Articles » Lee Ann Brady, DMD's Dental Blog

Total Etch or Self Etch: The Debate Continues

Sep 092011

Dentistry IQ

August 5 2011

Lee Ann Brady DMD

My partner and I had dinner together this week, and once we had handled our agenda items about the office, the conversation turned clinical. Before I knew it we were discussing etching techniques. My experience is that this is a common conversation amongst dentists; we poll one another to see what everyone else is doing and what their experience is with their chosen technique.

I make my choices about dental materials and techniques based on a variety of factors that include effectiveness, longevity, efficiency and patient satisfaction. For these exact reasons when I am asked which I use total etch or self etch, my answer is both depending on the clinical situation.

The purpose of etching is to remove the smear layer that is present after tooth preparation. In addition it opens the dentinal tubules, demineralizing enough of the dentin to allow the formation of resin tags within the dentin structure. This process in combination with dentin adhesives result in bond strengths adequate to place and retain restorations. Both techniques accomplish these goals, and come with risks and benefits.

Total etching is the classic technique of utilizing a 30-40% phosphoric acid gel to prepare both the enamel and the dentin for adhesive procedures. One of the greatest advantages of this technique is its ability to prepare enamel, dentin and sclerotic dentin for bonding, resulting in high bond strengths. Additionally total etch systems due not interfere with the polymerization of dual cure resin products so can be used universally.

On the other side are the risks. Utilizing a total etch system can be technique sensitive. First we have the challenge of adequately etching the enamel without over etching the dentin. Enamel surfaces require 25 seconds of exposure to phosphoric acid. Dentin on the other had should not be exposed to the gel for more then 15 seconds. Over etching dentin results in post operative sensitivity as well as decreases in bond strength due to the demineralization penetrating further into the tubules then the resin tags will go, and formation of a gap. To compensate for this challenge I ring the enamel in etching gel and count off to ten seconds, I then cover all of the dentin surfaces, wait fifteen more seconds and then rinse.

Rinsing adds the next challenge as then we have to understand how moist to leave the prep before placing the dentin adhesive. The concept is to rinse the gel away and dry to remove pooling of water, but to leave water in the dentinal tubules. The water is important because when the dentin is too dry the collagen matrix of the dentin tubules collapses and an adequate hybrid zone is no formed. This collapse prevents penetration of the resin, and decreases bond strengths. Primer is hydrophilic and designed to chase water, so having moisture is inherent in a successful bond. I have been taught many ways to do this. My current favorite is to place the high volume suction over the tooth and leave it in place for twenty seconds. The other challenge of rinsing the gel comes from its acidity and ability to cause the patient to salivate during a time when isolation is critical. We utilize a disposable surgical suction to remove as much of the blue gel as possible prior to rinsing. Then rinse with the high volume suction directly over the tooth, to minimize the amount of phosphoric acid that gets on the patients tongue. In my total etch technique I utilize a rewetting/desensitizing agent after rinsing and prior to placing the primer to overcome both the risk of post-op sensitivity and over drying.

Self -etching systems rely on 10% maleic acid or acidic monomers to remove the smear layer and demineralize the tooth structure. The over arching advantage of these systems is the near absence of postoperative sensitivity. Almost every dentist I talk to who uses a self etching system reports that they struggled with post op issues when using total etch, and it has all but disappeared since the switch. The absence of post op sensitivity comes from not over etching or over drying the dentin as part of the protocol. Not having to manage the timing of the material against enamel versus dentin, or worry about rinsing and drying are advantages all to themselves.

This up side does however come with some risks. Self-etching systems are less effective at preparing enamel surfaces and sclerotic dentin. The result can be lower bond strengths and the concern about adhesive failures. Many of the clinicians I speak to are utilizing a hybrid technique to overcome this challenge. They place phosphoric acid gel on only the enamel margins for 25 seconds. They rinse and thoroughly dry, and then use a self etching dentin adhesive. The etching component in the dentin adhesive, results in the product having an acidic ph. This acidity can interfere with the chemistry of some dual cure resin products. If you are using a self-etching system I strongly recommend that you verify the compatibility between your dentin adhesive and the resin systems you use routinely.

So let the debate continue for everyone else I keep both systems close at hand. Whether I self etch or total etch, or use the new hybrid technique depends on my assessment of the clinical factors present, and which technique I believe will be most efficient and effective, resulting in the highest patient satisfaction and clinical longevity.

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Maximizing Bond Strengths

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Sep 092011

Heraeus 360 Newsletter

August 2011

Lee Ann Brady DMD

Adhesive dentistry is the mainstay of what we do, and two of the most common questions I get are about how to improve the predictability and durability of bonded procedures. The first thing I think about when asked this question is going back to the basics to see where we can maximize bond strengths and success.

1) Are you properly storing your dentin adhesive materials? Take a look at the manufacturers recommendations for your dentin adhesive. Does it say “refrigeration required”? Most offices store their dentin adhesives in procedure tubs in order to make room set-up efficient, but many of these products are temperature sensitive.

2) Keep a close eye on expiration dates. We always check expiration dates when we receive product, and then make sure we use it in the order of the expiration. I have been in office where the new product is put away in front of the old, and then when they need that older stock, it turns out it is well beyond the expiration.

