mouth. Fortunately advancements in technology and materials have allowed dentists and their teams to be on the same page with the patient, lab, and specialist that help you create extra-ordinary results that are predictable and profitable for the practice and often affordable for patients.

Learning Objectives:

• 1 .Learn critical factors in smile design that help you create beauty and” keep it real”

• 2. See how veneer cases can be easy to do by always doing 4 critical steps

• 3. Discover how laser technology can make your cases esthetically beautiful, biologically healthy that promote healing and improve your bottom line –even 2 months faster in complex cases.

• 4. Find out how having the ability to efficiently and effectively design smiles with composite is not a “lost art’ using minimally invasive preparation design and properly layering composite resin with simple layering of opacity, translucency and color to achieve the beautiful and believable results.

• 5. Learn updated techniques in posterior composites that are minimally invasive.

Hugh Flax DDS, AAACD MICOIAtlanta ,GAFlax DentalMember of Catapult Grouph.flax@FlaxDental.com

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DISCLAIMER

• As a Catapult Group member we participate in multiple product reviews each year in order to stay at the fore front of the latest materials, techniques and services available, ensuring that the message we are delivering is current and relevant to today’s continuing education needs.

• Some of these products & services I will be sharing with you today.

• Today I am supported in part by:• Shofu• AMD• SDI• Lending Club• Kettenbach• Microcopy• Solution Reach• Contact EZ

DISCLOSURES

• Huge proponent of “Responsible Esthetics”

• Leading edge vs. Bleeding Edge

• Products that I mention I use all the time and like to share what is working for me (companies that are sponsoring or contributing products for this presentation only for that reason)

• Learning-sharing new and reinforcing “time-tested” knowledge and learning from each other

USA TODAY STUDY (1997) OF ATTRACTIVENESS AND SELF ESTEEM

WHAT WOULD YOU CHANGE ABOUT YOUR PHYSICAL APPEARANCE ?

• Weight

• Height

• Face

• Hair

IF YOU COULD CHANGE ANYTHING IN YOUR FACE WHAT WOULD IT BE ?

• Nose

• Eyes

• Teeth

• Chin

• Lips

• Head shape

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ABC-TV’S“EXTREME MAKEOVER” SHOW !

DIVERSITY IN CULTURE AND EXPECTATIONS

TODAY’S CHALLENGES OF ESTHETIC DENTISTRY

• ESTHETICS

• BIOLOGY

• FUNCTION

• ECONOMICS1. Expectations of patients2. Chairtime3. Minimally invasive4. Affordability5. Durability/ Reparability

TIME FOR CHANGE• Diversity of people and choices in treatment• How we build value for people and meet expectations

• The speed and volume of providing information and care

• How to fit someone’s budget-time and financial• How we perform dentistry

EXTREMECUSTOMIZATION

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EXTREME CUSTOMIZATION

• LEVERAGING TIME

• INNOVATING

• BE CREATIVE

JIM ROHN

STONE TOOLS COMPUTER MOUSE

“Innovation distinguishes between a leader

and a follower.” Steve Jobs

http://www.ted.com/talks/lang/en/matt_ridley_when_ideas_have_sex.html

You need to understand how human beings bring

together their brains and enable their ideas to combine and recombine, to

meet and, indeed, to mate. In other words, you need to

understand how ideas have sex.”

CREATIVITY

"Don't think. Thinking is the

enemy of creativity. It's self-

conscious, and anything self-

conscious is lousy. You can't try to

do things. You simply must do

things."

ESTHETICS

FUNCTION

PERIODONTAL

SUPPORT and CONTOURS

BIOMECHANICS

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INTERDISCIPLINARY CARE

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

ORTHO LABPERIO

ENVISION THE SMILE

“Begin with the end in mind”Stephen Covey

WHAT IS ESTHETICS ?The science of beauty in nature as

an art

“Beauty is the association of many complex associations”

Charles Darwin

FACIAL EVALUATION

In repose

Middle 1/3 =Lower 1/3

Maxillary lip length : YAF 20-22 mm

YAM 22-24 mm

MIDLINE

MATCH THE MIDLINE OF THE FOREHEAD (NOSE ?)

INCISIVE PAPILLA

INCISAL and INTERPUPILLARY PLANES

Parallel to each other

Skeletal defect ? Ears?

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SMILE FRAME

The “Broadway Play”

Proportions

Symmetry

LIPS

Form

Fullness

Competence

Symmetry

Position (repose/smile)

Affect of upper incisors (length/inclination)

SMILE LINE

Plane of incisal edges

Lower lip curve

Convex-youthful

Concave-indicates disharmony esthetically (“curb appeal") and functionally (“under the hood”)

GINGIVAL SYMMETRY/CONTOUR

No excessive display

Centrals match each other

and canines

Laterals?

Edentulous

spaces ?

AXIAL INCLINATION

Long axis of teeth

Harmony-occlusally

visually

Tipping

Profile

/gingival shaping

PROFILE

Contour of facial surfaces Parallelism with adjacent

structuresEstheticsFunction

Incisors ? Canines ? Lab communication

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BUCCAL CORRIDOR

What is it ?

Factors ?

Arch width

Muscles of cheeks

Soft tissue contour

Posterior teeth

EMBRASURE SPACES/OUTLINE FORM

3 Dimensional (incisal/gingival)

Characterization

Transition

Dozens of combinations

Communication tool—several resources

-- Smile Guide (Discus)

-- Imaging systems

Image FX now called

Patient Gallery http://www.patientgallery.com )

GPS 3D Design http://dentalgps.com/gps-store/gps-software/

COLOR

3-D multi-chromicity

Translucency- degree?

color?

clarity?

“Halo”

How to communicate it

Resources: Analysis (Ubassey)

Voyage (Sieber)

Ceramic Works (Aoshima)

TEXTURE

Ultimate in

“microanatomy”

Age factors

Communicate with the patient and lab

PROPORTION / GENDERIZING

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

DENTO-FACIAL EVALUATION

Esthetically pleasing?

Tooth display?

Incisal edge position?

Gingival level?

Proportional width?

Maxillary lip position?

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RULECreate Reference Points

1.Display2.Length: At least 10 mm3.Width: At least 7.5 mm4.Midline: Must be vertical5.Lateral incisor: 2 mm rule6.Canine: 1 mm rule

PLAN1.Incisal length2.Gingival level3.Implant level

PLAN1.Mock Incisal and/ or Only

2.Full waxup (function)3.Test Final Mock

ESTHETIC FACTORS

• Midline• Facial thirds are ideally equal• Interpupillary line• Maxillary Tooth Position

1) Labial-support maxillary lip and balance of face2) Vertical canine position in repose—level with the lip (Misch/

Kois)3) Centrals-1-2 mm below the horizontal line drawn from canine to

canine4) Canine tip in line with ala of the nose5) Posterior occlusal plane meets labial angle forming a 90 degree

angle

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GIVE ‘EM WHAT THEY WANT !!!

