working with your assistant - vsds

FOR THE EXCEPTIONAL DENTAL OFFICE ~ A TEAM APPROACH~

SAM SIMOS, DDS [email protected]

I WOULD BE HAPPY TO E-MAIL LECTURE HANDOUT OR LECTURE INFORMATION OR ANSWER ANY QUESTIONS

630-336-2127

▸ Dr Sam Simos— I do what you, do everyday

▸ 27 year career… & counting! ▸ Have worked with master dentists from around the world

▸ Adopted techniques/materials that I can use in almost any clinical situation to solve any problem or desire a patient may have.

▸ Worked in Crown & Bridge lab in college ▸ Master Ceramist mentor — 3 key concepts;

1.“Master the handling characteristics of the material you are working with”

2.“Have a complete understanding of the technique you will employ”

3.“Visualize the result before you begin”

INTRO

WHAT THEY DIDN’T TEACH ME…▸ HOW TO BUILD A TEAM

▸ HOW TO WORK WITH AN ASSISTANT

▸ HOW TO BE EFFICIENT

▸ HOW TO BUILD A CULTURE

I CAN’T FIX EVERYTHING SO LETS WORK ON ONE THING!

working with your assistant

INTRO

AND THE SURVEY SAYS…

▸ Assistant has worked with me for over 10 years.

▸ Assistant has worked with me for over 5 years.

▸ Assistant has worked with me 1-5 years

▸ Assistant has worked with me for under a year.

INTRO


▸ My assistant and I need to get on the same page.

▸ My assistant does not bring what she needs for the appointment

▸ My assistant could use a little training

▸ My assistant could use a lot of training

▸ My assistant does such a great job I should give her a raise but she is already making more than me!

INTRO


▸ I could communicate with my assistant better

▸ I should give my assistant more direction

▸ I should try to understand millennials better

▸ I should give my assistant more training

▸ I should give my assistant a raise

GOALS

TAKE A FRESH LOOK AT WHAT MATERIALS/TECHNIQUES YOU USE LOOK AT IT FROM YOUR ASSISTANT’S POINT OF VIEW ASK THE QUESTION; WHY? …WHY DO I USE WHAT I USE? GAIN A BETTER UNDERSTANDING OF MATERIALS & TECHNIQUES AVAILABLE SO YOU CAN USE THEM PROPERLY & IN THE PROPER CLINICAL SITUATION (EFFICIENCY) DELIVER BETTER DENTISTRY TO YOUR PATIENTS Q & A

INTRO

YOUR PARTICIPATION IS APPRECIATED▸ If YOU could get your assistant to do one thing better what

would it be?

▸ What material or technique could your assistant get better at?

▸ What does your assistant do really well?

THERE HAS NEVER BEEN A BETTER TIME TO BE A DENTIST…THERE HAS NEVER BEEN A MORE CONFUSING TIME TO BE A DENTIST MATERIALS

Adhesives Cements Composites

Impression material

Zirconia/ LiDi

TECHNIQUEDr. Sam Simos, Bolingbrook, IL

Dr. Sam Simos, Bolingbrook, IL

TECHNOLOGY MATERIALS


Impression material

Zirconia/ LiDi

TEAM

GET THE RIGHT PEOPLE ON THE BUS

MATERIALS


Impression material

Zirconia/ LiDi

INTRO

YOUR PARTICIPATION IS APPRECIATED▸ When it comes to materials, what material(s) would you

like YOUR assistant to have more knowledge of?

▸ Adhesives▸ Cements

▸ Composites

Buildup materials

Impression materials

IDEAS

GOALS OF ADHESIVES

1-5 microns deep

Is partly porous, but dramatically reduce fluid flow from underlying dentin tubules

Smear LayerFreshly cut surface of dentin formed by Rotary Instruments

“Biologic Band-aid”

Limits Bond Strength

ADHESIVE- HISTORICAL SUMMARY

Early bonding agents tried to modify or attach to the Smear Layer

4th & 5th Generation Bonding Agents (total etch) attempt the removal of the Smear Layer

Current Bonding Agents (self-etch) incorporate the Smear Layer into the Bond

GOALS OF ADHESIVES

This replacement of Collagen + Bonding Agent creates a protective barrier from bacteria and post-op sensitivity

Bonding agent penetrates the space or “vacancies” to fill the tubular and peri-tubular dentin

Hybridization layer relies on moisture

HOW DO YOU CHOOSE YOUR BONDING AGENT?

