American Academy of Cosmetic Dentistry Criteria Workshop

So the question is tell me about the silicone putty. Tell me how that works, how does that help. There's two ways that I use it. I used it no. 1 as the full contour for my temporaries because the diagnostic wax up has been completed. I can do it. You don't have to send this to the lab. You can wax up yourself and you can make the putty matrix yourself, just build it right on the model. You form it over your diagnostic wax up. What that does is when you go to do your temporization, you can fill this with acrylic and you can lay it right up over the top of the teeth and then what's wonderful about this too is it just flexes right off the teeth. It's not like you have to rip the whole thing off. You can flex it and it just pops right off of there. Now you have it shaped. I tell you where else I use it is, you know, forget the snap on smile or whatever else stuff out there. I take a diagnostic wax up and I will load it with acrylic and I will just lay that right on there. Talk about a fast mockup. You just pop that on there and you peel if off and they get to see edge position. They get to see a little bit of contour. You can then if you wan to get fancier with it, you can take some of your composite and you can build some more on the surface cause obviously it's going to wear, you know, the areas that need to be prepped, its going to thin through on you. So you're going to add a little resin but you can do a nice mock up for them, it's also your temporary. So here's the second place. What they do, the lab will do this for you is you ask them for a cut back matrix. And what that simply means is they will go mid body of the tooth and there's another way of doing it actually is you can do it in layers. But about mid body of the tooth, they'll cut it back, a window. You slide this matrix on that goes over the occlusal surfaces back teeth and then it has an open window and when you set that and you look at the incisal edge just from your occlusal view, you will see places where the matrix sits right against the tooth and you'll see places where its gapped. Any place that you have a gap, why prepare the tooth. Why cut away anymore of that tooth structure. Maybe if you want to put up a finish line that's up to you, that's fine. But why would you need to cut back the tooth when there's plenty of room for the restorative material. Now in the tooth next to it, you see its laying right up against it. So you prepare that tooth back a little bit, put the matrix there again. Prepare a little bit, put the matrix in it until you have clearance. Remember if you're talking about doing a powder liquid feldspathic type of veneer. What do you need Half millimeter. Very very little in terms of your preparation in order to achieve that result. Now obviously we have to be careful. We're talking about teeth that we're not doing major shade changes. We're not talking about teeth that have huge rotations and things like that but again that's you slided it on, that's where you can look and see and gives you a heads up ahead of time of how much preparation that you actually want to put into that tooth. Then you also can take, and even if you just want to do it real quick, put a light little layer of acrylic on there, lay it right over, pop it back off, pop out your acrylic and measure it. Measure your acrylic and say, oh, wow that's thin. Oh that's nice and thick there. That's nice and thick there. That's good there. Okay. On no. 6 I'm going to take off just a little bit more on the mesial incisal. So, again just little steps along the way that can help you, conservative dentistry, minimal preparation but still get great results, but again that's what so valuable is just working with your laboratory on this. You know cause they're such a, like I said I'm totally spoiled now. I look back and think I used to sit in there and do those wax ups. You know I'm not as good at it and now I want to use them all the time for everything cause I want to see where I'm going. Again case type 5, do it yourself. Put you ahead of the game when you're facing that case. Okay. Cervical embrasures. We're talking about as a natural contour as it comes off of the tissue. Nice, healthy, full papilla and of course what everybody is worried about is the dreaded black hole and everybody sweats that so much that what I see over and over and over on cases is not healthy papilla or maybe it is looking healthy tissue wise in terms of color but its constricted. You see it over and over and over again in restorations. Some with the ceramics, a lot with the resin because there's this great fear that oh my god if I have a black hole left, I'm going to fail. That's going to be the end of it. Well these dark triangles and there are dark triangles. So just because you have a little dark hole at one spot on your whole case, does not necessarily your case is going to fail. Obviously you want none. But one little dot and one little spot is not enough to break out a huge sweat especially if the tissue is nice and healthy and you got great contact, both length and embrasure development around there. So again how you prepare your tooth goes a long way to how you can work in that embrasure area. So location of preparation is important. Contact area to the bone. The famous Parnell study and other studies since then that doesn't necessarily agree completely with that. We're not going to get into the details of that. But it's the simple rule of knowing if I prepare the tooth, if I know where my contact area is and if I know where crestal bone is, I can seat my restorations that have black holes in them, here, here, here, and here. And what's my chance if I'm 5mm or less, what chance do I have of that papilla filling in. 100%. Almost a 100%. We know where it's going to be. So we can confidently seat the restoration because I'm also famous for this is, you know, get a little tired, it's the end of the day, prepped a big case, lots of temporaries going in. Did I finish back my temporaries in the cervical embrasure spots enough And lots of times the answer is no, I didn't. As a result when I pop my temporaries off, what's been happening for the last month. Yeah, it's compressed that tissue up. So now I got a little black hole. But if I know where the contact is and if I know where the bone is, I can do the try in, the patient says doc what about this little dark hole. Don't worry about it. It's not going to be there. That's going to fill right in cause I know where the tissue of the contact area is built and I know where the bone is. What happens when you go to 6mm, 50-50. And now you're 50-50. It's not that it