Read All Ceramic 2006 Lecture Only hand out 2006.PDF text version

A Blueprint for Esthetics:

The Art and Science of Exquisite Esthetics

Jeff T. Blank, DMD

Private Practice

Adjunct Instructor Dept. of General Dentistry MUSC College of Dental Medicine

The content of this guide is the exclusive property of Jeff T. Blank, DMD and may not be duplicated or distributed without written permission by the author.

I. Basics of " Smile Design"

Smile Line ­ The line created by the incisal edge position of the maxillary anterior teeth. Ideally should follow the natural curvature of the lower lip Should be parallel to the horizon from a frontal view may be a masculine or feminine profile.

" Media Smile Line"­ When all the edges of the maxillary teeth fall in the same plane of curvature. This " Gull Wing Smile Line"­ When the edges of the maxillary lateral incisors are superior or coronal to the plane of curvature, creating step pattern similar to a bird' wing in flight. s

Central Dominance ­ The concept that the maxillary central incisors be the largest, most dominate teeth in the smile. General length to width ration should be 75 ­ 85% - Rectangular, not square

Midline should be perpendicular to horizon ­ even if not centered in face Embrasure must be succinct, and is defined by age

Axial Inclination ­ The angle created by drawing an imaginary line through long axis of the tooth. to the horizon

Ideally the maxillary anterior teeth should have axial inclinations that tilt slightly distal of perpendicular Centrals should be mirror images, deviations in laterals and canines more acceptable Incisal Embrasures and Contact Points ­ The small space between the incisal edges of teeth. Depth of embrasure dependent on age / wear. Contact points should be positioned more coronally (positive smile line) as you move more distally in

the arch

teeth should be on the same plane, and parallel with the horizon Contralateral tooth in same plane Acceptable alternatives are:

Gingival Symmetry ­ In the most extreme ideal circumstances, the free margins of the maxillary anterior

High centrals / low laterals / high canines Gingival Zenith ­ The crest or apex of the gingival scallop should be slightly distal to the middle of

each tooth

fill the negative space distal to the canines.

Properly filled buccal corridor ­ From a frontal view, having a wide enough maxillary arch such that teeth

Gender Identification Characteristics:

Male: Show less teeth at rest (avg 2mm) Shallow incisal embrasures

Sharp line angles and flatter incisal edges Generally " Media Smile"profile

Pronounced surface texture Bold Canines Female:

Show more teeth at rest (avg 3.5mm) Deeper incisal edges

Round line angles, more variation in edge shape Often " Gull Wing"profile Smooth surface texture Delicate canines

Age Characteristics:

Younger: More pronounced mammelons

Deeper embrasures ­ ranging from an open contact in youth, to non-existent in geriatric patients More incisal translucency and edge characterization Lighter shades Older:

Mammelons non-existent or worn Shallow embrasures

Less edge characterization

Shade shift to yellow/orange/ brown range

II. Gingival Esthetics

Lip Line High ­ excess gingival display ­ lip apical to free gingival margin of maxillary anterior teeth Normal ­ Lip drapes along free gingival margin of maxillary anterior teeth Low ­ Lip falls coronally below free gingival margin of maxillary anterior teeth Guidelines for Minor Gingivectomies Not a substitute for osseous surgery Plan surgery such that at least 3mm of attached gingiva remain post-oeratively Identify the margin in relationship to the CEJ If margin coronal to CEJ ­ Cut away!

If margin at, or apical to CEJ ­ Use Kois Technique Avoid papilla for most predictable results

Avoid Low Crest / High Crest Situations (See Kois Technique) If using all-ceramic restorations with invisible margins ­ you may impress the same day as surgery

If using PFM, and exact location of tissue is mandatory, 6-8 weeks healing may be required (when laser blade) or electrosurg is used healing may be as early as 5 ­10 days. Longer healing expected with surgical

Advantages of Ovate Pontics Most esthetic Literally " creates"interproximal papilla

Most hygienic

Literally emerges from the tissue like a natural tooth Rounded shape is far easier to floss

Tissue preparation: If extracting tooth:

No cavitations like ridge lap to hide plaque

May consider the placement of alloplastic bone filler/matrix such as HTR (Bioplant) or FDB with GTR if anticipate massive bone change.