3) When are you dispensing the dentin adhesive? All adhesive products contain a solvent. These solvents evaporate in the presence of air, altering the viscosity of the material. Most dental assistants I watch in the name of efficiency set out all of the materials in advance, including the dentin adhesive. Dentin adhesives should only be dispensed as they are about to be used, and discarded once they have been out in the air. The single use systems are fabulous for this, just twist it open when you are ready to apply to the tooth. For bottles, I have my assistant take the lid off and dispense a drop directly onto the micro brush as she hands it to me.

4) Do you know the manufacturer directions? Each dentin adhesive system is unique and has different instructions. Things to know about the product you use include, whether it should be shaken prior to dispensing, the amount recommended time the material should be applied to the tooth and the number of coats recommended.

5) What are the procedure and compatibility recommendations of the manufacturer? Not all dentin adhesives are compatible with all types of resin cements so confirm compatibility when you combine materials. The manufacturer has looked at the efficacy of the material in different clinical situations; know the procedures they recommend their product for.

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Managing Discolored Dentin

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Sep 092011

Heraeus 360 Newsletter

July 2011

Lee Ann Brady DMD

One of the challenges of completing esthetic dental procedures is managing discolored preparations. I restore teeth on a daily basis that were at one time restored with amalgam, and have that classic greyish black color to the dentin. In addition managing the variety of dark brown colors that come with secondary dentin is an equal challenge. Most of our esthetic restorative materials, like composite and porcelain tend to be translucent. The classic result when I combine a discolored prep with a translucent restorative material is a dark shadow where the underlying tooth is dark, or an entire restoration that is low in value and high in chroma.

One of the techniques I have used in order to assure an exquisite esthetic result in these clinical scenarios is to mask the darkened dentin with a layer of opaque composite. The challenge of traditional opaque composites has been that they are high in value and don’t offer a range of chromas to match the existing dentin. With this in mind when discolored dentin is present I will prep away additional tooth structure to create space for the opaque layer and composite to mask it. The final esthetics are obtained by managing the correct combination of composite shades over this layer, to get a final result that matches the tooth in value, hue and chroma.

The new chromatic shades of Venus Diamond composite have overcome these challenges. Their masking ability in very thin layers is incredible and allows me to prepare the tooth more conservatively. The range of available chromas allows me to perfectly match the existing dentin in both value and shade. I utilize the Venus Diamond chromatic shades to restore the tooth to an ideal prep shape and color. Once this layer is cured I no longer have any color issues to “manage”, and acquiring an exquisite final result is as simple as if the prep were never discolored to begin with.

In addition to direct composite, this technique will allow you to achieve exquisite results when doing indirect porcelain restorations. Prior to taking final impressions mask the discolored dentin with a thin layer of the chromatic composite. At the seat appointment these small areas of composite need to be prepared with air abrasion, in addition to etching the natural tooth structure. This will ensure excellent bond strengths.

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Dr. Brady’s Top Clinical Tips

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Sep 092011

Heraeus 360 Newsletter

June 2011

Lee Ann Brady DMD

I have the good fortune to interact with dentists from around the world. We discuss the practice of dentistry, share experiences, and trade little tips that we can take back to our practices. Some of these “tips” made such a difference in what I do, they have stayed with me, and I love to share them with others. Here are five of my favorites.

1) Place a wedge interproximally as soon as the patient is numb, before beginning the prep. It can take several minutes for the PDL to be compressed and a wedge to overcome the dimension of the matrix band. This way you will see a space between the adjacent teeth, making prepping the box easier, and the contact tighter. You may have to place a larger wedge when you are ready to place the matrix.

2) Don’t put your dentin adhesive out until you are ready to apply it. The solvent in dentin adhesive will evaporate; changing the thickness of the material and also altering it’s properties, such as bond strength. If you are using a unit dose of I-bond don’t snap the cap until you are ready to apply.

3) Dog Ear the corner of a sectional matrix to create a handle. Sectional matrix bands can be difficult to hold on to, and impossible to hold at the correct angle for placement. By bending down one corner, I create a handle that allows me not to contort my hand during placement.

4) Use Gluma routinely. A good friend of mine has a standard line whenever anyone mentions Gluma, “Every Prep, Every Time”. I am with him on this one, the near lack of post op sensitivity in my practice gives me peace of mind and it an incredible internal marketing tool.

5) Take four photos on every hygiene patient that you print and give them for their records. One of the most powerful tools for increasing case acceptance I have implemented is to have my hygienist take a full smile, retracted smile, upper and lower occlusal photos. We take them at the beginning of the apt., print them and give the patient a copy for their records. The hygienist instructs them that if they see anything in the photos they have a question about to circle it and then they will ask me when I come in.

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Polymerization Shrinkage

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Jun 052011

Heraeus 360 Newsletter

May 2011

Lee Ann Brady DMD

There are a few classic concerns I have when adhesively placing a composite restoration. For the first few days and weeks after the patient is in I hope not to see their name on the schedule because they are having sensitivity. When patients are in the office for their hygiene visits I worry about seeing discolored margins, gaps at the restoration margin, recurrent decay or fracture of the remaining tooth. All of these “failures” are contributed to by the stress caused when composite materials shrink during polymerization. This stress causes cusps to flex and stress at the tooth/composite interface. For as long as I have been doing composites we have been talking about how to manage this clinically. It is these clinical implications that are at the heart of my worries.