“Do what you do so well that people can’t resist telling others about you”

Walt Disney

COMMUNICATE VISUALLY ANYTHING TO ANYONE ,AT ANYTIME !

JCD WINTER 2015

WHY NOW?????????

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

WHY NOW???

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COURTESY CHRISTIAN COACHMAN

BOTTOM LINE

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ANALYTICAL EMOTIONAL

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Pink Esthetics WAYS TO MANAGE PINK

TRADITIONAL• ELECTROSURGERY• SCALPEL REDUCTION• OPEN FLAP CROWN

LENGTHENING• FREE GRAFTING• CONNECTIVE TISSUE

GRAFTS

INNOVATIVE• LASER REDUCTION• CLOSED FLAP GUM LIFT• TUNNEL GRAFTING

(Allen;Salama;Mahm; VISTA;Pin Hole)

• PEDICLE GRAFT• ADD WITH PINK RESTORATIVE

Macro-multiple teeth/ large areasMicro-1-2 teeth / small areas

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BIOMECHANICAL RISK ?

http://www.highlandmetals.com

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Axial—KS0; KS1 and KS1L coarseFine flame shaped

Lingual- Egg or pear shaped (coarse/ fine)

Final polish –rubber point

SMOOTH ROUND PREPARATIONS

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

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IT’S NOT ABOUT THE PAINT ! ! !

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

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DATA ACQUISITION ACCURATE

CALIBRATED

SYSTEMATIC

TREATMENT PLANNING FUNDAMENTALS OF DENTISTRY

• Biomechanics

• Periodontal support

• Occlusal/ Function

• Habits

• Medical management

• Esthetics

STRATEGY FOR “WIN WIN SUCCESS”

CODISCOVERY—at EVERY visit

1. Build understanding

2. Verify and validate

3. Create vision AND Manage expectations

BLUEPRINT OF CONCEPTS

“TEST DRIVE”

GO FOR THE WIN !!!

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MED HX

DENTAL HX

DOCUMENTATION

Review forms/Interview

Digital photos (AACD; DSD)

Digital radiographs

Periodontal exam

Occlusal exam

Oral cancer exam

Caries / Cracks

DIFFERENT CAMERAS FOR DIFFERENT NEEDS & DESIRES

• SLR

• I PHONE smilelineusa.com Smile Lite & Smile Capture Full Set - #6500/6550-SET

Adaptor for better focus/ zoom

5000K Light and Polarizing filter for depth/reflection

• EYE SPECIAL II

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UNIQUE FEATURESEYESPECIAL C-II

• Designed for dentistry• 8 pre-set shooting modes• Dental grid lines & spot focus • Water and chemical resistant – Essential

for infection control • Durable rugged Exterior

• User Friendly• Fast autofocusing & anti-shake

capabilities• Easy to use – no photography skills

required• Light weight/can be held with one hand –

weighs only 1lb

• Special Benefits• Compatible with the Eye-Fi X2 card –

Immediately upload images onto PC, iPad, Tablet or Smartphone

• SureFile Photo management software –Keeps record of patient information

8 DENTAL SHOOTING MODESFOR EYESPECIAL C-II

Standard Mode – For standard intraoral photography.

Surgery Mode – For intraoral photography from a certain distance.

Mirror Mode – For intraoral photography using a mirror; the image taken can be reversed.

Face Mode – For shooting facial views or half-body portraits.

Low-Glare Mode – For Photographing details of anterior teeth; working models and indirect restorations

Whitening Mode – For shade comparison between before and after whitening.

Tele-Macro Mode – For photographing anterior teeth, indirect restorations and working models in higher magnification. **Attach the close-up lens when taking pictures in this mode**

Isolate Shade Mode – You can isolate the shade for optimal shade matching.

STANDARD MODEFOR STANDARD INTRAORAL PHOTOGRAPHY

Everyday dental photography – The mode that will get used most

• Ideal distance 9.4 in

• Patient will be sitting up in chair or standing

• Will likely have cheek retractors in place

• Can be taken with normal operatory lighting

ISOLATE SHADE MODEYOU CAN ISOLATE THE SHADE FOR OPTIMAL SHADE MATCHING

• Gingival shades removed

• Improves visual acuity

• Excellent case selling tool

• Ideal distance 5.5 in

• Patient may have cheek retractors in place – could be used on a model at the bench in a laboratory

CASE ACCEPTANCE

Collaborative with DSD system

(Interconsultation and Emotional Dentistry)

Matter of fact presentation of:

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

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

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

Broad stroke description of a “progressive plan”

Technical Q & A (with Doc)

Plan the “first step”

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GENERALIZED WEAR CASE

WHEN A LASER IS USEFUL

ESTHETIC RISK?

UNSTABLE CHEWING ENVELOPES/ OCCLUSIONS

Kois Continuum #8

What pattern of wear?

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BIOMECHANICAL?BONE LEVELS?

KOIS CONTINUUM #8

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Futar® D Fast - Twice as fast

Rigid Shore-D hardness of 43

Dispensed with very little effort, saving time

Thixotropic and easy to remove

Total Set Time: 1 Min.

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Futar® Fast - The comfortable classic

• Shore-A hardness of 90

• Thixotropic and easy to remove

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

• Total Set Time: 1 Min.

Hydrophilicity: clinical aspect

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WHAT ARE MY BEST COHESIVE CEMENT CHOICES?

Dual Cure Resin

GC LinkACE

3M Relyx Unicem

Bisco Duo-cement

Ivoclar Multi-link

Bio-enhancing

Glass ionomer—Fujicem 2

Bioceramic--Ceramir

“Universal” Adhesive

Definition

•Usable for Direct & Indirect (Film Thickness <10 um)

•No additional resin layer required (1-Layer Adhesive)

•Compatible with D/C, S/C resin cement/composite without DC

Activator

•Usable with TE, SE & Select-Etch

Not Sensitive to Dentin Moisture Level

Shear bond strength on dentin with different moisture level, MPa

Adhesive Technique Desiccated Dentin Moist Dentin* Over wet Dentin

All-Bond

Universal

Total-Etch 26.9 (7.1) 33.2(7.8) 48.1 (7.8)

Self-Etch 28.4 (3.0) 31.0 (3.0) 34.2 (7.6)

•Recommended procedure by IFU.

Desiccated: strong air dry 10 sec; Overwet: a pool of water on surface.

DRY WET

Dry or wet? It doesn’t matter!

