At what point do you kick a case up to the next level?

Have you ever looked at a case and it gave you a creepy feeling? When you see a patient as a new patient or in recall, when do you decide this is not just your routine case?

I recently asked this question to dentists attending The San Francisco Institute for Advanced Dental Learning. Here’s what they said about the key boundaries that send
a patient over the line:

1. History of sound or pain in the jaw joint(s)
2. Limited or restricted opening
3. Muscle pain
4. Headaches
5. Tooth wear
6. Chipped/fractured teeth
7. Abfractions
8. Bone loss
9. Tooth mobility
10. Linea Alba
11. Scalloped border of tongue
12. Posterior interferences
13. CR – CO slide
14. The patient that reports: “my teeth don’t seem to have a place to land.”

Most of these criteria fall under the category of “physical evidence”. But physical evidence of what? Many of these conditions represent D A M A G E! The dentist’s most powerful word: DAMAGE!

When you just cannot figure out what to do, it is time to do an options analysis. How do you do that? You make a list of all of the possible options (good, bad, practical, impractical) and then one by one, you start crossing out options until you are left with only one.

L=T/F

“L” stands for longevity. This is what every dentist wants. Longevity for their patients teeth and gums. Longevity for the jaw joints. Longevity for our dental restorations.

“T” stands for time. Time is not within our control. The simple fact is we do not know how long our patients will live and therefore: how longs things must last. The old joke goes like this: "We offer a lifetime guarantee on dental work for all of our patients over the age of 95."

And “F” stands for force. In the end, force management becomes the Dentist’s primary strategy in influencing Longevity. The lower the force in the system or the lower the force on a tooth, the longer everything will last.

The trick is: how do we predictably lower force in the system. We know that in any biomechanical system, forces are being generated in two ways: 1: physics, or what we could call engineering and 2: muscles. In dentistry, there is a growing body of information on how we, as dentists or laboratory technicians can influence both the engineering and muscles of the chewing system.

(Future discussions from the SFI will touch on techniques for creating force engineering, force management, and which muscles are within our control.)

Quick-Learn Product Profiles
Predictable Cementation Technique for IPS e.max ZirCAD Posterior Restorations
Dentistry by Robert G. Ritter, DMD, Private Practice, Palm Beach Gardens, Florida;
Information provided by Ivoclar Vivadent, Inc., Amherst, New York

Fig 1 - View of a patient's core build-up on tooth #30 after endodontic treatment.

Fig 2 - The build-up was prepared uniformly with 1.5 mm axial reduction and 1.5 mm occlusal reduction.

Fig 3 - The IPS e.max ZirCAD/ZirPress crown was tried in dry.

Fig 4 - The Multilink Primer A and Primer B mix was applied to the preparations with a microbrush for 15 seconds.

Fig 5 - The primer was air-thinned for 5 seconds.

Fig 6 - The Multilink universal cement was dispensed into the internal aspects of the restoration and the crown seated into place.

Fig 7 - Excess cement was easily removed using a scaler after slightly hardening.

Fig 8 - Buccal view of the final restoration after light curing.

Fig 9 - Final view of the IPS e.max ZirCAD/ZirPress crown restoration on tooth #30.

To predictably seat today's scientifically proven CAD/CAM-processed restorations—such as IPS e.max ZirCAD posterior crowns—using a universal resin cement can enhance patient comfort and convenience during the cementation process. Multilink® Automix Universal Adhesive Cement is a true resin cement that simplifies the placement of these yttrium-stabilized zirconium oxide restorations by limiting the number of technique sensitive steps involved in the seating appointment.

What's more, because Multilink is based on the same composite matrix as the tried and tested Variolink® II luting system, this multi-purpose, self-etching and dual-curing cement produces high initial bond values to enamel and dentin when light-cured (20 seconds per surface) or self-cured (2 to 3 minutes). Available in three shades, Multilink Automix is quick and easy to use, and the new applicator tip promotes accurate mixing and precise placement.