We have been striving to overcome shrinkage stress and it’s affects through clinical technique and material development for many years. . On the technique side we vary placement of the material and light curing methodology in an attempt to reduce shrinkage stress.

Which of these to utilize and how well they work is still being unraveled in the literature. One theory is that we alter our clinical technique to manage the ratio between the bonded surface and unbounded surface of the material. Using this information the technique of applying composite in thin layers became popular. Recently we have come to understand that the mass of the material being polymerized also has an impact on micro-leakage

Other approaches include altering the light exposure in an attempt to increase the amount of time for resin flow. Curing techniques like “soft start”, “pulse delay” and “wave” work from these theories. Application of a layer of flowable in the base of the restoration, and newer concepts on pre-heating the composite material are also an attempt to manage shrinkage stress.

While we can continue to work from the technique side, what is clear is that working with composite materials that produce low shrinkage stress, due to their inherent chemical properties is the key to success. The inherent properties of the composite have been proven to be far more effective then any of the technique based solutions.

Class one restorations can be challenging when thinking about managing post op sensitivity and issues related to shrinkage stress. For this patient I chose Venus Diamond composite. Following preparation, the tooth was etched, Gluma Powergel was applied prior to the application of IBond Total Etch Dentin adhesive.

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Cerec & Paradigm

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Jun 052011

Virtual Model

Oral Health Journal

March 2011

Lee Ann Brady DMD

Pre-Op Quadrant

In the last six months I have only used a matrix band one time, and I am enjoying class two and class three restorations more then ever, thanks to my CEREC machine and Paradigm composite blocks. I like to joke and tell people that CEREC and I are the same age in dentistry, because the technology was brought to the US market the year I began practice. I was not one of the first people to jump in and use the technology back in 1988, as a matter of fact I didn’t pay much attention thinking, “ that will never take off”. I realize looking back that part of my resistance stemmed from my fear of technology. I am not naturally inclined to use technology and most of the time feel like everyone else is more proficient with his or her computers, cameras and iPods then I am.

I finally took a serious look at the technology when CEREC 3D came out and my Patterson rep arranged an in office demo. I was impressed by the technology, but truthfully couldn’t see how the numbers worked. At the time I was not doing partial coverage bonded porcelain, was comfortable with PFM for my full coverage, and that was the scope of the technology. Several years later after moving out of full time practice into education, I was given the opportunity not only to play with CEREC, but to spend time with some of the expert trainers and use the technology with their support. This was two years ago, and I have been an avid fan, and my day-to-day use of the technology has continued to grow since that time. I am clear for me that the integral part was training and getting comfortable enough with the technology that I could use it on patients without worrying about messing up the schedule or looking like I wasn’t sure what I was doing, so I strongly encourage everyone to commit to their learning process.

Final Preparations

One of my favorite applications for the technology has been using Paradigm composite blocks to restore class two and class three restorations. Truthfully I have also been known to use my machine and mill some class one restorations, but when the size of the restoration is smaller then the sprue even I give in and place the composite directly. The advantages of utilizing milled composite in these clinical situations are easy to share. I can reliably create contacts in all of the clinical situations I am presented with during the design phase, customize the intensity of the contact as well as it’s dimension in both a bucco-lingual and occluso-ginigval perspective. The days of struggling with matrix bands and wedging devices are over for me. I never wondered why there are so many booths at conventions on new matrix systems, it’s because being able to place a matrix system, wedge the teeth apart and predictably know you have a contact isn’t a part of everyday dentistry. Instead we remove the matrix, finish the composite, and then sheepishly reach for the floss, place it in the contact, turn our head and hold our breath as we hope to hear that longed for “snap”. What’s even worse are the phone calls days or weeks after the appointment where the patient reports packing “chicken” between their new filling and the adjacent tooth!

Final Paradigm Restorations

This is a thing of the past in my practice thanks to milling these restorations. I also have the ease of placement and finishing. I no longer have to layer in the composite and light cure each layer, wondering about the density of how I am condensing it against the previous layer. The Paradigm blocks eliminate worrying about voids from lack of adequate condensation or ineffective polymerization. I also have all my occlusal anatomy in the restoration before I seat is, cutting down dramatically on finishing time. In my hands I can image, design, mill and place a milled composite in the same or less time then doing one the conventional way, and I have a superior restoration.

I prepare the tooth as if it were going to receive a direct composite, I do not worry about draw of the restoration, accept in the interproximal box, where to minimize the marginal gap I want the walls parallel or to draw. Any undercuts in the body of the restoration are handled during the seat; as I place these restorations with composite, not resin cement. Once the prep has been completed, I powder the prep, image and then I’m ready to design. For smaller restorations, utilizing the Biogeneric design feature of the new 3.8 software it is not necessary to get a virtual impression of the opposing arch or a bite record. As the restoration size increase I will sometimes get these additional images to reduce adjustment time of the occlusion. My most complex paradigm composite restorations mill in 5-6 minutes and then we are ready to place them in the mouth. I place the sprue on the interproximal contact, and then adjust to exact tightness; some folks place the sprue on the undersurface of the restoration. Once my contact is set, I air abrade the underside with fifty-micron aluminum oxide, and apply a coupling agent like the resin from your dentin adhesive or Monobond Plus. Preparing the tooth in my hands looks like applying phosphoric acid to all the enamel margins, waiting 10 seconds, then covering the dentin for an additional fifteen seconds. Once I have rinsed and dried I apply Gluma as a desensitizer. I agitate the Gluma against the dentin for ten seconds. It is important to remove the excess Gluma, so with a cotton pellet I blot the cavity prep and then dry against the patients bib until the cotton comes out of the prep without leaving a circle on the paper. Following Gluma I apply I-Bond total etch dentin adhesive. The primer and resin are in one bottle, I apply to the dentin for fifteen seconds, then air dry for ten seconds until the prep looks satiny. Leaving the dentin adhesive uncured, I place a VenusFlow, a highly filled flowable, into the preparation liberally, making sure to coat all of the walls and the floor of the prep and place the restoration until fully seated. Holding the restoration in place Ilean all of the excess resin, including flossing. Lastly I place an oxygen barrier and then fully cure from all sides and angles.

