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Patients are brainwashed by the media.Let’s look at our typical patient who has been swayed by the media!

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How much American’s spent on over the counter tooth whitening products in drug

stores and in 2012.!!!

CVS --- 123.13 billion Walgreens-- 70.79 billion Rite Aid--- 26.1 billion

Why isn’t whitening a staple in all of our practices?

Teenage whitening=Who is doing it?

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The need for multiple whitening options in our practices.

Light vs. no light

The World’s Fastest BleachPola Office+

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37.5% Hydrogen peroxide

High pH activation for super fast release of peroxide ions

The World’s Fastest Bleach

Clear gel:

37.5% hydrogen peroxideThickenersWater

Composition of Pola Office+

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Built-in Desensitizer

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Flexible Gingival Barrier: Light Cured

Protects the soft tissue

Directly apply a thin layer of gel to all teeth undergoing treatment

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Before & After – Case 1Photos courtesy Dr I Franchi, (University of Modena, Italy)

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Combination technique.Pola day 1, Zoom or other day 2.Great for tough cases.

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pola day + pola night

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Worn in a custom made tray.Take home

High viscosity,neutral pH advanced tooth whitening gels.

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Pola Day: 3%, 7.5%, 9.5%hydrogen peroxide

Pola Night 10% 15% 22%Pola Night: 10%, 15%, 22%carbamide peroxide

Concentrations

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35% CarbamideTake home whitening.30-60 min per day.

Reduces dehydration of the enamel & decreases patient sensitivity

High water content

Ensures the full release of the peroxide without jeopardizing patient comfort.

Neutral pH

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The Pola Day & Pola Night gels contain adesensitizing agent which acts on the

nerve endings, and desensitizes them atthe pulp dentin border, in turn minimizingsensitivity & maximizing patient comfort.

Contains desensitizing agent

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Indications

Brush teethApply & leave onAvoid food & drinks for at least 30 minutesUse twice per day for 2 weeks.

Procedure

Millions of people in the United States suffer from chronic headaches that can be attributed to clenching or grinding of their teeth.Many dentists fail to look for obvious signs of dental damage that can be attributed to our clenchers and grinders.By looking out for damage cause by bruxism, we can establish a simple effective treatment protcol that is not only very helpful for our patients but can be profitable for us in the office.

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Many TMJ-related symptoms are caused by the effects of physical stress on the structures around the joint. These structures include:Cartilage disk at the jointMuscles of the jaw, face, and neckNearby ligaments, blood vessels, and nervesTeeth

Worn teeth or worn edges of teethFractures of teethLoosening of existing restorationsShiny spot on amalgams.Jaw clicking or painInability to open the mouth fully (trismus) or deviation of the jaw to one side upon opening.(usually opposite side of injury)Intraoral and extra oral muscle painNeck pain or shoulder painHEADACHES- especially in the early part of the day

Signs and symptoms of TMJ disorders may include: Pain or tenderness of your jawAching pain in and around your earDifficulty chewing or discomfort while chewingAching facial painLocking of the joint, making it difficult to open or close your mouthyHeadaches

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TMJ disorders can also cause a clicking sound or grating sensation when you open your mouth or chew. But if

there's no pain or limitation of movement associated with your jaw clicking, you probably don't need treatment for

a TMJ disorder.

TMJ disorders most commonly occur in women between the ages of 20 and 40, but may occur at any age.Misalignment and shifting of teeth due to Periodontal disease can contribute to bruxing.

Open and Closed TMJ ImagesCBCT of the Joint

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Thorough review of medical historyDo they report a history of migraines?Jaw pain, tightness, tenderness in face or scalpStress?Thorough head and neck exam, palpating the muscles that assist in open and closing the jaw as well as muscles of the head and neck

During the physical exam, your doctor or dentist will probably: Listen to and feel your jaw when you open and close your mouthObserve the range of motion in your jawPress on areas around your jaw to identify sites of pain or discomfortIf your doctor or dentist suspects a problem with your teeth, you may need X-rays. A CT scan can provide detailed images of the bones involved in the joint, and MRIs can reveal problems with the joint's disk.

Masetter- Superficial and deepLateral and medial Pterygoid ( intra oral)TemporalisWhen these muscles are tender and the patient complains of headache and jaw pain we may elect to treat the patient in a non invasive way

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Check centric occlusion.Check lateral excursions.( is something getting hung up)Check for balancing side interferences.Do you hear the squeak?TipUse Accufilm and rub Vaseline on both sides. This will enhance the ability of the colored carbon to show on yteeth and porcelain.