Sensitivity

Dual cure/self cure resin cements/Build up mat. inhibited by some adhesives

Thickness of adhesives

Enzymatic breakdown of collagen layer from acid etch

Poor enamel/dentin etch w/ self etch adhesives

PROBLEMS ASSOCIATED W/ADHESIVES;

CATEGORIES OF BONDING AGENTS

Total etch Self etch

# of components

Etchant

Primer

Adhesive

Generation

OptiBond FLScotchbondTenureAll Bond TE (3)

Optibond Solo PlusPrime & Bond NTScotchbond IClearfil SEAll bond Plus

6th

Xeno IIIAdper Scotchbond SEL-PopBrush & Bond

7th4th 5th

Prime & Bond ElectAll-Bond UniversalScotchbond UniversalFuturabond UG-aenial Bond

Adhesive brands

Etchprimer adhesive

Xeno IV DCAdper Easy OneClearfil S3 Bond PlusFutura bond DCOptibond All in one

A HISTORICAL LOOK

8TH



# of components

Etchant

Primer

Adhesive

Generation


Optibond Solo PlusPrime & Bond NTSingle BondAll Bond TE (ACE)XP BOND

6th

Optibond XTRClearfil SE BondSingle BondAll Bond SE

7th4th 5th

OptiBond All-In-OneXeno IV IBONDAll Bond SE (ACE)Prime & Bond Elect

Adhesive brands

Etchprimer adhesive

TOTAL ETCH3-COMPONENTS

(4TH GENERATION)



# of components

Etchant

Primer

Adhesive

Generation



6th


7th4th 5th


Adhesive brands

Etchprimer adhesive

TOTAL ETCH2-COMPONENTS

(5TH GENERATION)



# of components

Etchant

Primer

Adhesive

Generation



6th


7th4th 5th


Adhesive brands

Etchprimer adhesive

SELF ETCH2-COMPONENTS

(6TH GENERATION)




# of components

Etchant

Primer

Adhesive

Generation



6th


7th4th 5th


Adhesive brands

Etchprimer adhesive

SELF ETCH1-COMPONENT

(7TH GENERATION)




# of components

Etchant

Primer

Adhesive

Generation



6th


7th4th 5th


Adhesive brands

Etchprimer adhesive

A HISTORICAL LOOK

8TH GEN

1- BOTTLE SELF ETCH

DIFFERENCE; UTILIZES A DIFFERENT MONOMER THAN HEMA. UTILIZES 10-MDP AS 1° MONOMER & CAN BE USED FOR ZIRCONIA OR METALS AS A PRIMER



# of components

Etchant

Primer

Adhesive

Generation


Optibond Solo PlusPrime & Bond NTScotchbond IClearfil SEAll bond Plus

6th

Xeno IIIAdper Scotchbond SEL-PopBrush & Bond

7th4th 5th

Prime & Bond ElectAll-Bond UniversalScotchbond UniversalFuturabond UG-aenial Bond

Adhesive brands

Etchprimer adhesive

Xeno IV DCAdper Easy OneClearfil S3 Bond PlusFutura bond DCOptibond All in one

A HISTORICAL LOOK

8TH

Reduced Enamel Etch/Adhesion

Bond Incompatibilities

Post-Op Sensitivity Excessive Film Thickness

4th Gen

5th Gen

6th Gen

7th Gen

Limitations Are Present in All Bonding Agents

Limitations OF BONDING AGENTS

Self-Etch (6th/7th Gen) bonding agents are • Mildly acidic • Lower etch quality • Lower enamel bond strength • Require enamel etching

Swift E, et al, J Esthet Restor Dent. 2011 Dec;23(6):390-6. doi: 10.1111/j.1708-8240.2011.00465.x. Epub 2011 Oct 17.