If there are significant undercuts in the body of the prep, I will use my regular Venus composite instead of the VenusFlow. I heat the composite until it will flow easily, and using the same procedure as above place the restoration. When using heated composite I have found it is important to turn off any high volume suction that draws air over the tooth until after the restoration is in place. If the composite cools too rapidly, it hardens and you will not be able to get the paradigm down completely.

Prep On Upper Second Molar

My goal when I clean resin, is to get it all off and not have any cleaning to do with high-speed instruments or hand instruments. I never get it quite this good, but can get close. I like to use a rubber tip stimulator, which my assistant wipes with an alcohol two by two, or the micro tip rushes to clean the uncured resin. Once fully cured I utilize a brownie point in a high speed hand piece, running at low speed to clean al the excess and margins. The brownie will cut the resin, but not the enamel, and you do need to be using an electric handpiece that you can dial down for this, or they turn into little grenades. I finish the paradigm with the same polishing system I use for direct composite, and then last step is diamond-polishing paste on a prophy cup.

Upper Second Molar Final

My experience is that the paradigm is beautiful, it’s translucency allows the restorations to truly be a chameleon and disappear once cemented. If I need to bring the value up I choose a more reflective flowable composite like Venus Flow. I match the shade of the flowable I am cementing with to the tooth, and rarely if I have a very dark underlying prep from secondary dentin or amalgam stain, I apply a thin layer of opaque direct composite as a block out prior to powdering and imaging.

The addition of milled composite has made my life easier, dentistry more enjoyable and the results better clinically and more predictable for my patients. What more could I ask!

Link to article in Oral Health Journal

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Exquisite Provisionals: A Pattern for Success

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Jun 052011

Anterior Provisionals

Private Dentistry

April 2007

Lee Ann Brady, DMD

Exquisite provisionals are a key to predictable, beautiful, long lasting clinical results. Is there anything in dentistry more psychological disconcerting and unproductive than redoing your own clinical failures? For me the answer is a definitive “No”, and as I began searching for the answer to reduce failure and frustration in my practice, I kept coming back to provisionals. Now, let’s be clear about one distinction, this is not an article about “temporaries”.

: Provisonal Upper Left Second Molar

A temporary is a protective covering for a prepared tooth that bridges time (usually as short as we can make it) between preparation and insertion. Provisionals accomplish the same goal of covering the prepared tooth to prevent sensitivity and keep the relative position of the tooth in the arch stable. Provisionals also do much, much more. Beyond the semantics lies a fundamental shift in our thinking that allows us to see an interim acrylic restoration as an essential diagnostic tool and therapeutic modality.

Protecting the prepared tooth is a core responsibility of the provisional restoration. Research tells us that the primary causative factor in pulpal death is introduction of bacteria. As we look at the relative size of the bacteria as compared to the size of dentinal tubules, and the increasing number of tubules by surface area as we travel from the surface of the tooth inward, preventing leakage of oral fluids under an interim restoration becomes critical. This can only be accomplished with creation of marginal seal and adaptation equal to that of the final restoration as evidenced by unmarred cement upon removal of the provisional. If we are successful we will have also created an environment that allows the patient to function without sensitivity. Stability within the arch ensures that you are maintaining the inter-tooth and inter-arch relationships as they are represented to your ceramist on the working model. To accomplish this we need to have adequate inter-proximal contact and at least one cusp tip and one receiving area contact to prevent super-eruption, rotation or tipping.

Diagnostic Wax-Up

Strive to create ideal tooth form and inter-proximal contacts to create an optimal environment for tissue health and oral hygiene. For patients who present with combined restorative and periodontal concerns provisionals are a therapeutic tool to encourage optimal tissue health, evaluate tissue response and direct tissue development. Creation of anatomic gingival embrasures, emergence profile and heights of contour in addition to marginal adaptation in the presence of good oral hygiene allow optimal tissue response and healing. Place the initial margins in reference to the crestal tissue based on locating the base of the sulcus and evaluating the risk for recession based on tissue type and sulcus depth. If recession occurs it is preferential for it to happen during provisionalization, so that the opportunity is present to re-evaluate tissue health, biologic width, prep design and restorative contour to create a stable relationship prior to placement of the final restoration. Following adequate time to assess the tissue and completion of adjunctive periodontal procedures if necessary, reevaluate the margin placement prior to finalizing the restorations, with confidence that the relationship between marginal position and crestal tissue will remain stable.