In an acute situation treatment options may include, soft diet, rest for the jaw, ibuprofen or prescription anti inflammatory medications (Mobic) soft diet, heat,and impressions for a night guard.Severe long term problems- surgery, but not always successfulBotox for acute muscle pain is helpful as well.Issues-Night guard usually must be sent out to the lab after taking impressions and patients continue to suffer in pain.p p pBotox even if administered has a 5 to 7 days onset period

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Patients get some relief if done properly but if the vertical dimension is opened too much further pain and damage can occur.Full coverage night guards can protect the teeth from damage but will not relieve the clenching patient. Maximum clenching occurs when the posterior dentition is in maximum habitual intercuspation.p

Keystone- In office custom fit appliance that uses the body’s natural reflexology to relive the patients symptoms. The device takes only a few minutes to fit, is low profile and allows the patient to begin feeling better very quickly

NiteBite is thin and designed for placement in the patient’s freeway space – the distance between the normal centric rest position of the mandible and the first point of contact of the upper and lower teeth when the jaws are in centric closureNiteBitetriggers the jaw opening reflex, known as proprioception, but does not force the mandible to open beyond its normal physiological rest position.Each time the mandible closes, and lower teeth contact the NiteBitedevice, the jaw muscles are triggered to relax exactly where the patient’s rest position belongs, which is the mandible’s centric relation.

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NiteBite does not force the mandible to open beyond its rest position, as other night guard devices may tend to do. NiteBitetriggers the rest position, so parafunction, clenching and grinding are signaled to stop. Thus, teeth and restorative dentistry are protected and symptoms associated with TMJ dysfunction get relief.

Before I describe how to make a NiteBite device, I’ll describe its components.The hard outer shell is a biocompatible medical grade polycarbonate.The inner lining is a moldable, biocompatible, low temperature thermoplastic resin.NiteBite is a patented product and is FDA cleared for use.

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Molded resin

Hard outer shell

•The NiteBite is placed on the upper anterior teeth and pushed up evenly until the incisal edges touch the inner surface of the hard outer shell. Complete seating of the appliance is critical to ensure it is as thin as possible at the point of contact with lower anterior teeth. Wile seating, do not push up on the palatal aspect. While holding the appliance in place, the clinician can smooth any edges with a finger where flash has appeared.

After holding the device firmly in place for 2 minutes, remove it for inspection. You want to make sure there is a complete and accurate p pregistration of the teeth and palate. The thermoplastic liner will cool and begin to return the opaque state

Immediately after inspection, return the appliance to the mouth and hold firmly in place for 2 to 3 more minutes. It can be withdrawn and reseated slightly to ensure against locking into contours or undercuts. The thermoplastic liner will become more opaque.After the final set, remove and inspect the NiteBite for accuracy of impression, registered sharp edges, and the presence of material that may have squeezed into the interproximals. Some interproximal flash can be removed with a sharp scissor or a ceramic acrylic bur.. This will make the NiteBite more comfortable for the patient. However, snugness is important for fit. If you remove too much of the interproximal flash, the fit may become too loose.

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Once fitted have the patient sit for ten minutes relaxed with Nite Bite in place.Remove Nite Bite and ask patient if they feel differently?Recheck occlusion with Accufilm.

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Place a slight lubricant on the teeth prior to custom fitting the nite bite. This will insure ease of removal.If a diastema exists block out the diastema with either liquid rubber dam, cavit or flowable composite.The same is true for large embrasures around implants or crown and bridge.Once the material reverts from its clear appearance back to its milky original color place it into a bowl with cold water to finalize the set.

Ceramic pear shape acrylic bur from Komet.Straight hand piece low speed….material will heat up a bit and gum up if use at too high a speed.

While Nite Bite will be the perfect solution for most patients, it is contraindicated for patients with advanced periodontal disease, severe incisor crowding and flaring, provisional restorations, or upper anterior restorations with severe undercuts or very large gingival embrasures that can’t be blocked out.

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Patients are followed up in 7 days.Patients should report substantial decrease in symptoms.

If patient reports not feeling any better( almost never), question the frequency of wearing the appliance. If muscular pain still exists examine the amount of opening. If there is room, reduce opening on appliance so that teeth clear in excursive movements and not much more.Botox or Xeomin- sometimes may be necessary when all else fails.

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Many dentists have relied on the same technique for years despite the introduction of newer materials that make sense and despite the failures we see with older systems.

What are the most common types of post and

core failures?

1. Post Loosening2. Root fracture3. Endodontic failure4. Root perforation5. Bent/fractured post6 Caries6. Caries7. Periodontal failure

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choose a plastic sprue- 14-gauge solid plastic sprue (williams)- Spee Dee pinsadjust the sprue (passive fit

into the canal)lubricate the canal lubricate the canal (saliva, anesthesia, water)

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Apply monomer on sprue apply duralay or GC pattern

on the tip of sprue insert inside lubricated

canal, wait 30-45 seconds, pump pattern in and out to avoid locking of acrylic into any undercuts undercuts acrylic should reproduce

the exact anatomy of the canal. Length of the radicular part should be equal to the length of the canal

Traditional methods include cementing a laboratory made metal/gold post and core into a canal.Preparation design critical to success( Ferrule, post length)Problems: Extra appointment ,teeth fracture, post loosening lab costloosening, lab cost.