" unscrew it,"don' luxate buccolingually as it may damage buccal plate, increase resorption t

gingiva are supported. Recommend 5 ­ 8 mm depth into socket. Check/reline every 2-3 weeks prior to final impression Minimal healing time 2 ­ 3 months, longer is better

Place provisional pontic into extraction site (egg shape), making sure all walls of free marginal

If existing endentulous site: root)

Evaluate for sufficient bucco-lingual width to place ovate pontic (needs to be width of tooth If not ­ refer to Perio for bone graft

If sufficient width exists: socket)

Or place traditional ridge lap pontic

Ball electrosurge " dimple"5 ­ 8 mm into tissue (usually connective tissue in old Using needle tip, create sharp internal bevel on buccal free gingival margin

Check / reline every 2-3 weeks prior to final impression

Minimal healing time is 6 ­ 8 weeks

Support all walls with egg shaped provisional

III. Preparations for Anterior / Posterior All Ceramic Restorations

Recommended Preparation Protocol: 1. Recommend Kois Technique of osseous sounding for most predictable result. 2. If sounding dictates "Normal Osseous Crest" (85% of time) then: 3. Break contacts with fine diamond or 170L (Midwest) carbide, TAKE CARE NOT TO TOUCH INTERPROXIMAL PAPILLA! Treat like fluid filled bag! 4. "Rough in" preparations supragingivally

Favorite Diamonds for All Ceramic Preparations: Kits: *Axis All-Ceramic Preparation Kit ­ LS-7514 Axis Modified Shoulder Preparation Kit ­ LS-7532 Axis Posterior Preparation Kit ­ LS-7532 Individual Diamonds: Fast Cut/Gross Reduction -Two Striper (Premier) ­ 2005.8 C Disposable Heavy Chamfer -Ultrasharp (Local Rep Brand) 856 C Disposable Flame Shape Occlusal Reduction ­ Ultrasharp (Local Rep Brand) 368 C Disposable Barrel Shape Occlusal Reduction ­ Ultrasharp (Local Rep Brand) 811 C Light Chamfer - Brasseler 6856 018 4. Place 00 braided retraction cord (Ultradent braided) soaked in Hemodent plain. Expect 1 ­ 2 mm of apical movement of tissue. 5. Remove decay, place cores etc...

Recommended core materials: Build-It FR (Pentron) Luxacore (Zenith)

Vitrebond (3M) or Ionosit (Zenith) for very small undercuts or filling replacements

Dyract AP (Dentsply Caulk) ­ can be used with small to medium "filling replacements)

occurs, these margins will be SUBGINGIVAL once 00 cord is removed and tissue returns. emergence profile to prevent " black triangles"in interproximal embrasures. With veneer preps:

6. Finalize preparation margins TO the retracted sulcus (Note: if tissue is managed properly, no injury If diastemas are present, it may be necessary to place margin subgingivally to allow proper

contact entire

If contact present, do not break, but keep 3 plane reduction and hide all margins deep into

If diastema present, margins must extend to lingual marginal ridge to allow tech to fabricate Contact out of the restorative material.

7. Place second cord for LATERAL displacement of tissue: Recommend 03 cord for posteriors, 02 cord for anteriors. 8. Use Viscostat 2% (Ultradent) with Dentoinfuser, 2% Lido with 1:50K Epi with 30 gauge needle to infiltrate papilla if necessary 9. Allow both cords to stand for 4 ­ 5 minutes Special Note: If you use Viscostat, it is a recommended that you neutralize the oxides left on the teeth XTRA) to prevent tooth staining during provisional phase. The provisional phase should provide ample time to allow O2 to dissipate from tooth prior to bonding. (invisible now, but will turn black later!) by the Viscostat with 35% hydrogen peroxide (Opalescence

IV. Impression Technique:

placed in a Kerr Free Flow Syringe for wash For Triple Tray impressions, recommend Aquasil Rigid for tray material and XLV (Dentsply/Caulk) Polyvinyl Users:

For Full arch (recommend custom trays ­ easiest with Triad Custom Tray Material Syringe as wash.

(Dentsply/Trubyte)). I recommend Aquasil Monophase as tray material and XLV with Free Flow

Light for wash (Heraeus Kulzer) placed in Kerr Free Flow Syringe wash.