The provisional also plays a role in tissue development. The interdisciplinary team can work together using interim restorations to direct tissue development for creation of ovate pontic sites, following implant placement, and to facilitate crown lengthening procedures. Development of ovate pontic sites begins with having adequate tissue over the ridge and can require tissue grafting. The site can be initially prepared using a laser, electrosurge or even a diamond bur on a high speed handpiece. The provisional is than shaped to extend into the prepared site and replicate the top portion of the root structure with rounded contours that sit down in the pontic site surrounded by tissue. Additionally provisionals are used in restorative cases requiring esthetic crown lengthening as both the surgical guide and to ensure optimal esthetics during healing.

Silicone Model

A diagnostic wax-up is completed that changes the tooth and tissue shape and contours. From this work-up create matrices that serve as a guide for crestal tissue placement and to allow fabrication of the interim restorations. Following placement of the crestal tissue using an electrosurge (lasers, scalpels and diamond burs also work) and tooth preparation the teeth are provisionalized. The periodontist is now able to flap the tissue and place the crestal bone to create adequate biologic width using the restorative margin as the guide, and the patient doesn’t have the sensitivity and esthetic concerns of exposed root surfaces and high and dry margins.

Provisonals are the blueprint for making esthetic changes, they allow the patient and dentist to have absolute control over the esthetic parameters of the case and no surprises at delivery. Create a diagnostic wax-up based on discussions with the patient around their esthetic concerns and goals. It is extremely helpful for the patient to bring in 2-4 photos or magazine clippings of smiles that they find attractive, this creates a visual representation for the dentist of the tooth shape and alignment and smile characteristics they are seeking without the struggle to use words. Using this template, create the provisional restorations and allow the patient to experience the esthetic and phonetic changes. The patient and dentist re-evaluate the restorations and any esthetic, phonetic or functional changes are made and the patient is allowed to test these. As we move through the process of evaluation use digital photography, and work through an esthetic work-up of the provisionals to make sure the original goals have been met. Photographs are a valuable tool for patient communication about the restorations, and if the patient is requesting changes snap a photo, print a copy and ask the patient to draw the changes on the photo. Once the patient and dentist are both thrilled with the esthetic, and functional design of the provisionals it is time to take impressions of the provisionals, the preps, the opposing arch, and a facebow transfer and bite registration. The models are mounted on an articulator and sent to the ceramist along with incisal edge guides. Now the ceramist uses the provisional restorations as a blueprint and recreates the esthetic parameters exactly.

Putty Matrix

As a blueprint provisionals also serve to verify the functional design parameters of a case prior to finalization. The provisional is used to create the occlusal relationships and anterior guidance based on the original diagnostic work-up. Over time the provisional is monitored for cracks, breakage, de-cementation and wear. The patient and dentist work together to smooth the guidance, adjust the transition from canine to central in crossover, even the intensity of the posterior stops until the patient is happy and comfortable and the occlusal relationship works for success. Given the opportunity of time the interim restorations will direct re-evaluation of the occlusal design of the restorations so that the final restorations won’t fail because of inappropriately handled force. Create this opportunity for learning by scheduling a final impression at a separate appointment from the preps, this appointment is arranged once both the patient and dentist are ready to move to the final restorations.

Provisional restorations can become a valuable routine diagnostic tool in your practice. They are an integral part of the protocol for assessing cracked teeth that require full coverage restorations, and being able to evaluate symptom response to our proposed treatment and the potential need for endodontic therapy. Provisionals are used to help clarify restorability in borderline situations before the teeth are condemned to loss.

When interim restorations are used as a tool, and allowed the time to direct the dentist to parameters of the case that need to be evaluated and altered we can move to the final restorations confident of long-term predictable results. Exquisite provisionals also build practice referrals. The time and care you take to develop esthetics and function equal to the final restorations differentiates you and your practice to both patients and the specialists you refer to.

Creation of exquisite interim restorations begins with a comprehensive evaluation and diagnostic work-up of the case. During the comprehensive evaluation the patient and dentist have clarified the present dental condition as well as the patient’s goals for reaching optimal function, structure, health and esthetics. Finalization of the restorative treatment plan and new records if appropriate will follow preliminary

treatment. Working from an accurate set of diagnostic casts that are mounted in centric relation evaluate the parameters of the case. Begin by looking at the anterior coupling and incisal planes. The goal is to create even contact, level incisal planes, and smooth function both on the outgoing and incoming stroke. This process may involve reshaping the anteriors, or an additive process using wax or composite to meet both the proposed esthetic and functional goals for the case. Once the anterior guidance is established adjust the models to eliminate any arc of closure interferences and achieve centric occlusion being equivalent to maximum intercuspal position, and eliminate any posterior working or balancing interferences. As you work through this process refine the proposed treatment plan and blend the findings of the diagnostic workup with health and esthetic concerns. Based on the findings of the work-up proceed forward with the equilibration to create a stable posterior occlusion and obtain a new set of mounted casts. These models are used to finalize the diagnostic work-up. The completed diagnostic work-up, which establishes the esthetic and functional parameters of the case, is than sent to a master wax technician who adds the anatomic detail and produces a creative masterpiece. The final diagnostic wax-up is returned to the dentist along with a duplicate in stone, and a prep model. The duplicate stone model of the wax-up is used to create a matrix for fabrication of the provisionals as well as reduction guides. Silicone lab putty is mixed and shaped over the model covering the teeth to be prepared as well as one to two teeth on either side. Once set this matrix is removed from the model and relined using a light body vinyl polysiloxane impression material which captures all of the primary and secondary anatomy from the waxup. The matrix is than trimmed close to the cervical margin of the teeth on the labial, without scalloping into the interproximal, this allows excess material to come out and the matrix to be fully seated. The lingual is left with adequate soft tissue contact to ensure proper seating and unprepared teeth are covered by the matrix on either side.