Lithium DisilicateZirconia

Shear Bond Strength to Indirect Substrates using Duo-Link

(Self-Cured Mode), MPa SUMMARY of ALL-BOND UNIVERSAL:

the ONLY TRULY UNIVERSAL one-bottle dental adhesive

bonds to all dental substrates (Directs and Indirects)

can be used with Self-Etch, Total-etch or Selective-Etch techniques

hydrophilic (good wetting) before curing… after curing, it is more

hydrophobic (non-permeable & durable) than other adhesives

long-lasting (durable) bond strength

doesn’t need additional resin/adhesive layer

bonds to dentin regardless of moisture level (over-wet, moist or dry)

compatible w/ S/C and D/C resin materials without additional activator

doesn’t need refrigeration

the solvent is easily evaporated (no water residue)

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SEQUENCE: 8,9, 7,10Cuspid bicuspids each side

APPLY 2 coats thoroughly15 sec per coatDRY lightly to remove excess

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LIGHT CURE –10 seconds per tooth

Ceramir Crown & Bridge Ceramir C&B is a material that combines glass ionomer technology with the

innovative Ceramir (Calcium Aluminate – CA) technology.

The GI contributes to: Low initial pH, short duration

Flow and Setting characteristics Early strength

The CA contributes to: Increased strength and retention

Biocompatibility Sealing of tooth material interface Apatite formation Sustained long term properties, no degradation Basic end pH

RetentionValues equal to self-adhesive resins

Metal

Cement Retention (gold crown) (kg/f)

Ceramir Crown & Bridge 38.6 ± 8.5

RelyX Unicem 39.8 ± 15.3

MaxCem (Kerr) 15.9 ± 9.3

Ketac Cem 26.6 ± 4.4

ZinkPhospate 13.9 ± 4.5

0

5

10

15

20

25

30

35

40

45

Ceramir Crown &

Bridge

RelyX Unicem MaxCem (Kerr) Ketac Cem ZinkPhospate

Retention (gold crown) kg/force

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FMR PREVENTIVE MEDICINEGET TIME/FORCE OCCLUSAL INFORMATION WITHOUT RELYING ON SURFACE “PAPER MARKS” OR PATIENT/DOCTOR PERCEPTIONS

USE THE T-SCANBETTER TIMING & BALANCE

LESS WEAR/FRACTURESBETTER COMMUNICATION/DOCUMENTATION

SALAMA, COACHMAN, GARBER, CALAMITA,ET ALInt. Journ of Perio and Restorative Dentistry Vol 29 No 6 2009; 573-581

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

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USING TRANSITIONAL BONDING FOR INTERDISCIPLINARY CARE

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• Highly filled and durable for fracture resistance in thin areas

• The fillers are coated with a silane coupler that allows for predictable bonding to substrate (which is already enhanced by the Composite Primer)

HOW TO BOND GRADIA GUM

GC Ceramic Primer is used to bond Gradia Gum to Ceramic.

GC Composite Primer is used to bond Gradia Gum to Composite/Acrylic.

GC Metal Primer ll is used to bond Gradia Gum to Metal.

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CADDY WOMPUS JOURNEY

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BOTTOM LINE:1) No implants over 4.3 mm in the anterior zone

2) Lingualize the implant placement3) Fill the gap with 50/ 50 mix DMFB/ cortical bone4) Consider a connective tissue graft

OPTIONS:1) Do nothing

2) Remove implant (s)3) Augment the tissue and restore (single? splinted?)

and add pink

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MICROGINGIVAL PORCELAIN ENHANCEMENTS• Create a “palette” of colors/ blendsMockup

• Sandblast with Prepstart (27 micron AlO2)

• Porcelain etch with Ultradent HF (60 sec) and rinse thoroughly

• Silane (airdry for 1 min)

• GC Composite or Ceramic Primer-cure for 1 min

• Place restoration in the mouth

• Apply composite and blend

• Polish and/or glaze

WHY NOW?

• Desire to go digital with impressions—lots of choices; wanted the complete pkg.

• Confluence of more user friendliness (impressions/ design/ milling) and better material choices (esthetics; seal; strength; bonding mediums)

• CEREC-30 years experience and Sirona’s desire for “CAD/ CAM for everyone”

• Expand the breadth of options for our patients

Restorative (crowns; partial crowns; and inlays)…..YOU CAN BE CONSERVATIVE

Implant surgery and restoration ( crown down approach)

Ortho impressions ( Clear Correct; Invisalign 6/15)

Digital waxups and integration with DSD

• It’s FUN and DELEGATABLE

• Create a WOW experience-One Visit/ One Shot/ No temp

Saves time and increased case acceptance

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• EXCEPTIONAL STRENGTH FOR MULTIPLE SITUATIONS

• EXCELLENT AESTHETICS• FASTER MILLING TIME• REPAIRABLE IF NEEDED• EASIEST MATERIAL TO FINISH.

Finishing & polishing

1. Grind off the connector

2. Use medium silicone point

3. Use fine silicone point

4. Use diamond paste such as GRADIA DIAPOLISHER Paste for high

gloss

Treat with hydrofluoric acid (5%) for 60 seconds or Phosphoric acid (35-37%) can be also used for the purpose of cleaning the surface, preferably scrubbing with a microbrush for 10-15 seconds.

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Repair of Cerasmart restorations

248

1. Roughen

Slightly roughen the bonding area (restoration and exposed tooth structure) using a coarse diamond point or carbide bur

2. Silane the restoration

Apply silane coupling agent on the restoration such as Ceramic Primer

II and gently dry.

If other primer is used, followed the manufacturer’s instruction

GC G-ænial Universal Flo is recommended in order to repair the surface of Cerasmart restorations since it is based on the same technology.

4. Apply the composite

Apply the chosen restorative material and light-cure it

according to the manufacturer's instructions.

Apply a bonding agent such as G-aenial Bond on the

exposed tooth tissue, dry and light-cure following

manufacturer’s instructions

3. Bond the exposed tooth

OUR FIRST CERASMART

GC IFU

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Shake the bottle

Dispense

Apply a thin layer with a

brush

Do not air blow

Cure light-curing device

having a wavelength in

the range of 400-430 nm

for 40 sec (exceptions

Kerr Demi Ultra and 3M

Elipar 10 S)

Selective etch15/10/10

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THE BU$INESS OF MAKING YOUR PRACTICE PROFITABLE

You GotA Problem

With That ??

Your patients

can confirm

by email and by text!

Recare Reminders bring your

patients back to You!

$605,462.00 from past

Appointments

Newsletters

keep your Brand

in front of your Patients!

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for watching an online demonstration of the

Text “FLAX” to

801.201.6357

to receive a

$25 American Express

gift cardfor watching an online demonstration of the SOLUTIONREACH Platform

RECURRENT DECAY/ CRACKS PRESENT

DOCUMENTATION

DENTAL BENEFITS• Better more natural smiles—conservative (preserve enamel)

3 R’s—Relocate Replace Restore

• Prevention---better fitting bite (peaks; valleys; side of the hill) decrease stress; cracks; and wear

• Improved gum health due to less crowding

• Avoid unnecessary treatment and unneeded expense

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p (360) 694-1000f (360) 694-6191

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The ContacEZ IPR Strip System is an innovative interproximal reduction system that makes IPR safer and more accurate without creating sharp corners. Designed for use with Invisalign®, ClearCorrect™, eCligner, Inman Aligner™, and other clear aligner treatment systems, these strips curve and flex along the natural contours of the teeth to prevent soft tissue irritation, avoid cutting excessive enamel, and maximize patient comfort.