Outlined below are the clinical steps for seating a posterior IPS e.max ZirCAD/ZirPress full-coverage crown restoration using Multilink Automix Universal Adhesive Cement. The IPS e.max ZirCAD block was indicated in the case illustrated (Figures 1 and 2) based on its high strength (i.e., flexural strength greater than 900 MPa). The IPS e.max ZirPress material was used in this case, which maximized the marginal integrity of zirconium oxide substructure—thereby assuring an accurate fit—and which also provided a biaxial fracture strength of 110 ± 10 MPa.

Cementation Technique

1. When the IPS e.max ZirCAD/ZirPress crown restoration is returned from the laboratory, inspect it to verify color and anatomical form.
2. Remove the provisional restoration and clean and dry the preparation.
3. Try in the restoration dry to verify fit, marginal contacts and color (Figure 3).
4. Remove the restoration from the mouth and acid etch the internal aspects of the restoration; rinse and dry.
5. Silanate the internal aspects of the restoration, then dry.
6. Mix the Multilink Primer A and Primer B in a well; apply the primer mix to the tooth preparation using a microbrush for 15 seconds to complete the self-etching adhesive conditioning (Figure 4).
7. Air-thin the primer to reveal a shiny surface (Figure 5).
8. Using the automix applicator, mix the base and catalyst of the selected shade of Multilink Automix Universal Adhesive Cement and inject it into the IPS e.max ZirCAD/ZirPress crown restoration.
9. Seat the restoration into place and allow excess cement to be displaced from the margins (Figure 6).
10. Spot cure the restoration from the buccal aspect for 3 seconds to initiate the gelling phase of the resin and slightly harden the excess cement.
11. Use a scaler or curette to clean excess cement from the margins (Figure 7); remove excess from interproximal contact areas using floss.
12. Light cure the restoration for 40 seconds each from the buccal, lingual and occlusal aspects (Figure 8); verify and/or adjust the occlusion and polish (Figure 9).

Conclusion

The hydrolytically stable phosphoric acids in Multilink Automix provide high immediate bond strengths and long-term durability to meet your and your patients' expectations. So, when you prescribe IPS e.max ZirCAD/ZirPress restorations and seat them using Multilink Automix, you can confidently provide your patients with treatments that balance both strength and esthetic requirements.

With a possible forty year career in dentistry, progression and change will keep you in the game. There is no other career like private practice with great choices to fit individual skills and temperaments. To stay in the fascination and reward mode, one needs to access not only where your income is derived but also the amount of enjoyment you receive in doing particular treatments. My advice is to jettison those parts of your practice you no longer find great joy and look at areas you may want to explore to add to your repertoire.

Keep challenging yourself with the excellent continuing education courses. Involve yourself in hands on education. Keep looking for ways to differentiate your practice and add to your skills. When cosmetic materials and techniques became available, many veteran dentists said, "I don't want to retire; this is too much fun." Enjoyable dentistry does not come knocking on your door. You must seek it. If you have dabbled in endo or ortho and no longer find it fun, you can find someone in your area to refer to or purchase that portion of your practice.

Add new skills like implants, sleep or nap dentistry, implant supported cosmetic dentures or sleep apnea. Become skilled in relieving headaches and chronic pain. Find something new to keep you in the game. It's not over yet.

Perspectives for a Successful Practice
by Michael Kulwiec, CDT

In Dentistry, our goal is to find solutions to problems. Sometimes a solution requires more investigation than average. This month's article by Dr. Jeff Morley underlines the signs separating the average case from the more complex.

Our Product Profile reviews the use of Multilink Cement with e.max ZirCad restorations. You will see more from us in the coming months about the new products in the e.max line of metal-free restorations.

e. max ZirCad is Ivoclar’s Porcelain to Zirconia crown and bridge material. It offers the high-strength of Zirconia and the esthetics of the same ceramic family that is used for Empress. Therefore, the name e.max translates to "Empress taken to the max." It is the maximum combination of all ceramic strength and esthetics.

Dr. Bill Blatchford's article reinforces the freedom you have in choosing to do particular treatments. Today's dentistry offers an array of skill and treatment choices that should keep your enthusiasm going from now until retirement.

As the school year ends and graduations commence, best wishes for a pleasant and productive spring and summer season.

Sincerely,

Michael Kulwiec, CDT
President and General Manager