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. Accident

Attributed to design of post (tapered, parallel sided or threaded)

Hydraulic pressure during cementation

Absence of ferrule

Traditionally, metal post cemented in tooth followed by some sort of a composite as a buildup material.Metal post weak link.Problems: loosening of post and core, fracture of core from post, time consuming( waiting for cement to set.

Today with the newest bonding agents and with fiber reinforced composite posts we can quickly and effectively create a monoblock( from apex to crown) and bond our post and cores into place.Created a strong, long lasting restoration.

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New Endo Tip for root canal application

VocoUsing Futurabond DC and Rebilda Post and core system, quickly create that bonded tooth from apex to crown.

Advantages

Dentin-like elasticity behavior, high transverse strengthHigh radiopacity (350% Al)Translucency like dentineAnatomical shapeAdhesive lutingRemovableAll materials in the set match each otherP t i ti d b ild i tPost insertion and core-build-up in one step

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Know YOUR

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80‐90’s

BEYOND

20’s, 30’s,40’s,50,s

60’s‐70’s

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MenIf you are in the top 25th % health-wise at 70 you have apredicted life span of 18 years but if you’re in the bottom

25th% only 6.7 years

E Prognosis.com

At 80, if you are in the top 25th% you have a predictedlifespan of 10.8 years versus 1.5!

Women21.3 years for the top 25th% at 70 and 9.5 for bottom 25%

13 years for the top 25th% at 80 and 4.6 for the bottom 25%

Conservative/Tooth preserving ideologyA periodontal/restorative approach with state of the art periodontal therapiesHygiene based growthDiagnostic tools that enable my team to follow the philosophyPrevention at every agePrevention at every ageAge/Health related dentistry

Cases in Point….Patient Paradigms

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Transillumination TechnologyIt can find caries and cracks often not seen on X-rayIt can help identify recurrent cariesCan be stored in patients fileUsed for insurance documentation

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Red Areas showing areas of porphrine absorption from

carious bacteria via Spectra Doppler Affect

Medium sized Wedge to seal gingival marginBurnished bandMesial groove beveled over

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Total or Selective Approach Followed by All Bond Universal Bonding AgentSurefil SDRKalore A2 in 2 layers

i i i B/L lmaximizing B/L cuspalplacement and low stress

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2% Chlorhexidine for 30 to 60 seconds or NaHypochlorite, or Ozone or micro-etchingRinse…suction or blot dry LEAVE MILDLY MOIST (Technique Tip: Dip a micro-brush in a dappen dish with water, then remove excess on gauze and lightly moisten the dentin)Place TheraCal and light cure for 20 seconds at leastNo more than 1mm in thicknessOne can re-prep excess away once light curedThen etch, bond and complete restorationThen etch, bond and complete restoration

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Selecting the Right Matrix

They are broken down into sizes for Maxillary Centrals and large Laterals

The Canines are differentiated by curvature of the incisalSeparate matrixes for lower anterior teethOptions also include extremely large black triangles and

extremely large diastemasTraditional DiastemasTraditional Diastemas

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Less curvedLess curved

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Remove all plaque, tartar, via ultrasonicsWe micro etch each surface…PrepStart by DanvilleOther options exist, many office utilize micro-etchers with water spray that remove stain, etc

For lower incisors and upper lateral incisors

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I pre-wedge often to get the matrixes into place, they are a bit thickWhen they are in place, one can manipulate to hold them in place during the procedure to etch and bondInsure they are tucked into the sulcus to prevent overhangsRemove as much excess prior to curing with multiple traditional brush tips.

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Mastering the SingleTooth IMPRESSION

With a whole new twist!

NO Cord !!NO Cord !!

89%

1-Samet N, Shofat M, Livny A, Weiss EI. A clinical evaluation of fixed partial denture impressions. J Prosthet Dent 2005; 94:112-117.

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Lava COSITERO

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ITEROVPS

Lava COS

margin

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Delivery Tip Comparisons

Type Back‐fill

Impregum 50 ml teal

50 ml yellow

digit® regula

r

Root canal

power flow TM

OD .100 .072 .062 .057  .072 .041 .034

ID .042 .037 .022 .024 .046 .031 .022

Digit loaded for impression

Regulator for pressure…1-4

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Superb Tear Strength, Hydrophilic, Excellent flowAll t t t ti d t ll t i i ith th f f f All to retract tissue, and capture an excellent impression with thus far, far fewer voids, pulls and fins

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•I took a traditional Aquasil with retraction after my Cordless impression to compare•Sent to my lab to compare and returned with the comment, “My docs would love this!”