• Single-handed design offers optimal tactile control.

• Will not cut lips or gums and eliminates gagging.

• Flexible strip will contour the curvature of the tooth without creating subgingival ledges or sharp corners.

• Reduce binding and prevent residual crowding.

• Easy access to tight anterior or posterior areas.

• Autoclavable up to 280° (steam heat only, not dry heat), and multi-usable.

PASS ALL CONTACEZ STRIPS BACK AND FORTH BUCCOLINGUALLY ONLY

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p (360) 694-1000f (360) 694-6191

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IPR Strip System

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0.12mm│Double-Sided│Medium Diamond

0.15mm│Double-Sided│Coarse Diamond

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p (360) 694-1000f (360) 694-6191

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Double-Sided Optional StripsReduce enamel on two adjacent teeth.

Purple IPR Super-Widener0.25mm│Coarse Diamond

Brown IPR Mega-Widener0.30mm│Coarse Diamond

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p (360) 694-1000f (360) 694-6191

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CleanAfter cementation, remove excess cement with an explorer. Pass a ContacEZ

Serrated Strip buccolingually in the interproximal spaces to cut and clean out any remaining excess cement.

White Serrated StripGentle Saw

0.35mm│Serrated

Blue Serrated StripHeavy-Duty Dental Saw

0.065mm│Serrated

Safely remove cement from multiple restorations without disturbing placement prior to light curing.

Cut into massive excess cement, and separate fused contacts of multiple veneers after light curing.

HEAL

IT

NeoDiamond is America's highest-rated, #1 selling diamond bur.

• 20% more diamond cutting surface for a faster cut with less chair time.

• NeoDiamond is individually packaged, sterilized,

and color-coded with Quick Grit ID for safety and convenience.

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TEXT

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More patient-friendly financing helps increase case acceptance:

• More Payment Plans: True No-Interest Plans* provide patient-friendly options.

• More Flexibility: Fixed APR based on term selected and applicant’s credit score.

• More Approvals: Credit policy expansion approves more patients.

So we can treat MORE patients.

More patient-friendly financing helps

increase case acceptance

MORE Flexibility: Terms up to 84

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MORE Cases Accepted: Patients are

nearly 12% more likely to move forward

with treatment at APRs lower than

14.99%*

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fees or prepayment penalties

So we can treat MORE patients

MORE payment plansTrue No-Interest Plans*

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•Fixed APR starting at 3.99% based on term selected and applicant’s credit; $5 late fee versus a default rate.

•Financing up to $50k; great for large cases.

•Terms to 84 months; payments better able to meet applicant’s budget.

MORE of what you wantWhite glove customer service

• A live Customer Care representative answers each call, giving our patients and us the attention we deserve.

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Independent Solo Dentists

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SmileSource.comSHADE MATCHING

CHALLENGES IN SHADE MATCHING• Lighting

• Metamerism—two objects appearing to match in one situation and not matching in others (office vs. home)

• Contrast Effects—visual phenomena that alter perceptions of color (skin tone; background –use blue/gray; large vs small teeth; crowding; successive shades)

• Reflections on surfaces

• Experience and knowledge

• Eyes

• Subjectivity of dental team and patient

• “Hit man vs. The Healer”

CREATING A WORLD DENTAL SHADE STANDARD

1927

1956

1940

1950’s

1983

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ADVANCING DEVELOPMENTS

1983

2003

1998

Dr.Hall

(Drs.Jung)

Dr.Saddon

2010

1998

Dr.Paravina

MOST SHADE MATCHING TODAY…

TECHNOLOGY FROM THE 1950’S WHAT ARE YOU USING?

The color of the tooth REALITY OF SHADE MATCHING TODAY

Courtesy of Dr. R. Nash

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51

SHADE SELECTION; IT’S A PROBLEM…

• Doctors are matching shades by looking at the whole tooth or incisal areas.

• Doctors are mainly buying and using the enamel shades in current composite systems.

• In a recent study 86% of dentists couldn’t agree on a shade.

• A recent SCAD poster showed that three leading composite brands didn’t match the intended Vita shade, for numerous shades.

Healthy Tooth

Decalcification and

decalcification are

equilibrium

Caries occurs

Resin filling Bo

nd

ing

ag

en

t

Direct Restoration

Secondary Caries

Pulpectomy

Crown treatment

Build up core

Crow

nCement

Bo

rde

r cari

es R

oo

t bre

ak

ag

e

Extraction

BIOLOGY

TOOTH SUBSTRATE MANAGEMENTENAMEL VS DENTIN

FUNCTIONAL RELIABILITY FOR COMPOSITES

FUNCTIONAL RELIABILITY FOR COMPOSITES

STRENGTH and FLEXIBILIBILITY UNDER MULTIPLE FORCE LOADS and VECTORS

• EFFECTS of POLYMERIZATION

1. Volumetric shrinkage

2. Shrinkage stress

• FLEXURAL MODULUS—the higher the more brittle

• COMPRESSIVE STRENGTH

• RADIO-OPACITY

Polymerisation Shrinkage Stress

0

1

2

3

4

5

6

Aura

Dentin

SonicFill Kalore Xtra Fil Surefil

SDR

Quixx Venus

Bulk Fill

Tetric

Evo

Ceram

Bulk Fill

Rok Ice Glacier

Po

lym

eri

sati

on

Sh

rin

kag

e S

tress

(MP

a)

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52

COMPRESSIVE STRENGTH

Radiopacity

(mm Al)

0

0.8

1.6

2.4

3.2

4

4.8

A ura F ilt ek Sup reme

X T E

Est het X HD Herculit e U lt ra Kalo re T PH3

Rad

iop

acit

y (

mm

Al)

IN THE END, IT’S ALL ABOUT THE LOOKS

Patients judge their dentists by how their restoration looks!

HUE , CHROMA & VALUE

Hue - Basic color of a tooth e.g red, blue or yellow

Chroma – Intensity of the color (hue)

Value – Lightness or darkness of the color(hue)

Opacity – ability for light to pass, translucency

Aura’s shading system• Based on natural make-up and colors of enamels

and dentin

• Linear, logical and scientific arrangement for

predictability and customizing shades

• Simple layering technique to reproduce the natural colours of teeth

• Designed to simplify shade matching for busy clinicians; minimal effort.

• Shade matching in ten seconds is recommended,

then the clock starts ticking when the patient entering the chair.