6th generation, 50,000X 7th generation, 50,000XPhosphoric Acid 50,000X

Limitation: Reduced Enamel Etch and Adhesion of Self-Etch

SURFACE CARE & ETCH TIMES

Selective Total Self

Solution

U

C

D

Sclerotic or Hyper-mineralized30-60 sec.Dentin

3-5 sec

Un-ground Enamel30-60 sec

Cut/Ground Enamel15-20 sec

UNDERSTANDING ETCHING TIMES

Suh, Johnston, Barkmeier, Goes Solution Single Bottle Adhesive System•5th Generation Total-etch Adhesive•7th Generation Self-etch Adhesive

Acidic

Acid/Base Reaction and Phase Separation

uncured Acidic Monomers

Limitation: Bond Incompatibilities of 1-Bottle Systems

Self/Dual-cured Resin Cement/Core Material• PFM /PFZ• Metal Crowns• Opaque Restorations• Bulk-Fill Composite Core Material

SolutionSelf/Dual cure

Resin Cement/Core material

Ensure the Adhesive is compatible

with the Resin

Know your adhesive— Need

additive for Dark/Dual cure?

Solution

coat foil w/adhesive

Incompatible Compatible

ADA PROFESSIONAL PRODUCT REVIEW

“Adhesive compatibility with the core material or the dual-cure or self cure resin cement is the main issue. Although some manufacturers have better adhesives to match with their core material or cement than what they package with the product or recommend… Sometimes their recommendations don’t quite match even in their own product line”.

ADA PPR; Vol. 5, Issue 2; Spring 2010

Compatibility

Open space between collagen fibers

maintained by water

Collagen fibers collapsed and space

between collagen fibers closed

Hot/Cold stimulus

Limitation: – Post-operative Sensitivity of Total-Etch (4th &5th)

U

C

D

Sclerotic or Hyper-mineralized30-60 sec.Dentin

3-5 sec

Un-ground Enamel30-60 sec

Cut/Ground Enamel15-20 sec

UNDERSTANDING ETCHING TIMES

Suh, Johnston, Barkmeier, Goes Solution


CONSIDER CORRECT SURFACE MOISTURE

WET DRY

MOIST

Solution

>35µm

SEM magnified of ClearFil SE Bond at 2,000X

Limitation: - Excessive Film Thickness of Adhesive Layer (4th & 6th)

Root cause It is the high viscosity • Due to lack of solvent • Higher filler loading

What are some issues? • Limited indirect use • Pooling • Caries misdiagnosis

Non-radiopaque adhesive layer

BLOW OFFADHESIVE

SolutionNO

PUDDLING

Limitation: - MMPs - Enzymes activated by acid which consume the collagen layer (ALL)

PROBLEM • Weaken Bond • Sensitivity • Debond • Bond failureAdhesive Resin

Diffusion

T/E “Effective Hybridization”

Limitation: - MMPs - Enzymes activated by acid which consume the collagen layer (ALL)

Brackett et al., (2009) Operative Dentistry; 34(4):381-385

Immediate (MPa)

Control 29.3 (9.2)CHX 32.7 (7.6)

Carrilho et al., JDR 2007; 86; 529

14 mo (MPa)

Control 19.0 (5.2)CHX 32.2 (7.2)

New

Research!

Benzalkonium ChlorideBAC infused etch 2% CHX

Solution

(BISCO)(BISCO)

Wash dentin with BAC or CHX

(Ultradent)

Consepsis

ADHESIVES

WHAT INFO ARE YOU GOING TO TAKE BACK TO YOUR ASSISTANT?

CURING LIGHTS

YOUR PARTICIPATION IS APPRECIATED▸ Beyond pushing the button to turn it on: Does your

assistant Understand Curing Lights?

▸ Besides looking at the pretty blue light: Do You Understand Curing lights?

DR. RICHARD PRICE“THE FATHER OF LIGHT CURING” ALL CURING LIGHTS HAVE A BLUE LIGHT

ALL CURING LIGHTS ARE NOT CREATED EQUAL

MISCONCEPTIONS OF LIGHT CURING

When elaborate case studies arewritten with multistep techniques for material manipulation and placement there are usually only 5 words that describe the most critical phase of the technique…

“…And then you light cure”

Under cured resin DOES NOT DELIVER the manufactures intended results

Under cured Adhesives/hybrid layers DO NOT DELIVER the manufacturers intended results

Bond Strengths are reduced or not existent

No Manufacturer recommends under curing

When lights are use incorrectly or poor quality lights are used

~ Poor results are obtained~

PHOTOS COURTESY OF DR. RICHARD PRICE

DENTIST CAN ONLY SEE THE TOP OF THE BERG

What you need to know about your light…

• Power/Energy• Spectral Emission• Irradiance/ Effectiveness

• Tip Size

**All of the above curing light attributes are related to each other


• Tip Size

ENERGY

HOW POWERFUL?