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An absorbent paste that provides hemostasis and minor retraction to soft tissue:

15% Aluminum Chloride (AlCl)Paste is preloaded into disposable syringesMaterial is dispensed through a bendable tip Clay absorbs fluids & expands – helps dry the sulcus and enhance tissue displacement. Has an affinity to blood. In 2 minutes…this stops bleeding!I use this very often without the caps in somany clinical situations.

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Retraction Caps for tissue compression3 sizes, small for lower incisors, medium for bicuspids and upper anterior teeth, large for molarsSimply cut them down in size, place over your 2nd cord if retracting and if using cordless place over the paste directly and OMG….just wait the 2 (cordless) or 5 minutes and the tissue looks

t!!great!!Seriously…every impression

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The material sheers as it exits out the tip, this allows the flowWithout the air pressure, you couldn’t express the material

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Size Color Work Time

Mouth Removal Time (MRT)

No. of Teeth 

Fill Amount

Single Light  35” 3’00” 1 ‐ 2 .7 mL

One tooth MAX!

• Scannable• Eliminates waste compared to traditional 50mL

gun

Purple

Multi Light Blue

1’00” 4’30” 3 ‐ 4 1.6 mL

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Save time on • Retraction 5 minutes per tooth• Waiting time 5 minutes for retraction

Distance

Close up

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Ivoclean to remove the contaminated pellicle after the crown was rinsed and pellicle after the crown was rinsed and

dried

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• Injected into the crown

2.5-3 minutes of work time Easy clean up

The Core Question…..

Do you remove this large amalgam buildup if the margins seem solid?

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A cement that seals and has great retentionA cement that resists micro-leakage and is acid resistantInhibition of caries and plaqueLow solubilityA cement that is thin and simple to applyA cement that is easy to clean A cement with long term studies that ensures peace of mind because

it integrates with dentin and creates remineralizationA universal cement for metal, zirconia and all ceramics

6 year fractured crown Micro-leakage, Recurrent Decay, Solubility??? Seal ???

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Property Result

Working time 2 min…TIME TO GET THOSE CROWNS INTO PLACE

Net Setting time 5 min….CLEAN UP BEGINS AT 3 MINUTES…

Film thickness 15µm NICE AND THIN

Compressive strength ( 24 h) 160 Mpa

Radiopacity 1.5 mmAl NO TRANSLUCENCY

In the intro pack, you get the plunger agun, you only need your trituratorSo you activate for 3 secondTriturate for 5 or 8 secondsThen turn the nozzle 180◦ and inject intthe crown2 unidose packages:Single units (triturate 5 seconds)Single units (triturate 5 seconds)Multipack for up to 3 units (8 seconds)

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• Cementations are booked for 15 minutes • It’s about removing the temporary cement

and the cement being on the temporary and the patient NOT being numb

• Trying in the restoration and minmaladjustments

• Cleansing the tooth and the internal surface

• Final Cementation that has great properties and easy to use

Cling² by Clinicians Choice

GC FGC Forceps

Ceramir

GC FORCEPS

Removes temporaries, permanent crowns that are temporarily cemented, implant crowns that are cemented in….

GC FORCEPS

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Sh t h i htShort height

Bisco’s Cavity Cleanser 2% Chlorhexidine

Simply then place moist gauze while cement was

i dmixed

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Zirconia Crown

After 3 minutes…peel the excess cement floss down initially and at 5 minutes

I floss up…full set for retention and say bye-bye at 5 min!

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56 years oldWanted some old PFM’s on 9 and 10 replacedDid NOT want to crown 7 and 8Liked her natural colorPost Laser Crown lengtheningFirst off replacing an ugly crown on 28

Margin

LG:

Tissue soundingallows the practitioner to properly place the margins of the preparation. Rule of thumb: If the tissue probes 2-3 mm, prepare .5mm sub-gingival and no deeper, probing of 4 mm means themm means the margins should be placed 1-1.5 mm below the tissueand for 5 mm probing, 2mm plus sub-gingivalClosing black spaces and diastemas , interproximal probing applies

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Stump shade (not required due to preparation thickness)…Used LT e Max IngotPictures with color shade tabs for each 1/3 of the toothMultiple pictures from different angles with comparative pictures for surface texture and

l ticolorationClear directions make this possible

Lubricated Teeth with “Wink” as separatorCured Dentsply’s Integrity Buccal and Lingual and removed in 20 seconds

Triimmed, Microetched and used Flowable to redo any margins or contacts

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