SHADE SELECTION METHOD

1. Choosing the dentin

shade

2. Choose the enamel

shade

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COLORIMETRIC PROPERTIES OF AURA DENTIN CHROMA RANGE

• Single opacity

• Single hue

• Large chroma scale, aka color intensity, (Db,DC1 – DC7) is equally spaced

• Fluorescence

Aura has a linear and scientific arrangement for

predictability and customizing shades

AURA’S FEATURESS

• Non-sticky – less uncured resin is used, creamy handling

• Easy to polish to mirror finish

• Large particles (60 microns) = high filler loading & strength

• Low flexural modulus (big bonus); better fracture resistance, less stress at composite interface means less debonding

• Lower polymerization shrinkage

Shade selection for layering technique

• Shade selection must be carried out

before isolation, ideally under day light using Aura shade guide provided

• Do not dry the teeth

• Start with Dentin shade/ bodyEnamel

• Aura’s shade guide is made from actual

Aura’s pastes.

• No shade change from pre-cured state to

cured state

Enamel shadesBased on different colours of natural enamels:

E1: most whitish/lightest, high opalescence with

some degree of translucency. Designed to emulate young enamel. Age under 20

E2: neutral in colour, less opalescence with intermediate translucency. Designed to replace adult enamel. Age 20-60

E3: tinge of yellow, high translucency & is suitable for aged enamel. Age 60 plus

FEATURES OF E1 – E3 SHADES

• Prepolymerized microfilled composite – market advantage, stronger than a standard microfill.

• Easy to polish to high gloss

• Contains opalescence (bluish glow in natural light) to match natural enamels, gives life to restoration

• Superb gloss retention without the “plucking effect” of large particles

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54

• College student (about to begin nursing school) very unhappy with her post orthodontic results

• Discolored teeth-white spots and yellowed composites

• Prominent upper left canine

• Inconsistent shapes and papilla

• Worn edges of teeth

Muscle tenderness and sense of not having a consistent bite, prominent canine, slight fremitus of #6-11, and general tooth wear were indicative of occlusal dysfunction

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

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

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

Surface discolorations and previous composites conservatively removed with a flame shaped diamond maintaining the outer enamel and creating room for forthcoming layer of Aura.

• Suspicious decalcifications checked with cavity detection dye

• All remaining “affected” enamel removed with the Erbium or new CO2 laser

Set at 27 micron AlO2 and 40 psi

Consepsis(Ultradent) thoroughly irrigated

over microabradedareas to disinfect surface

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37% phosphoric acid was placed over the

entire labial surface with a 30 second exposure time (since

no dentin was involved) and thoroughly rinsed

with water for 15 seconds each

A universal bonding resin was placed carefully placed using a

microbrush and thinned with an Adec warm air dryer

Each tooth being treated was cured for 20 seconds using SDI’s

Radii Plus light with its wide tip.

Aura Enamel (Shade E1) was thinly applied and sculpted using

Cosmedent’s Titanium IPCT Instrument placing the gingival half first blending the interproximal. After a 40 second cure, the incisal portion is

adapted to the tooth using the anatomy of the incisal edge and adjacent anatomy to guide initial contouring.

CURING TIMES

Actually 10mm+

Gross finishing is achieved with a thin 16 bladed ET 9

bur to clean the gingival margins and establish labial anatomy.

Interproximal surfaces were smoothed with

plastic finishing strips

Labial surfaces were polished using a series of

abrasive disks

Final gloss achieved using a flexible felt disc

and aluminum oxide paste

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58

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59

PUTTING IT ALL TOGETHER

MARK YOUR PATH

LASE

IT !HEAL

IT

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60

VERIFY

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61

CONCLUSIONS

• Smile design and composites are a great entry point for patients who want smile “makeovers”—use the right tools (photos; DSD; and bonding materials) to create artistic success and “good business”

• Utilizing minimally invasive preparation design like lasers; air abrasion; and bevels will help to preserve tooth structure and blend composites to look more lifelike

• Properly layering composite resin with color friendly materials like Aura helps achieve the beautiful and believable results

ANY QUESTIONS ????

Thank

You

CONTACT INFORMATION

HUGH FLAX,DDS(404) 255-9080

Email: h.flax@FlaxDental.comFor lecture info

on cosmetic dentistry, implants and lasers

http://www.catapultelite.com/flax.php

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62

Laser History and Physics

1916

Einstein took Bohrs theory

of Spontaneous emission

and came up with the

stimulated emission theory

that would be the basis of

laser technology.

LASER is an acronym for :

L = Light

A = Amplification by the

S = Stimulated

E = Emission of

R = Radiation

Spectrum of Medical Lasers

110000 nnmm 440000 nnmm 775500 nnmm UUllttrraavviioolleett VViissiibbllee IInnffrraarreedd

HHeeNNee ((663322nnmm))

KKTTPP ((553322nnmm))

AArrggoonn ((551144 nnmm))

DDiiooddee 881122nnmm

DDiiooddee ((998800nnmm))

NNdd:: YYAAGG

((11,,0066 µµmm))

EErrCCrr::YYSSGGGG 22..7788 µµmm

EErr::YYAAGG (( 22..9944µµmm))

1100,,000000 nnmm

XXeeFF((335511 nnmm)) EExxcciimmeerr

XXeeCCll ((330088 nnmm))

KKrrFF ((224488nnmm))

AArrFF ((119933nnmm)) RRuubbyy ((669944nnmm)) HHoo:: YYAAGG

((22,,0088 µµmm))

--rraayyss xx--rraayyss UUVV vviissiibbllee IIRR mmiiccrroowwaavveess rraaddiioo wwaavveess aaccoouussttiicc wwaavveess

AArrggoonn ((448888 nnmm))

1100--1122

1100--99

1100--66

1100--33

11 110033 wwaavveelleennggtthh,, mmeetteerrss

CCOO22 ((99..66 oorr 1100..66mm))

Absorption

Scatter

Transmission(Refraction)

Reflection

Laser-Tissue Interaction

Laser SpectrumFOCUS ON THE TARGET What happens when tissue absorbs laser

energy? Ablation, vaporization and cutting

CellLaser energy

• Laser Light is absorbed by TARGET TISSUE and turned into heat that cuts tissue.

• The PRIMARY action of a laser is absorption in chromophores it is attracted to (e.g. melanin, hemoglobin, water, HA)

• The photothermal reaction of absorption produces a temperature rise in the target tissue until it vaporizes – and incision/excision occurs

• All dental lasers are PHOTO THERMAL.

