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MONOLITHIC RESTORATIONS The New Gold Standard In Dentistry

Bruxzir Zirconia Crown IPS eMax

Eugene L. Antenucci, DDS, FAGD, DICOI

Esthetic Restoration of Posterior Teeth “Extension for Prevention”

Esthetic Restoration of Posterior Teeth Extension for Prevention

Restorative Dentistry 2016 We have witnessed and have participated in the decline of the age of amalgam and metallic materials in restorative dentistry.

AMA LGA M RIP

Restorative Dentistry 2016 • • • • •

Pit and Fissure Sealants Preventive Resin Restorations Direct Adhesive Composite Restorations CAD CAM Chairside and Lab Produced Ceramic and Hybrid Ceramic Restorations - Lithium Disilicate Restorations - Zirconium Restorations - Empress Ceramics • Ceramic Bridges

This is a New Age in restorative dentistry. The Metal-age served basic needs - freedom from pain and the restoration of function. Our patients had limited value for the services that dentistry provided. We used available technologies, which today are old and dated, and offered non-esthetic materials. The New Age is an Adhesive Age. It is an age that requires routine restoration with esthetic materials, and of elective dental care that enhances our patient’s appearance. It brings with it a high degree of cosmetic consciousness. It is an age of brighter smiles and higher patient demands. It requires relationships, advanced technology, and the promotion of value in all aspects of practice.

We were all taught In dental school That GOLD was the Standard when it came to dental restorations

Glidewell Dental Lab

Benefits of Gold Bio-compatibility: Gold will wear similarly to enamel, and will not abrade enamel as traditional porcelains do. The human body tolerates gold exceptionally well, with insignificant adverse reactions. Excellent Strength and physical properties: Gold will not fracture or break Longevity: While all restorations are prone to fail over time, the success rates for gold restorations is high Contour and gingival harmony: Gold restorations can be intimately adapted to tooth structure, with margins that are thin and well-contoured to the restored tooth as well as to gingival tissues.

Disadvantages of Gold ESTHETICS: The majority of patients consider gold and metal to be unesthetic, and do not desire gold or metallic restorations COST: Although Gold prices fluctuate, the laboratory cost of a gold restoration in high, and that cost will be passed on to the patient TIME and convenience: Gold restorations require at least 2 patient visits and do not give the dentist or patient the option of a single visit CAD CAM restoration PREPARATIONS: Metal-based ceramic restorations require sufficient reduction for both the metal coping and overlying ceramic. CERAMIC TO METAL FAILURE: Excess stress and/or insufficient amount of ceramic veneering materials, coupled with laboratory errors cause a consistent rate of ceramic to metal fusion problems and debonding.

Disadvantages of Gold However the main disadvantage is ESTHETICS. What would your patients prefer?

JADA June 2011 Gordon Christiansen wrote:

“In my experience, most patients want tooth-colored indirect restorations, regardless of whether such restorations are in their best interest.”

PFM Restorations Dr. Charles Land introduced the first all-ceramic crown in 1903 after having attained a patent in the late 1800’s. The “Porcelain Jacket Crown” was made of feldspathic porcelain. They were very esthetic, but exhibited relatively high failure rates.

PFM Restorations PFM’s became available in the late 1950’s, and by the mid 60’s they had become a popular alternative to the porcelain jacket crown that was developed and made popular in the early 1900’s by Dr. Charles Land.

Trends in Dentistry

So Lets Explore and Make Sense of What Is Going On In The World Of Restorative Dentistry In a Way That Is Clinically Practical To You

Revolutionary Changes in Restorative Dentistry

Dr Mike DiTolla and Glidewell Laboratory

Revolutionary Changes in Restorative Dentistry Add to this the number of in-office CAD CAM restorations being performed annually. At last count, there were over 12,000 in-office scanning and milling machines in active use in the United States – counting both Cerec and PlanmecaFit (formerly E4D).