Following preparation obtain a retracted impression of the teeth using hydrocolloid to facilitate making the provisionals indirectly, this allows time and concentration to create an excellent result, and allows the patient some time to relax. The impression can either be poured with a quick setting stone, or die silicone (this material will not work with VPS impressions) which is injected into the preps, and than the

remainder of the impression is filled with bite registration silicone, making sure to turn it over (not when using stone) on a counter and create a flat base. Once the prep model is completed fill the putty matrix with a methacrylate or bisacryl interim restorative material. With methacrylate use a salt and pepper technique and layer different color acrylics into the matrix to create incisal translucency, body and cervical shading. This can also be accomplished with some of the slower setting bisacryl materials, or use a single light shade bisacryl and than utilize tints to create the same color affects. Once the matrix is loaded with acrylic place over the prep model, seat to place with the model base against a counter top for resistance, and hold until the acrylic sets. Once the acrylic has set remove the matrix, the provisional normally remains on the model and is removed separately. For multiple unit restoration the flexibility of the die silicone model is an advantage as you can separate the provisional and the model without causing fractures.

Following removal the provisional is checked for voids, marginal integrity and surface anatomy. If needed flowable composite can be used at this point to fill voids or correct marginal integrity. When using a bisacryl submerge the provisional in rubbing alcohol for thirty seconds to remove the air inhibited layer prior to trimming and shaping. The next step is removal of the gross flash and excess utilizing a carbide bur(H79E). Once this is accomplished begin to define the interproximal embrasures with a carbide bur (H261EF), and than polish and finalize with a lab diamond (8860). Embrasures, both incisal and gingival and anatomic contour are created using diamond disks (911HP followed by 934-180). These disks are used with a pulling motion allowing the flexibility of the disk and applied pressure to create a natural curve to the restoration.

The anatomy that was transferred to the restoration from the wax-up is enhanced using a carbide bur (H78E), paying attention to surface texture and light angles. Once this is complete a burlew wheel begins the polishing phase, the sharp edge of a new wheel allows access to the embrasures. Next fine sandpaper discs are used to smooth the interproximal areas of the provisional. Finally polish using fine flour of pumice and than polishing compound on hand held rag wheels. If the provisional is made from bisacryl prior to polishing I will use light cured blue and ochre stains to create the incisal translucency and body and cervical shading. Following staining the provisional is coated with a laboratory unfilled resin and cure for ninety seconds.

Link to Private Dentistry Journal website (United Kingdom)

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Shade Communication

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Jun 052011

Dental Practice Report

August 2006

Lee Ann Brady DMD

The dental laboratory needs many important pieces of information in order to produce exquisite esthetic results. One of the most frustrating moments in a dental practiced is trying in a restoration and realizing it doesn’t match. One part of my laboratory communication is the shade. Three major components contribute to our perception of the shade of a tooth: value, chroma and hue. Value is the most critical of the three parameters when attempting to match an adjacent natural tooth; hue is the least important.

To assess the value of the tooth, we look at whether the tooth appears light or dark. This perception is controlled by the amount of light reflected back to our eye after hitting the surface of the tooth. Value is intimately related to the surface morphology of the tooth. When light hits the surface of a tooth, the more surface texture that is present, the greater the amount of the light reflected away from our eye. Therefore, the tooth appears darker or lower in value. In contrast, a smooth surface allows a larger amount of the light hitting the tooth surface to be reflected back to our eye and gives the tooth a lighter appearance, or higher value.

When communicating the value of a tooth to the laboratory, work with a shade guide that lists value as a separate parameter. Our eyes are better when judging value in a less illuminated environment. Turn off the dental operatory light, close the blinds and even turn off the overhead lights. Allow your eyes a moment to adjust to the reduced light levels before choosing the shade tab that matches in value.(not sure about meaning of the following sentence) The color information that is filtered from our eyes to our brain can act to inhibit our ability to determine value. A digital image of the teeth that has been converted to grey scale will make the different values of teeth much easier to discern than if they were in full color. The Vita classic shade guide links the value and the chroma together. Try taking a digital photograph of your classic shade guide, converting it to grey scale, and reordering the tabs from dark to light by value.

Chroma and Hue are the two components of color that should be provided to the laboratory. Chroma is the intensity or amount of color present, and hue is the name of the color. If I take a bottle of red food coloring and a glass of water, and place one drop of the food coloring in the glass, the intensity or chroma is very low and the hue is red. If I pour the entire bottle of food color into the glass of water, it is much higher in intensity or chroma but the hue is still red. Chroma on a classic shade guide is communicated by a number, with less intensity being a lower number like 1 and greater intensity being a higher number like 4. Hue is indicated by a letter, in the classic system A, B, C or D.

To increase our ability to accurately determine the chroma and hue of a tooth we need to have light that supplies a full spectrum of color wavelengths. Often people discuss choosing a shade in natural daylight. The challenge with this is it works very well at noon on a cloudless day, but most of the time taking a patient into the office parking lot to match shade isn’t very helpful. Set up at least one operatory with color corrected bulbs in the overhead lights. When choosing color corrected bulbs, look for a CRI rating of 100 and a 5500K color temperature.