The cell expands until it vaporizes

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Zone of Necrosis -tissue is irreversibly damaged and will

die

Zone of coagulation - most of the tissue will recover and return

to normal

Vaporized

Area

Tissue effects caused by thermal exposure Doctor’s advantages when using a laser

1. Less Hemorrhage to control

2. Less Pain - Reduced need for prescription drugs for pain

3. Less need for post operative bandages…lymphatic help seal

4. Less need for local anesthesia….saves time for many procedures

5. Patients appreciate the technology and will pay more

6. Fewer post-op complications …..reduced microbial colonization.

Cosmetic Restorative Clinical Applications

Soft Tissue Procedures

•Gingival Recontouring

•Gingivectomy

•Frenectomy

•Troughing

•Fibroma Removal

•Hemostasis

Possible Soft Tissue Dental Lasers

CO2 Er:YAGEr,Cr:YSG

G

Nd:YAG Diodes

• Soft tissue (hard as well with Solea

• Gas-based• Used for surgery

• Hard tissue• Erbium crystal• Hard tissue cutting• Cavity preps• Very expensive

($80K+)

• Soft Tissue• Neodymium crystal• Perio / LANAP• Soft tissue• Very expensive

($100K)

• Soft Tissue • Semiconductor diode• Excellent for soft tissue• Affordable 3k-5k• Portable• Easy to use• Low Maintenance

AMD LASER

Laser Gingival Troughing

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

Advantages of using a laser vs. packing cord

Eliminating packing cord – time saver

Fast and easy perfect impressions

Little to no post-operative pain and discomfort

Initial Trough Impression Provisionals

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Laser Gingival Troughing

Continuous wave .8 W (anesth)/ 1.6 W pulsed (topical)

Initiate fiberDrag/ Angled toward tooth in

short segments slightly into sulcus (90 sec)

H202 or Expansyl

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

Laser Implant Recovery

1.8W Continuous Wave mode, initiated tip, may required anesthetic)

Move slowly, use more energy as needed,

and be sure to cool the tissue and site with lots of H20.

Oral Lesions (Apthous Ulcers) A diode laser is an ideal tool to treat aphthous ulcers and

herpectic lesions.

Laser is used in NON-CONTACT mode, where the tip of the laser not initiated as the goal is for the energy to penetrate into the lesion.

Advantages of using a laser vs. traditional modalities

Reduce pain and discomfort

Quicker healing than corticosteriod treatment or other treatment modalities

Delayed reoccurrence of the lesion

Pre-op Immediate Post-op 3 days post op

Soft Tissue Laser Comparison: Diode vs. Hard Tissue (HT)

Both diode lasers and HT lasers are used today to manage soft tissue.

Diode lasers are more precise than HT lasers as diode laser energy is transmitted through an optical fiber that can reach areas where a HTlarge articulating arm cannot.

Diode lasers are great at coagulation and hemostasis as the wavelength is absorbed by melanin and hemoglobin, the HT laser wavelength is absorbed by water making it more difficult to achieve coagulation.

Diode lasers are compact and weigh less than 5 lbs whereas HT lasers can weigh up to 40 lbs and are often over 3 ft high.

Diode lasers are all electronic and optical, with very few moving parts; making diodes more cost-effective, compact and reliable than the much larger, more cumbersome, and more expensive CO2 laser.

Optical Photomicrograph of a Human Tooth

ErYSGG Cut A

The combination of the YSGG laser and

the water spray created hydrokinetic

energy, which in turn produced a

precise, clean and straight cut.

Er-YSGG vs. Laser EnergyComparative Clinical Evidence

SEM of the cut tooth.

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Erbium Lasers vs. Air AbrasionMagnification (x1000)

Air abrasion causes smear layer and

debris on enamel.

100 µm

Scanning electron micrograph of enamel cut

with the air abrasion instrument. The

surface shows smear layer and debris.

(x1000)

Er, Cr: YSGG cuts enamel precisely with NO

smear layer, no micro fractures.

100 µm

Scanning electron micrograph of enamel cut

with Er, Cr: YSGG HydroPhotonic™ system

The structure is compact with no column

displacement and no modification of the

intercolumnar distances. Notice no smear

layer or denaturated tissue structure.

(x1000)

Bonding surface quality for enamel

Cutting Hard Tissue with High-speed Dental Drill

100 µm

Notice smear layer surface

structure and microfracture of

approximately 10 microns in

width. (x200)

10 µm

This SEM shows detail of the

microfracture at a higher

magnification. (x2000)

*All of the above slides were performed at a magnification

of x200 and x2000 on a Jeol SEM model JSM-840.

The studies were performed at the BIOLASE Technology research and development laboratory by Ioana Rizoiu, M.S., at

the MIFAS, independent Southern California analytical laboratory specialized in optical microscopic high resolution SEM

(scanning electron microscopy) and also at the University of California Los Angeles school of dentistry in collaboration

with professor Lewis R. Eversole, D.D.S., M.S.D., M.A.

High-speed dental drill causes smear layer

and microfractures

10 µm

Scanning electron micrograph of enamel cut with

YSGG Hydrokinetic™ system. This surface

shows hydroxyapatite columns (and

interprismatic substance specific to this enamel

structure) free of any mechanical or thermal

damage. (x3500)

ENAMEL

*All of the above slides were performed at a magnification

of x3500 on a Jeol SEM model T-20.

BOTTOM LINE:

CO2 (9.3) and Erbium lasers create clean and precise cuts on enamel -

No smear layer, crystalline structure preserved

Cosmetic Restorative Clinical

Applications

Hard Tissue Procedures(for adult & pediatric patients)

•Desensitization for bleaching

•Cavity Prep - Classes I-VI

•Caries and Restorative Material Removal

•Roughening & Etching

•Enameloplasty

•Bony recontouring

Clinical Paradigm Shift

Micro dentistry (conservative care)

Minimally invasive soft/hard tissue treatment

Little to no need for anesthesia

BE GENEROUS TO YOUR PATIENTS !!(as if the clinical benefits weren’t enough)

Give them comfort

Give their teeth strength

Give people courage and hope

Give them beauty...mimic nature

Give people a message

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MAGNIFICATION AND ILLUMINATION ARE CRITICAL

IN WORKING WITH LASERS

XV1™ Loupe + Light First & only cable-less headlight

Counter-balance design

Capacitive touch controls

Supports all Orascoptic™ telescopes

EyeZoom™ First & only adjustable magnification loupe

3x, 4x and 5x magnification powers

Maintains working distance at each magnification power level

Co-engineered by Konica Minolta®

Laser Analgesia

Proposed mechanism of action

Reducing the action of the sodium potassium pump at the cellular level thereby slowing or even stopping nerve conduction in the pulpal tissues long enough to “painlessly” ablate enamel and dentin without the use of anesthesia in most cases

Lasers in Dentistry (Miserdino and Pick)

Quintessence Publishing 1995

Chapter 19 Modern optics and Dentistry

page 287

“ For example, radiation scattered in enamel and dentin can be entrapped by these natural waveguides and transported to the pulp chamber”

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TREATMENT PLANNING FUNDAMENTALS OF DENTISTRY

• Biomechanics

• Periodontal support

• Occlusal/ Function

• Habits

• Medical management

• Esthetics Thank you Graeme Milicich

DIAGNOSIS and STRATEGY OF TOOTH PRESERVATION

Diagnosis

Determine risk and treatment with CAMBRA System (Featherstone et al)

Remineralize-with Low Risk

Remove areas of decalcification and preserve vital tooth structures-especially enamel with High Risk

*

•Featherstone, JD., S. M. Adair, Anderson MH, Berkowitz RJ, Bird WF, Crall JJ, Den Besten PK, Donly

KJ, Glassman P, Milgrom P, Roth JR, Snow R, Stewart RE. Caries management by risk assessment:

consensus statement, April 2002. J Calif Dent Assoc 2003; 31(3): 257-69

• Young DA, Featherstone JDB, Roth JR, Anderson M, Autio-Gold J, Christensen GJ, Fontana M, Kutsch

VK, Peters MC, Simonsen RJ, Wolff MS. Caries management by risk assessment: implementation

guidelines. J Calif Dent Assoc. 2007 Nov ;35 (11):799-805.