For Triple Tray impressions, recommend P2 Polyether Heavy for tray material and P2 Polyether

Polyether Users:

For Full Arch impressions, I recommend P2 Polyether Monophase for tray material and P2 Light for

Disposable Trays:

Axis Originate Trays ­ Color coded, use with or without adhesive

Steps:

Viscostat 2% and Lido 1:50 Epi if necessary. 2. Thoroughly rinse preparations, then dry

1. Wet, and remove second cord. Inspect for proper lateral retraction and visibility of all margins. Use

3. " Front load"Free Flow Syringe with wash (yellow) 4. Assistant loads tray with monophase material 5. Syringe wash into dry sulci sequentially 6. Seat Tray Bite Registration: Regisil Rigid (Dentsply Caulk) ­ semi rigid, can trim with scaple Luxabite (DMG Zenith) ­ extremely rigid, must cut with a bur Products:

Technique: Placed on lower teeth, patient placed in CO / CR with favorite method! permits technician to mount case parallel to horizon.

Place 6"cotton tip applicator stick or disposable brush in excess aligned with the interpupillary line -

Bis-Acryl or Bis-GMA Provisional materials;

V. Provisional Restorations:

Not new, first released in 1982 ­ but not in automix gun!

NO MIXING! NO MESS! EXTREMELY EASY TO USE. Less shrinkage ­ under 3-5% Stronger, more durable Less heat generated ­ well under 100 degree F.

All now come in " guns"with automix cartridges/ Either 10:1 or 4:1 ratios of catalyst/base

Can be repaired, and relined with traditional composites or flowables Can be " characterized"with flowables or composite tints and stains

Integrity (Dentsply Caulk)

Products:

IsoTemp (3M)

Protemp Garant (ESPE)

Luxatemp Plus (Zenith) and Luxatemp Solar (Zenith ­ light cured)

Advanced Functions of Provisionals:

1. Serves as cosmetic " preview"of case

2. Can " train"tissue, in the case of ovate pontic formation, or diastema closures

3. By using silicone index of patient approved provisional, vital lab information can be communicated

Two Esthetic Provisional Techniques:

1. Clear " suck down" matrix ­ allows visualization of seating, venting of air bubbles, great when no " wax up"needed. Can use light cured material like Luxatemp Solar or Triad a. Negatives: Must duplicate wax up in stone, trim model, have tray unit, temps usually

too high due to inaccuracies that occur due to model error and air trapped under matrix

2. "Wash Impression" technique- perfect for wax ups ­ no need to duplicate model ­ super accurate ­ little adjustment necessary. IS THE BEST METHOD FOR FABRICATING COMPLEX CASES a. Soak model in soapy water for 5 minutes initial " impression"of wax up

b. Use favorite lab putty (Sil Tech Extra Hard Lab Putty ­ Ivoclar/Vivadent) to take c. Take " wash"impression with Aquasil XLV or P2 Wash inside lab putty impression

3. I prefer to leave the 00 cord in place while fabricating provisionals cores exist

d. Incredibly accurate.

4. Lubricate preps with light coat of Glycerin or DeOX (Ultradent) ­ especially if composite 5. Place Integrity (Dentsply Caulk) usually A1, in matrix or impression, seat 7. Trim and polish ­ Recommend Axis LS-909 Temporization Set. a. Pogo (Dentsply/Caulk) 6. Remove in 1 ­ 2 minutes ­ work on and off as usual

Can polish chairside with Enhance Cups, Discs and Points (Dentsply/Caulk) and

b. Axis PDQ Single Step Polishing System c. Polish ­ Buffalo Dental Itself

Or on polishing lathe with Coarse and Fine pumice, followed by Acriluster Acrylic

8.

Reline with: Best results, clean inside out with alcohol, roughen with diamond b. Flowable composites a.

Cementation of Provisionals:

1. TempBond Clear (Kerr) ­ not related to Temp Bond at all ­ this is actually a soft-setting 2. Provilink (Ivoclar) ­ Also a soft setting composite, but not clear ­ has more of a dentin shade composite system. Dual Cured ­ Very Clear!