Our eyes can tire of looking at and perceiving certain colors, or become confused in their ability to ascertain color. It is important not to expose our eyes to vivid red or orange colors prior to choosing the chroma and hue for a restoration. My preference is neutral colors for our patient bibs like light blue or grey as they are restful to our eyes and enhance our ability to perceive the parameters of shade selection. If a patient is wearing very vivid lipstick, we ask them to remove it, and if they are wearing vividly colored clothing we cover it with a patient bib and allow a few moments to pass before completing our shade matching.

Desiccation of the tooth structure causes modified hue, less translucency, increased value and decreased chroma. I obtain all of my shade information prior to commencing any dental procedures whether for indirect or direct esthetic restorations. Accurate photographic information is difficult to obtain if the teeth are dessicated, so I take a set of digital images for the laboratory, including a set with shade tabs prior to preparing the teeth. During the course of treatment I take both stump shade images, as well as prepared teeth, to provide additional valuable information to the lab.

When selecting chroma and hue for a reconstruction where we are not matching any adjacent natural teeth, it is important to discuss with the patient their preferences around tooth appearance. Restorations fabricated with a chroma gradient are more intense in color at the gingival and towards the canines. It is imperative to explore these options with the patient as an increasing number of patients today want the restorations a uniform color throughout.

Many shade guides contain tabs that have been created to mimic the appearance o f natural teeth. They contain a chroma gradient; the true shade of the tab is only contained in the body portion. If you are utilizing this type of shade tab consider a few ideas. First, utilizing the incisal edge on this type of tab can help prevent color blending, which is a phenomenon that occurs when we see similar colors side by side. Our brain will automatically blend the colors together making them look similar. By placing the dissimilar color of the incisal edge of the tab against the incisal edge of the tooth we space the two colors we are actually trying to evaluate. You can also eliminate the color gradient by spending a few minutes with your shade tabs and a lathe and remove the sides and incisal edge of the tab leaving the named chroma and hue behind on the slenderized shade tab. I keep a quantity of the most common shade tabs available. After selecting the matching tab, I photograph the tab and the tooth together for the lab, and send the exact tab used that day with the case to the lab. One final thought about shade tabs: Remember that the tabs are affected over time by sterilization and exposure to chemicals in the operatory, so replace them on a routine basis to maintain color accuracy.

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Creating Great Patient Relationships

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Jun 052011

: Listening is The Key

Women Dentist Journal

January 2009

Lee Ann Brady DMD

When I reflect on my perspective on patient relationships it has been a long journey with many course changes over the twenty years I have been in practice. I have always valued my patients, but sometimes for many different reasons and in a variety of ways. As my belief about the role I play in the lives of my patients has changed so has the way in which I view the relationships we develop. For many years I came to work thinking accomplishing something meant fixing teeth. As a result my focus was on teeth, not people, and more specifically what was broken not where health was present. These days I know my role is to help people choose health. The result has been incredible, I enjoy what I do far more and I am far more successful at creating the opportunity to “fix teeth”.

Picture an incredible technical success you have had in practice. A time when everything went exactly as you had hoped, the preps were perfect, the materials worked, the margins were exquisite, and you sat back and felt so good about what you had just accomplished. It feels great! How long does it last? My answer is until the very next procedure doesn’t go according to plan. The moments that last, the ones we can each recall, are about relationships and making a difference to another person.

Pat called my office for a new patient appointment on the recommendation of her oncologist. Five years earlier she had battled cancer, recent tests confirmed the cancer was back, and he wanted her to make sure

her dental health was stable prior to beginning chemotherapy and radiation. Pat was very diligent about her dental health, following her examination I recommended a hygiene visit and we decided to replace a few discolored composite restorations. Most of the time together we discussed ideas to maintain Pat’s dental health and comfort during her medical treatment. Months later I received a card that I still keep with me in a special place in my desk. It read

“Dr. Brady, thank you for believing I would be here to need my teeth.”

Becoming intentional about building great relationships with our patients is the key to improving our experience of practicing dentistry, and helping a greater percentage of people choose health for them selves. It begins with recognition that each of us is a very distinct, unique individual –, an amalgamation of our temperament, behavioral style, life experiences, current circumstances and objectives. Truly building a trusting relationship with a patient is about getting to know and understand all five aspects of who the patient is. If we build a bridge of communication and then LISTEN carefully, people will share with us all we need to know. During all

Understanding a patient’s behavioral style allows the office to create an experience where they feel most at home, laying the foundation for true relationship to grow. A behavioral assessment tool that works well in dentistry is Social Styles. The key to the Social Styles (1) approach is that it is based on two observable patterns of behavior making it easy to learn and implement for the entire team. The two behavior patterns observed are, “assertiveness” and “responsiveness”. Together they define four distinct styles “driver”, “amiable”, “expressive” and “analytical”.

When we interact with people whose style compliments our style we are immediately at ease and communication seems fluid. The challenge is people whose Social Style is different than ours. So if we know our own Social Style and can objectively assess the other person’s style we have the opportunity to flex and make the other person feel more comfortable. In my office the team was trained in understanding social styles and from the very first phone call we implemented tools to help objectively assess our patient’s style. This allows the office to create an optimal experience for our patients individually, and also works wonders for the flow of the office. Every morning in the huddle along with the relevant clinical information we discuss how we can best work with each person we will be seeing.