won't fill in but now you're rolling the dice. You don't want to roll the dice in your accreditation case. Another thing with temporaries is when you're doing bridge case. And again one of the things that we see are these connector areas, get really long. Sometimes it's the material. This morning for you all who were not here this morning, everybody was shocked when I showed the case that had two missing lateral incisors. Everybody wanted to know what the material was, what's the material. So we'll get to that. So we get to the end, two conventional Marilyn Bridges metal retainers. Like yuck who does those things anymore. Well this case looked really good and contact areas were nice and small cause they used metal. Everybody wants to use all ceramic now. Let's prep for Zirconia. What's our dimension of Zirconia What do we need 4x4 4x5 Well anyway the bottom-line being is somebody who doesn't have really long teeth, you have, they have to build, the lab has to build the connector so this guy is going to last for us, right. I mean they can't be breaking these bridges every six months. So the connector has to be thick enough and long enough and you've got a short tooth. Now you got this jammed up cervical embrasure, you got this nothing down here because you had to have the connector to be that long for strength of material in that location. So again you're watching your case type but you're watching your material type also. And a good place to look is if you're doing full preparations especially is look at your temporary. Build the temporary with the black hole if you want. The patient says I don't like the black hole. Just be patient. It might not fill in. You know I've measured and that's pretty close, I'm not sure. Fine. Find out in the temporary. Cause that's where that tissue is going to end. Let is heal for a little bit. Says that black hole is still there. You're right, I'm going to fix that today and we're going to take your impression today cause now I know where to tell the lab we're going with this. Cause I give them impression of the temporary. I give them a photo of the temporary and said this is where the contact was. This is where my height was. This is where we need to build it. So you've given them the communication to eliminate that without constricting this papilla, without driving this up. Cause we see that happening over and over and over again. We started with a black hole. We did some contouring. Beautiful veneers. Beautiful embrasures. Beautiful papilla. Nice contact zone. Okay. So periodontal criteria. We're looking gingival height. We're looking gingival health and the shape and the contour. Remember we talked about, there are approximately 40% of the cases are failed cases. 35% to 40% that come in in any given exam session are failed. But anytime you bring tissue that looks like that, and even if you said well I ran out of time, well it doesn't matter. The story doesn't matter. I mean what do you mean ran out of time. Just submit it for the next exam session and let it heal. We don't know its going to heal. We don't know what you did with your margin. We don't know where the bone is. We don't know what's going to happen. As examiners, all we do is judge what we see on the screen. Look at the tissue on here. Look at the health, color, staple, how clean that case is done. Gingival heights. We know we have an ideal and we have a default and here's our ideal. Our ideal is that our lateral incisor is going to be approximately a millimeter lower than the gingival height of our cuspids and our centrals. But this is our default. Knowing that even if we're pretty much even, this nice oval shape that we have on our lateral incisors sometimes help differ that to our eye a little bit. So even if we're even across here, these shapes help keep it smaller in that location and not as thick and full. So our eye kind of says yes there is a variance between that tissue, that tissue and that tissue. So this is ideal, this is the backup. Okay. So centrals are symmetrical, even with the cuspids and apical and lateral. Now we're also talking about the gingival shapes as well. We're talking about shapes as we're talking about the height and we're talking about the zenith and they're not the same thing. Okay. So the zenith is in a different position than the gingival height unless we're talking about the lateral incisors where they're coincidental. Okay because of the shape of the tooth cause it's a nice open angle. When you have the elliptical shape, your zenith is always going to be slightly distal. Well does that mean you have to break out in a huge sweat on every case on every zenith and the answer is no. Of course not. But if you're going to start moving tissue and start changing it, it becomes more important to make sure you're creating these contours that are correct so that you're shaping the tissue into that correct position. So laterals are half ovals and canines and centrals are elliptical so that creates a different position with the zenith. So for great tissue you have to have, you have to have known where the bone and your contact is and your gingival margins. Your gingival margin to bone, contact to bone on the cases that you have a question in your mind or a case where you're altering the tissue. You have to give adequate healing time for all these cases. Don't rush them in. Give them time to heal and you have to consider multidisciplinary treatment. So if you're looking at this case, right here on the right hand side and you see these gingival heights, how are you going to treat this case What are you going to do to get this ready for accreditation and having your gingival architecture positions in the correct spot Suggestion for that case. So you're going to crown lengthen so you're going to bring up cuspid, central, central and cuspid and we know that they have to be at least even with the laterals or they have to be a millimeter above the laterals. Okay. Now that you've done that, tell me about your length to width ratios of your central incisors. Okay. So now you're here. So you're starting off with the proportion central. You've now move the tissue up to here and you move this tissue up to here and you move this up to here. So tell me about the proportion, length to width now of your centrals. Aha, I see you now. Now the look is like oh yeah, okay, I got it. Alright. What's the simpler solution Bring them down. How long is that going to take to bring those two laterals down A few months and then retention for a couple of more months maybe. It's quick. It's easy. Just drop these laterals down. So again you're looking at your case. What's your simplest solution to