4. Dycal (Kerr) ­ Used primarily in posteriors ­ yellow show through a big problem in anterior.

3. Duralon (ESPE) ­ Great for low retentive preps, single units, posteriors

VI. Delivery of Final Restorations:

" Bulk Cure" Technique: Jeff T. Blank, DMD 1. Remove temps, microetch or clean with non-fluoridated pumice (NuPro ­ no Fl ) 2. Use cord, hemostatic agents judiciously ­ but secure non-contaminated field form,esthetics. Receive patient approval. 3. Try in Restorations with Calibra (Dentsply Caulk) Water Soluble Try In Paste- check fit, 4. Rinse restorations and preps vigorously with air/water spray to remove try in paste (Porcelain Etch ­ Ultradent)

5. Dessicate ceramic restorations ­ check internal etch ­ if suspect ­ re-etch with HFl-5% 6. Silanate bonding surfaces of restorations with Calibra Silane (Dentsply Caulk) or 7. Etch preparations with 37% phosphoric acid for 15 ­ seconds Ultradent Silane ­ BE SURE TO WATCH EXPIRATION DATE!

8. Rinse vigorously with air/water spray ­ suction excess with high volume evacuator ­ DO NOT DESSICATE! LEAVE MOIST. (Use Dr. Blank' " s Ross Perot" technique!) a.

9. Adhesive Products:

5th Generation ­ Primer/Adhesives:

b. 4 Generation ­ Separate Primer and Adhesive 10. 5 Generation Adhesives (see above) a.

th

th

iii. Gluma Comfort Bond ­ (Heraeus Kulzer) no " activator"needed i. All Bond II - Bisco

ii. One Step ­ (Bisco) no " activator"needed

i. Prime & Bond NT with Self-Cure Activator (Dentsply/Caulk)

Doctor: apply with multiple coats, preferably with disposable brush (brings more to prep at one time) over a 20 second time period. Air thin (to prevent pooling in line angles and to evaporate volatile solvents) ­ Light cure all sides of preparations for 20

b. Assistant: with same mixture, apply to inside of each restoration, air thin ­ DO 11. If thin veneers: a. NOT LIGHT CURE.

seconds (traditional halogen light)

If full coverage, or thick veneer (greater that 2 mm at any spot in restoration) Caulk), apply to internal aspects of restoration, seat.

Fill each veneer with light cured base of Calibra (Dentsply Caulk) only, seat.

Mix equal quantities of light cured base with regular catalyst of Calibra (Dentsply

12. Once seated ­ DO NOT WIPE AWAY EXCESS. Simply cure BRIEFLY

(depending on shade, cure from 2 seconds to 5 seconds) with traditional halogen light to begin polymerization of the excess. Touch with explorer to check when " ready." Once it has the with and explorer and floss ­ just like with Rely X or other cement. consistency of traditional cements, have assistant apply finger pressure and peel excess away

13. Once 100% of cement is removed, increase intensity of curing light {Spectrum 800 (Caulk), 14. Seat additional units in same fashion until complete. Optilux 501 (Kerr/Demetron) or PAC (ADT)} and cure for 1 minute per surface.

15. Place glycerin on all exposed margins (to permit cure of air-inhibited layer), and cure at high 16. If necessary, use #15 scapel blade (Bard/Parker) to remove excess ­ avoid rotary instruments 17. Adjust occlusion ­ recommend CeraGlaze (Axis) a. c. Metal Strips (GC) Epitex (GC) on root surfaces. intensity for 1 minute per surface. More than one light speeds process.

18. If you accidently get things "stuck" together:

b. VisionFlex Diamond Strips (Brasseler) d. Cerisaw (DenMat) e. f. Sof-Lex (3M)

VII ­ Post Insertion Porcelain Adjustments

1.Best to delay final finishing and polishing until 24-48 hours post-delivery to permit bond strengths to mature 2. Kits: a.

b.

3. Individual Discs

edges, embrasures, gingival margins, linguals

Finishing Concepts Set ­ LS-7538 (Axis) Tiny diamond burs for shaping

Aesthetic Recontouring and Polishing Kit ­ LS-7701 (Axis)

a. Latch Grip Diamond Disc for embrasure shaping ­ 945-B (Brasseler)

If you are interested in having Dr. Jeff Blank speak to your study club or symposium, please contact Jennie Cahill at 803-327-3240 0r [email protected] Or visit our Website at www.carolinasmilecenter.com

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