John was a patient at my office for a few months before we implemented using Social Styles. I used to wonder why he kept coming back because it seemed he was always upset with the office. John is a “driver”, he prefers to be on time, direct and decisive. Once we understood this he was scheduled so that the assistant was at the reception door to bring him back before he was through greeting the receptionist. Then I made sure I was in the room before the patient napkin was placed and our appointments were efficient and undisturbed. Once we started creating an optimal experience for John’s style he became one of my favorite patients because we were able to openly communicate. We even created a system where he didn’t have to stop at the desk on the way out so he could get right back to work by prearranging how payment and future appointments were handled.

Theresa is one of my favorite patients. She and I hit it off from the very beginning; and I love hearing her stories. On the other hand; every time she comes in the rest of the team gets agitated because I run behind the rest of the day. Theresa is an expressive (and so am I), we are both high energy, spontaneous and engaged in communication. Once the team identified this we started scheduling extra time into Theresa’s appointments just so she and I can talk. It worked great! I really enjoy spending time with her; and now I’m not worried about the rest of the team or the next patient when I do. Theresa has become a truly valued patient because now the rest of the staff also has the time to spend with her and she really enjoys being at our office. So much so that she is one of our best referral sources.

Creating the experience of your office on an individual basis for each patient is easy and extremely rewarding for everyone involved. Now the foundation is in place for building caring, trust based relationships with your patients.

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You Only Treat What You See

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Jun 052011

Joint & Muscle Exam

AAWD Chronicle

August 2006

Lee Ann Brady, DMD

As a woman and a mother I am very well acquainted with preventive medicine. Prevention requires three vital components. They are patient education, comprehensive examination, and active monitoring. The medical profession has done a phenomenal job incorporating this concept into our lives. We are all part of this process as it relates to breast cancer, pre- term birth and low birth-weight babies, and well child care. I have watched over the last 2 decades as dentistry has incorporated these same concepts into our profession. Our patients are well educated around the topics of decay and periodontal disease. It is standard of care to complete a thorough examination on our patients to look for signs of caries and periodontal disease and the techniques for early detection are constantly being improved. Patients who become an active part of our practice are continually monitored for any changes in their condition so we can intervene at the first sign of caries or periodontal breakdown. It would be remiss of us to wait until our patients had symptoms of either of these diseases before we treated. Why then do we treat TMD and occlusion so differently?

For me Temporomandibular disorders and occlusion are important for several reasons. The first is that I became aware of my own TMD when I developed frank symptoms. As I began a journey to understand my own condition I realized that there had been many signs along the way that if I had been aware of and proactively treated, the current breakdown of my joints, muscles and teeth might have been prevented. I also discovered that having a thorough understanding of my patient’s current condition was the key to eliminating some of the frustration and failures around the dentistry I was providing. Armed with this new understanding I expanded my comprehensive examination to include all of these areas and it transformed my practice, changed my relationship with my patients and is a key component to my personal satisfaction in the office.

It is up to us as a profession to educate patients and raise their awareness of temporomandibular disorders and occlusal disease. We don’t have large corporations helping us with national advertising campaigns as is the case with caries and perio, because they aren’t selling any products to treat or prevent these problems. First we have to educate ourselves and raise our own awareness because I truly believe the following. You only treat what you diagnose, you only diagnose what you see and you only see what you know. I find it amazing and somewhat bothersome when I think back on the patients in my practice that had mild wear, crazing, sensitivity, muscle fatigue, and even fractured teeth and I never “saw” it because I didn’t have the knowledge to put the pieces together until the symptoms set in. Now I can look at the twenty year old patient with mild wear and in my mind’s eye see the forty year old who will come in concerned that her front teeth are so short and offer the option of not having to have crown lengthening, endodontics and major restorative twenty years later.

So where do I start? I need to have the answer to several questions about the patient. Are the joints healthy and are the joints stable? I use a thorough patient history, palpation and auscultation of the joints and careful observation of mandibular movement to help me begin to understand the current condition. If I find signs I am concerned about I can include further diagnostics to help finalize my diagnosis. Next I look at the cervical and masticatory musculature. Patient history, palpation, range of motion measurements and careful observation are the ingredients of a comprehensive muscle examination.

Finally I look at the occlusion. I want to understand the current functional occlusion and how it relates to a seated condylar position. I also document any signs consistent with parafunctional activity or maladaption to the current occlusal scheme. Some of the signs I look for are inappropriate wear, crazing, cracks and exostoses. For me the examination isn’t complete without mounted study models and a series of digital photographs that includes functional and parafunctional movements. It’s common for me to make new discoveries about the patient when studying the models and photographs as I work through all the diagnostic data I collected.

The time I invest in the comprehensive examination is well worth it because I gain confidence about my treatment recommendations and confidence about treatment success. More importantly I have partnered with my patient to prevent or slow the future deterioration of their dental health from another possible threat.

I am not the same dentist I was before my journey to understand. I “see” way more than I used too when I observe the patient’s present condition. When I share what I have observed with the patient and help them understand how it will affect the treatment we may be undertaking together, or there dental condition in the future I am giving them the very best I have to offer as a dentist.

American Association of Women Dentists website

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