▸ Light energy needs to be strong enough to create free radicals, which are molecules with an unpaired valence electron

▸ Leads to a chain reaction binding many carbon chain (monomers) to form long interconnecting chains of molecules called polymers

▸ If light energy not strong enough some monomers won’t join polymer system and will leach out, form soft spots, low retention, discoloration and weakness of restoration.

Chapter 1516 J/cm2

HOW MUCH ENERGY IS REQUIRED TO ADEQUATELY CURE THE RESIN?

MANAGING TODAY’S DENTISTRY

composite 2mm

16 joules energy=

lightenergy

400 mW/cm2

40 seconds

66

DEBRIS ON LIGHT TIP HAS A HUGE EFFECT ON THE ENERGY DELIVERED


• Tip Size

EMISSION SPECTRUM FROM CURING LIGHTS

CURING LIGHTS HAVE DIFFERENT SPECTRAL EMISSIONS

COURTESY OF DR. RICHARD PRICEPremiumLow grade

TETRIC BULK FILL412 nm

COURTESY OF DR. RICHARD PRICE

CQ

LUCIRIN

SAME POWER DIFFERENT SPECTRAL EMISSION

COURTESY OF DR. RICHARD PRICE


• Tip Size

IRRADIANCE

EFFECTIVENESS High Irradiance

HIGH IRRADIANCE =

HIGH POWER

COURTESY OF DR. RICHARD PRICE Images courtesy of Richard Price, DDS, MS, PhD – Dalhousie University


• Tip Size

POWER: WATTS (W) IRRADIANCE = POWER/AREA (mW/cm2)COURTESY OF DR. RICHARD PRICE

COURTESY OF DR. RICHARD PRICE COURTESY OF DR. RICHARD PRICE

ZIRCONIA

LITHIUM DISILICATE

Courtesy of Dr. Richard Price I N T

E N

S I

T Y

D VS I RULE OF POWER

D I

S T

A N

C E Picture of tooth with measurement

A High energy LIGHT CAN BE USED IMPROPERLY

StabilizationDr. Sam Simos, Bolingbrook, IL

Courtesy of Dr. Richard Price

ENERGY; MW/CM2 RADIOMETER

WHAT DO THESE #’S TELL YOU?

SAME LED MANUFACTURER WHY THE DIFFERENCE?

are you testing?

are you looking?

ENSURE SAFETY IN LIGHT CURING

RISK OF RETINAL DAMAGE

• Photoretinitis• Premature aging of the retina

• Macular Degeneration

CURING LIGHTS


BETTER DENTISTRYMATRIX SYSTEMS

YOUR PARTICIPATION IS APPRECIATED▸ Do Assistants struggle with matrix systems?

▸ What if you use more than 1 system?

MATRIX SYSTEMS

GOALS OF MATRICES

▸ Create an anatomically correct interproximal wall

▸ Create a contact between the restored tooth and the adjacent tooth

▸ Help seal the margin of the proximal box so that there are no resulting composite overhangs

▸ Help seal the margin of the proximal box so that moisture is retarded while restoring the tooth.

Amalgam & Caries Removed

MATRIX SYSTEMS

ANATOMICALLY CORRECT INTERPROXIMAL WALLMATRIX SYSTEMS

CREATE CONTACT



MATRIX SYSTEMS

PROXIMAL WALL SEAL/MOISTURE CONTROL


SECTIONAL MATRICES & INSTRUMENTATION

Caries Caries Removed



PALODENT PLUS Dr. Sam Simos, Bolingbrook, IL

MATRIX SYSTEM


Paths to improve the procedure

Bulk-fill flowable with universal cap

Bulk-fill single viscosity

Traditional layering technique

©2012 Trademarks are property of their respective owners

SonicFill™ Sonic-Activated, Bulk Fill Composite

Bulk FillingMATERIAL Clinical Requirements

1. Adaptation 2. Depth of cure 3. Low shrinkage

PLUS: maintain critical qualities of posterior composite…

1. Compressive strength 2. Wear strength

SUREFIL SDRDEPTH OF CURE....4 mm (DENTSPLY)

Venus Bulk Fill Fusio Bulk Fill

In the Spirit of “Time Saving Dentin Replacement”

SONICFILL

DEPTH OF CURE...5 mm (KERR)

©2012 Trademarks are property of their respective owners

SonicFill™ Sonic-Activated, Bulk Fill Composite

Sonic energy

Low Viscosity (adapt & fill cavity < 5 seconds)

High Viscosity (Press & Sculpt)

High Viscosity

Soni

c off

BULK FILL




630-336-2127

INTRO

YOUR PARTICIPATION IS APPRECIATED

▸ Is your assistant knowledgable about the different composite techniques in your office?