Monolithic Crowns as Compared to Traditional Bi-Layered Crowns

Ceramo-Metal Restorations (PFM Crowns) - weakest point is the ceramo-metal interface - fusion is a combination of mechanical retention, charged particle attraction and chemical bonding - tensile strength is approximately 4% of its compressive strength – layering porcelain on metal gives support - studies have shown the mean de-bond strength of feldspathic porcelain to gold-palladium alloy to be 42 Mpa Venkatachalam B, Goldstein GR, Pines MS, et al. Ceramic pressed to metal versus feldspathic porcelain fused to metal: a comparative study of bond strength. Int J Prosthodont. 2009;22(1):94-100. See more at: http://www.dentalaegis.com/special-issues/Dawson/2010/08/monolithic-versus-bilayered-restorations-a-closer-look#sthash.NwV9ovM3.dpuf

Monolithic Crowns as Compared to Traditional Bi-Layered Crowns Monolithic Restorations – Lithium Disilicate - iPS eMax Press and iPS eMax Cad - produced either from an ingot that is “pressed” to form, and as a precrystallized block that is milled in CAD CAM systems and then sintered in an oven. Both allow for cutback, porcelain addition, staining and glazing.

- fracture toughness studies show it to be 3 Mpa-m1/2 or greater. - studies have shown that veneering ceramics on lithium disilicate show no difference in the restoration’s longevity - conventional or adhesive cementation.

Monolithic Crowns as Compared to Traditional Bi-Layered Crowns Monolithic Restorations – Zirconium - Flexural strength of 1000+ MPa - Adequate esthetics - Low wear of opposing tooth structure

- Conservative tooth preparation - Indicated for 3+ unit anterior bridges and 3 unit posterior bridges, as well as single unit posterior crowns

- Conventional or adhesive cementation

IPS e.max

IPS e.max

IPS e.max

IPS e.max

New York University Mouth Motion Fatigue Study

New York University Mouth Motion Fatigue Study

New York University Mouth Motion Fatigue Study Of An IPS e.max Crown

New York University Mouth Motion Fatigue Study Of A Zirconium Crown

New York University Mouth Motion Fatigue Study

New York University Mouth Motion Fatigue Study

IPS e.max and Translucency

IPS e.max Refractive Index Demonstration

IPS e.max Esthetic Superiority

IPS e.max Esthetic Superiority

IPS e.max Esthetic Superiority

IPS e.max Esthetic Superiority

IPS e.max Esthetic Superiority

IPS e.max Esthetic Superiority

IPS e.max Esthetic Superiority

IPS e.max Esthetic Superiority

IPS e.max Esthetic Superiority

IPS e.max Esthetic Superiority

Our Goal at All Times Should Be To Provide The Most Conservative Approach To Treatment

Establish defined protocols for each restorative situation:

Esthetic Restoration of Posterior Teeth How do we approach the treatment of defective existing restorations? What parameters do we follow in order to restore posterior teeth having more than a moderate amount of tooth structure requiring replacement?

Decisions in Treatment Planning

Composite

Crown

What do you do here???

Decisions in Treatment Planning

Composite

Ceramic Onlay

Crown

Decisions in Treatment Planning

What do you do here???

Esthetic Restoration of Posterior Teeth Indications and options for determining types of restorations: •Size of the lesion •Size and number of restorations •Location of restoration margins •Location of the tooth in the arch •Tooth anatomy

Tooth Preparation for IPS e.max

1.5mm Occlusal Reduction Bur

Minimum Material Thickness – Inlay/Onlay

Full Crown Preparation

Onlay Preparations

Veneer Preparations

Tooth Preparation for IPS e.max

Tooth Preparation for IPS e.max

Tooth Preparation for IPS e.max

Tooth Preparation for IPS e.max

Tooth Preparation for IPS e.max

Tooth Preparation for IPS e.max

Tooth Preparation for IPS e.max

IPS e.max Adjusting and Finishing

IPS e.max Adjusting and Finishing

IPS e.max Adjusting and Finishing

IPS e.max Adjusting and Finishing

IPS e.max Adjusting and Finishing

IPS e.max Adjusting and Finishing

IPS e.max Adjusting and Finishing

IPS e.max Adjusting and Finishing

Cementation of IPS e.max Restorations

Cementation of IPS e.max Restorations

20 seconds

60 seconds

15 seconds on dentin or 30 seconds on enamel Light cure

Cementation of IPS e.max Restorations with Relyx UniCem 60 seconds

20 seconds

Everyday Dentistry with IPS e.max and Planmeca Fit 42 year old male patient presents with pain #6. He not seen a dentist for years, is traveling to Greece in 4 days, is very concerned about his pain and has high esthetic demands. And he wants a discount!