Classic Caries ModelWe must remember caries is a

BACTERIAL INFECTION Cavities are basically a consequence of an

uncontrolled Mutans Streptococci infection

Transmittable

Tooth to tooth

Parent to child

Demineralization of enamel rods that is reversible until the protein matrix collapses in Striae of Retzius

A more contemporary view

THE US

Bacteria Diet Saliva pH?

Bacteria

(Biofilm) Diet SalivapH

Genes

THE USUAL SUSPECTS

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68

Smooth surface dentin caries

slow onset

Acid attack

Ca2+ and PO4 2-

RemineralizationNo bacterial

involvement

in the dentin

caries

Decalcified

or

hypocalcific

enamel

Chamber

within

fissure

complex

Demineralizing

dentin

Extremely narrow fissure in

almost direct contact with

dentin

Note the inverted, non-cavitated

caries presentation

The Reality of Patient Compliance

Food choices

Temptation

Compliance to

protocol

Sometimes this is

all we are doing

BIOLUMINESCENCE (using CariScan)

KaVo DIAGNodent laser

®

Milicich GW, Rainey JT:

Clinical Presentations of

Stress Distribution in Teeth

and the Significance in

Operative Dentistry.

Pract Periodontics Aesthet

Dent 2000:12(7)

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69

THE PERIPHERAL RIM

*

The

marginal

ridge is just

part of the

peripheral

rim of

enamel

Rainey’s Ridge

“There are the solid

sections of enamel

that comprise the

inter-connecting

enamel web of the

occlusal surface”

J Tim Rainey. Clin

Pediatr Dent 21(1) 9-13,

1996

The Basic Occlusal Restoration

Strong dentinal bond

eliminate shrinkage

fluoride remineralization

GIC

FLOWABLE

Glass ionomer

Composite

PREOP

AFTER: STRONG,HEALTHY

CLASS 2 RESTORATION

20 yo College Student

No Hx of decay

Missed 2 CC Visits

No Diagnodent Reading

Cari-Free 6200

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70

WITH ANESTHESIA

USING SEPTODONT

INFILTRATION

START WITH MESIAL

CONTACTS FIRST

6.5mm V3 Tab-Matrix with sub-gingival extension

Tab can be bent 90˚ for

contra-angle placement

Side holes for

easy removal

Holes designed to fit with

positive-grip Pin-Tweezers

The only matrix band

with marginal ridge contour

Hole to fit with positive

grip Pin-Tweezers

Interproximal contour for a better

gingival seal and V-shaped

concavity to protect the papillae

No 1 2009

FIRST LAYER OF

THE

“SANDWICH””

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Paste viscosity of GICs expressed in gF

0

50

100

150

200

250

300

350

400

Riva SC

HV

Riva SC

Fast

Chemfil

Rock

Fuji IX Fuji IX

Fast

Fuji IX

Extra

Ketac

Molar

Ketac

Molar

Quick

Paste

vis

cosity (

gF

)

ERGONOMIC MODIFICATION OF FIRST LAYER

Brand Workingtime

Initial settingtime

Final finishing

37 degrees C

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

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

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

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

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

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

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

Chemflex Regular 2:00 2-3 N/A

ChemFil Rock 3:20 4:30 6:00

GLASS IONOMER COMPARISON—

TIMING IS EVERYTHING

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

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

Lightweight and cordless

Warranty 5 years-highest in the industry

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BEAUTIFYING INCISAL EDGES-QUICK AND EASY

CONSERVATIVE,GENTLE,AND QUICK

T-4 tip

WHAT IF YOU TO REMOVE A VENEER?

SETTINGS:

4.5 W 20 Hz

15 % H20 35% Air

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73

If we have

Better diagnosis

Better understanding of anatomy

Better decay removal

Understanding of occlusion and how cracks develop in teeth

HOW COULD WE IMPROVE?

Health Tooth

Decalcification and

decalcification are

equilibrium

Caries occurs

Resin filling

Bo

nd

ing

ag

en

t

Direct Restoration

Secondary Caries

Pulpectomy

Crown treatment

Build up core

Crown

Cement

Bo

rde

r cari

es Ro

ot b

reak

ag

e

Extraction

How can this get better?

Can we enhance the bond strength effects of lasers?

Can you improve on stability and usability of glass ionomer?

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

Create a continuous supplement of fluoride

More plaque resistant

Able to enhance pulp preservation

BETTER DENTISTRY THROUGH CHEMISTRY

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74

How to tackle

Can you improve on stability and usability of glass

ionomer?

Make teeth and restorations more resistant to acids

when patient compliance decreased

Create a continuous supplement of fluoride

More plaque resistant

What’s A GIOMER?

GIOMER products are characterized by their Surface Pre-Reacted Glass

(S-PRG) filler. S-PRG filler have a glass core that is pre-reacted with a

poly acrylic acid solution. This means that unlike GI that require light

curing and water absorption for ion transfer to occur, GIOMER’s filler

are protected from water sorption and material degradation by a surface

modified layer.

13 YearPhotos

University of Florida8-Year Vs. 13-Year Results

8-Year results as published in JADA 2007:16 of 26 Class I, and 25 of 35 Class II restorations were observed.

• No failures

• No secondary caries

• Maintained aesthetics

• No post-op sensitivity noted

13-Year results as presented during IADR 2013 poster session:19 of 26 Class I, and 22 of 35 restorations were observed.

• Retention rate 66% (27 of 41)

– 52% of retained noted as excellent

– 41% of retained noted minor changes

• Secondary caries rate 3.27% (2 of

61) restorations noted

• Overall positive results and low secondary caries attributable to Giomer technology

8-Year: J Am Dent Assoc. 2007 May;138(5):621-7

13-Year: 2013 IADR Poster Presentation, Gordan et al.