get you to the position you need to get in. Is it contouring the tissue Is it moving the tooth Especially Invisalign. Docs in here, who is using Invisalign Yeah. I mean come on it's a slam dunk. You know while I agree with you in a pure sense I've done a couple here recently that not bad. You know it's not ideal, I'll grant you that. Okay. So let's back away form Invisalign. Put a wire on it. Put the bracket on. Put the wire and bring it down. You know it didn't matter how you get there. I was just saying Invisalign for you know for docs who don't usually do their own orthodontics and aren't used to placing brackets and bands and all the rest of that. Invisalign can be a pretty simple treatment modality and I don't just mean for doing eruption. I mean for positioning teeth in general. You can set up some of these cases beautifully and remember the great thing about Invisalign is you know it's a tough modality to get every tooth in its exact position, but if you're going to be treating it anyway, did they all need to be in exact position, no they need to be in the ball part. You need to get them home. You need them in that general area to get to fix those axial inclination issues and those gingival architecture issues and some of the different things that are going on. So you just do the minor adjustment with that and then you bring the case home the rest of the way. Okay. So when use stair-step when you go high, down, down, here, down and way back up again. When you start here and go down hill from here to here and then back up all architecture issues. All problems. It doesn't matter where the lip line is. The story doesn't matter. First few shots maybe okay but retracted has to be okay also because you're showing you understand the principles. By this picture, you're showing me you understand that the cuspid is here, that the lateral should be 2 mm above that. It should drop down a millimeter here. It should back up a millimeter here. It should back up a millimeter here and it should come down a millimeter here. That's what the candidate is telling me they understand about gingival architecture. That's the way an examiner is looking at. So you have to make sure you're looking at each case of how can I present it. Again we start down. The other one went down this way. This one is going to go uphill. So we're going to start here. Not bad over here but then we're just going to go steady up hill all the way across. We talked about gingival health and we talked about submitting cases that look like that. Catastrophic. This case doesn't matter what else they did. It doesn't matter how nice the rest of the dentistry is. It doesn't matter anything else went on, that case is not going to pass. The angle that you shoot doesn't help you either. These gingival positions are probably not a whole lot better but when you shoot up hill examiners don't have a shot. They can't tell you exactly where these positions are. At least I can't. I'm pretty sure they're off, but I don't I'm looking at, it's like I'm sitting down below and I'm looking straight up. So the angle of your shot is important to demonstrate what you have there as well. So the candidate starts and they understand that they've got some buccal corridor issues, they've got some gingival architecture issue, they've got black hole issues, they 'vegot some wear issue, they've got edge issue and what they did is they came through. They trust the corridor and they put the tissue in exactly the right spots. Okay. So they went through and saw what was going on here and not only did it in terms of height, they did it in terms of zenith as well. Okay. Look at how different that tissue looks than that tissue and look at how they balanced it here. And when I say they, I don't know. That could have been a periodontist. Fine. You're the quarterback. You're bringing it home as the dentist so just get it in the right position and understands the principles of where those things need to be. Okay. Gingival contours proportion health. Questions Okay. Shade. Hello. Shade. Of all the problems with shade and the colors, we have the big three, we've got the chroma, we've got the hue and we've got the value. And if you ever struggle to remember those, the way I always remembered them was that the name of the color is the name of a person. So the hue goes with a name. So hue is a name of a guy. Our next president of the academy will be hue, its Hugh. And so that's the name of the color. So that's your brown, that's your orange, that's your red, that's your yellow. When you're talking about value, you're talking about level of brightness. So I always thought of it like a diamond. So the higher the value of the diamond, the brighter it is. Cut, clarity all those other things that go into diamond which I don't know all that stuff. And then chroma is the one that's leftover. So I don't have a great one for that one other than richness. That's the richness of the color, the intensity of the color that's in there. Okay. So shade we're also looking at the characterization. Are they natural Have they been handled correctly as the halo handled correctly Okay. Finishing can be a big deal. So you can build all of these colors in there and then when you cut and grind away at everything that was there you can lose everything that was in place so we saw this case before that you can over characterize or you can under characterize. Single tooth treatment can be a real bear when it comes to value issues. If you're choosing to do a single central incisor, I'm not telling you not to do it because we face them all the time. But there are single centrals and then there are single centrals. And when that single central is an old endo tooth that's dark and black and everything else under the sun, of course you're going to do the crown for the patient. Of course you're going to deliver it. I just had a young lady recently trauma and I have never seen on that younger person a tooth go that dark that fast. And I've done everything under the sun and I finally have given her restoration that is average. And we did everything that we could possibly imagine in terms of cut backs and block outs and shadings and materials and everything we could possibly think of that's what it is. I mean she's satisfied. It's better than the way it look before. She's living with it. Would I show it for accreditation Not in a million years. Would I even consider it for accreditation Not in a million years. Simply because the case is way too hard. So when we're talking about value, when we're talking about color, case selection again becomes really important on what you're choosing, what you're trying to hide.