Endodontic treatment was performed on an emergency basis and temporized with composite until later in the day when time was available to complete the treatment

When the patient returned at 6pm a direct post and composite core was placed. The diode laser was used at 2W for 30 seconds to perform a soft tissue crown lengthening beyond the level of decay.

PLANMECA FIT Fully Integrated Technology

Rapid Scanning with Planmeca Fit

A direct post and core was placed and a digital impression was taken with the PlanScan image of the preparation, the opposing arch and the bite which was recording by having the patient close.

Digital impression of the opposing occlusion

Digital impression of the bite registration

Powerful and Simple Design Tools With Planmeca FIT

Design Basics

The design was completed, including morphology, occlusion, and proper contacts within 5 minutes of time.

An LT e.max A2 Block was milled chairside in the PlanMill Unit

An eMax LT shade A2 crown was milled by the PlanMill 40 and the crown was prepared for crystallization, staining and glazing in the Ivoclar oven after an intial tryin for contacts, form and occlusion. After adjsutments are made the crown is placed in the oven. The cycle is approximately 20 minutes and the crown is ready to try in.

Ivoclar Programat P 310 Furnace

The crown was seated with MultiLink Clear Cement after a ten minute 5% HF acid etch and 60 second of silane. This photo was taken 3 days post-op prior to the patient leaving for Greece

Understanding the benefits of single-day dentistry from this case

Understanding the benefits of single-day dentistry from this case Case Fee: Root Canal treatment Direct post and core Laser crown lengthening eMax crown TOTAL: Total Time required: Emergency assessment and root canal treatment Direct post and core and customized eMax crown TOTAL: Productivity per hour:

$1150 $ 350 $ 350 $1495 $3345.00

1.25 hours 2 hours 3.25 hours $1029.23 / hour

MONOLITHIC ZIRCONIA RESTORATIONS

MONOLITHIC ZIRCONIA RESTORATIONS

MONOLITHIC ZIRCONIA RESTORATIONS

MONOLITHIC ZIRCONIA RESTORATIONS

MONOLITHIC ZIRCONIA RESTORATIONS

Indications: - Crowns - Bridges - Veneers - Inlays and onlays - Screw-retained implant crowns

Preparation Requirements for Monolithic Zirconium

Cementing Monolithic Zirconium Restorations

Adjusting, Polishing, Finishing and Removing Monolithic Zirconium Restorations

Removing a Monolithic Zirconium Crown

MONOLITHIC ZIRCONIA RESTORATIONS

One of the biggest issues with Monolithic Zirconium to date is its opacity, or lack of translucency, resulting in a compromise in esthetics. Bruxzir Anterior was developed to remedy the esthetic compromises in using Zirconium. It exhibits a reported flexural strength of 650 Mpa with color and translucency similar to dentin. They are indicated only in areas of lesser stress since they are weaker, and they can be conventionally cemented or adhesively bonded.

MONOLITHIC ZIRCONIA RESTORATIONS

Tooth #10 restored With Bruxzir Anterior

MONOLITHIC ZIRCONIA RESTORATIONS

Bruxzir screw-retained implant crowns #14, 15

Bruxzir crowns #18, 19

MONOLITHIC ZIRCONIA RESTORATIONS

MONOLITHIC ZIRCONIA RESTORATIONS

MONOLITHIC ZIRCONIA RESTORATIONS

MONOLITHIC ZIRCONIA RESTORATIONS

MONOLITHIC ZIRCONIA RESTORATIONS

MONOLITHIC ZIRCONIA RESTORATIONS

Sample Lab Fees for Crowns

The Dental Practice Paradigm has dramatically changed “A paradigm is like a pair of glasses, affecting everything you see in your life. Your paradigms are the source from which your attitudes and behaviors flow.” - Steven Covey

Success in dentistry isn’t the result of luck. It isn’t something reserved for somebody else. With a sound foundation of concrete goals, technical skills, communication skills, business savvy, and the proper use of technology, your practice will rise to the highest achievable levels.

There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in a new order of things. - Niccolo Macchiavelli

The proper use of Advanced Technology in Dentistry will help to get you where you want to go.

And you’ll have fun getting there!!!!

QUESTIONS???

Questions?

Eugene L. Antenucci, DDS, FAGD, DICOI 1579 Brentwood Road BayShore, NY11706 Phone: 631 665-8484 Email: [email protected] Web: www.baydentalhealth.com