Mineral Trioxide Aggregate (MTA) High biocompatibility

Hydrophilic

Highly alkaline pH of 12.5 (Bacteriostatic)

Excellent sealing ability

Low solubility

Parirokh M, Torabinejad M Mineral trioxide aggregate (MTA). a comprehensive literature

review—part I: chemical, physical & antibacterial properties. J Endodo. 2010;36:16–27

Able to enhance pulp preservation

Able to enhance pulp preservation

Cannon M, Gerodias I, Vieira EM, et al. Effects of Different Pulp Capping Techniques on Hard Tissue Bridge Formation,

European Academy of Pediatric Dentistry. June 2006, Amsterdam, Netherlands.

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

Gandolfi MG, Suh B, Siboni F. Chemical-physical properties of TheraCal LC pulp capping material. Presented at: International

Association of Dental Research (IADR). March 18, 2011; San Diego, CA. Abstract #2521.

Gandolfi MG, Siboni F, Taddei P, et al. Apatite-forming ability of TheraCal LC pulp capping material. Presented at: International

Association of Dental Research (IADR). March, 2011; San Diego, CA. Abstract #2520.

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

pulp-capping, International Endodontic Journal, 2012.

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75

• Only one coat is required

• No agitation required

Apply and let stand for 10

seconds

• Light force to dry/spread material

• Take care not to splash

Gently air-dry for 3 seconds

• (5 seconds LED)Light cure for 10 seconds

halogen

Phosphonic acid monomer enamel

Carboxylic acid monomer dentin

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76

Fluoride/Ion Release/Rec

harge

Anti-Plaque

Pre/Post-curing color

stability

Light diffuse material

Chameleon properties

Non-sticky Excellent

flow

Good ergonomics

SOME REAL PERSPECTIVE

Erbium YAG

CO2CO2

Types of dental lasers used in 2016

CO2

Er:YAG

Er,Cr:YSGG

Nd:YAGDiodes

• SOFT TISSUE ONLY

• Gas-based

• Used for surgery• Expensive

($40K+)

• HARD TISSUE/SOFT TISSUE/BONE/ENDO/P

ERIO

• Solid-state – uses an Erbium crystal

• Hard tissue cutting• Cavity preps

• $50K+

• Solid-state – uses a Neodymium crystal

• Soft tissue surgery

• Perio / LANAP• Soft tissue

• Not common in ortho• Very expensive

($85K)

• Semiconductor diode• Excellent for soft

tissue

• Lots of brands• ~25K installs in USA

• Affordable ($2K-$20K)

Er,YAG

Introducing You To The LiteTouch

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LITETOUCH EDU

LiteTouch Uses PERIODONTICS • Effective and unrivaled pocket debridement: Bactericidal effect (disinfection) • Excellent surgical precision: Precise & selective granulation tissue ablation avoiding unnecessary damage of

healthy tissues • Effective and selective calculus removal • Faster healing of surrounding tissue and bone: Minimal postoperative swelling and discomfort, leading to

fewer follow-up visits

PEDODONTICS • The preferred method for treating children: No fear factor; shorter procedures; less noise; no vibrations • Preventive Dentistry: Precise and delicate treatments; minimally invasive; enables microsurgery (pits and

fissures) that preserves healthy tissue • Friendly equipment: Well-accepted by kids • Ideal for hard or soft tissue crown lengthening either open field or closed through the sulcus • Improves treatment of periodontal disease by sterilization of the pocket, granulation removal and

stimulation of the crestal bone

AESTHETIC DENTISTRY • Precise manipulation: Gingival re-contouring, smile design & depigmentation of natural melanin deposits • Excellent for debonding porcelain veneers: Allows dentists to reuse veneer while maximally preserving

tooth substance • Anesthetic free treatment makes patient management easier on staff, doctor and patient

DEXCAM CARIVU

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Light-microscopic view of the Er:YAG lased dentin

showing heat-denatured layer observed in red with

the thickness of approximately 30 µm (Masson’s

trichrome stained)

TEM image of the Er:YAG lased dentin

demonstrating amorphous and nonfibrous subsurface

layer (☆) (demineralized, UA/LC stained). The

resultant heat might superficially denature the

dentinal collagen fibers.

Excerpta Medica, International Congress Series 1248. 1st ed. Elsevier Science B.V.:

Amsterdam; 2003. 161-166.

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

Information provided by Professors Akira Senda and Fujitani Morioki Aichi Gakuin University

Micro-FTIR spectra of the non- and lased dentin (CO2 laser, 69.0

J/cm2) revealed that the laser-irradiation eliminated the amide peak

wavelengths (box) and increased the crystallinity of dentin (arrow).

Jpn J Conserv Dent 42(5): 860~877, 1999

Jpn J Conserv Dent 55(6): 411~423, 2012

Er:YAG was done at Hiroshima Univ. (former university for Morioki), CO2 laser work was carried out in our department of Aich Gakuin University.

• Only one coat is required

• No agitation required

Apply and let stand for 10

seconds

• Light force to dry/spread material

• Take care not to splash

Gently air-dry for 3 seconds

• (5 seconds LED)Light cure for 10 seconds

halogen

Phosphonic acid monomer enamel

Carboxylic acid monomer dentin

Fluoride/Ion Release/Recharge

Anti-Plaque

Pre/Post-curing color

stability

Light diffuse material

Chameleon properties

Non-sticky Excellent flow

Good ergonomics

RADII PLUS—using since 2008

Excellent power and width/ Easy to charge

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

Lightweight and cordless

Warranty 5 years-highest in the industry

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DO IT OFTEN!IF YOU DON’T USE IT, YOU LOSE IT!

Practice

Always try new things as you climb up the “learning curve” Unconscious

Competence

ConsciousCompetence

Conscious in compentence

Unconscious

Incompetence THE LEARNING CURVE

“Good-to –great organizations avoid technology fads and bandwagons, yet

they become pioneers in the application of carefully selected technologies…used

technology as an accelerator of momentum not the creator of it”

WHAT’S NEXT?

Evidence based research (co-op?)

Better delivery systems and wavelengths

Specialty acceptance

New standard of care

Public awareness to increase demand

Penetration into the dental market

CONCLUSIONS

Minimally invasive restorative care

Avoid lengthy recovery times from gum surgery (less invasive.....no stitches !)

Give the dentist more control of their cosmetic cases (no referrals and better

artistry !)

The best part: Patients are happier by completing the "smile makeover“ cases 2-3

months faster (much better customer service!)

If you want to learn more:

Dental Clinics of North America—Cosmetic Dentistry UpdateApril 2011 Vol. 55 No 2

A FINAL THOUGHT…….

“We are not creatures of circumstance;we are creators of circumstance”

Benjamin Disraeli

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CONTACT INFORMATION

HUGH FLAX,DDS(404) 255-9080

Email: h.flax@FlaxDental.comFor lecture info

on cosmetic dentistry, implants and lasers

http://www.catapultelite.com/flax.php