COMPOSITES/ POLISH

Universal microfil

Gayle Dr. Sam Simos, Bolingbrook, IL





VITA®

– Cloud shadesDr. Sam Simos, Bolingbrook, IL









•The smaller the filler

-The better the gloss

-The lower the total degree of filler

→ lower mechanical toughness

→ impaired handling properties

How to overcome these contradictions?

! Make large fillers out of smaller ones!

Principles of Filler Technology

Filler technology - overview

Ivoclar-Vivadent Pre-polymerized Combination of pre-polymerized macrofiller and submicron glass filler

resin

submicron glass filler

silanized submicron-

filler

irregularly shaped pre-polymerized macro-filler (10-100 µm)

milling resin

resin matrix

curing

Filler Technologies: Tetric EvoCeram (Ivoclar)

Latta MA (2015)

Surface after generalized wear (2500x)

Tetric EvoCeram

30 µm

FS combines “Nanoclusters” with nanofillers

zirconia- and siliciumdioxide nanoparticles (10- 20 nm)

irregularly shaped „Nanocluster“ (1 - 20 µm)

1. spray-drying

2. calcination 3. milling

Filler Technologies: Filtek Supreme Ultra (3M ESPE)

FS combines “Nanoclusters” with nanofillers .

zirconia- and siliciumdioxide nanoparticles (10- 20 nm)

irregularly shaped „Nanocluster“ (1 - 20 µm)

1. spray-drying

2. calcination 3. milling

Filler Technologies: Filtek Supreme Ultra (3M ESPE)

4. silane 5. resin

+ nanofiller resin matrix

Latta MA (2015)

Surface after generalized wear (2500x)

30 µmFiltek Supreme Ultra


3M EspeIvoclar-Vivadent

NanoclusterPre-polymerized *patent applied


Dentsply Sirona3M EspeIvoclar-Vivadent

NanoclusterPre-polymerized *

Filler

▪ Pre-polymerized spherical granulates

▪Barium glass (≈ 0.6 µm) granulates (≈ 15 µm)

Experimental paste comprising SphereTEC-Filler only

Filler

+

TPH Spectra® ST comprising SphereTEC and submicron glass filler

Blend

1. Excellent handling 2. Durable restorations

3. Fast and easy polishing 4. Simplified shading

Development objectives

complain about handling

74%

1 Dentsply Sirona Restorative, user survey 2015 (297 dentists in Europe)

Polishing – composite with large filler particles

Resin matrix

Primary barium glass particles

filler particles

Resin matrix

Primary barium glass particles

Polishing – The amazing gloss of TPH Spectra® ST Composite

After contouring

After finishingAfter polishing

Vita Classical Shade Guide

valueversus

The Cloud Shade Concept How can 5 A-shades match 16 Vita shades?

A composite with a distinct Chameleon Effect

Vita Shade Match

Genuine VITA tab

VITA tab filled with TPH Spectra® ST Composite Shade A2

Class III cavity

VITA Classic shade tabs restored with

TPH Spectra® STUniversal Composite Restorative

Exposure to black light makes the restorations visible!

DannaDr. Sam Simos, Bolingbrook, IL














Prof van der Vyver, South Africa

Replacement of several Class II restorations in premolars

Before Post-operative view

Dr José Bahillo, Spain

Class I restoration on a molar


Dr. Walter Dias, Germany

Class II restoration

Preparation Post-operative view

Dr. Walter Dias, Germany

Class II restoration

Preparation Post-operative view

Dr. Ian Cline, UK

Anterior restorations

Before

Post- operative view

Prof Dr Gabriel Krastl, Germany

Anterior Restorations


COMPOSITES/ POLISH DIRECT COMPONENTS

Traditional 2mm layering Bulk Fill Flowable

with Universal CapMatrix

Bulk Fill

Adhesive

CompositePolish

Bulk-fill single viscosity



630-336-2127

working with your assistant - vsds

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