Check List for the Layering Technique

Transcription

Dr. Bud Mopper Continuing Education
Interactive Seminar
Dr. “Bud” Mopper
Check List for the Layering Technique
Always REMEMBER:
1)
2)
3)
First use the Extra Coarse Sand Disc to simulate the etch step.
Apply the unfilled resin (blue bottle) and polymerize.
Apply clear liquid and polymerize.
Once the Above is Complete, THEN:
► Apply Pink Opaque.
► Apply A1 Hybrid or Nano.
► Apply A1 Opaque (if needed).
► Place Tint on Cervical
(Honey Yellow & Light Brown mixed together).
► Place Tint to simulate incisal translucency on incisal edge (use
Gray Tint or Gray Tint mixed with a little Violet Tint).
► Apply A1 Microfill, inner sculpting anatomy into incisal third of tooth.
► Apply Flowable Incisal Light Microfill under filling the inner
sculpted troughs.
► Apply Incisal Light Microfill over the incisal third of the tooth, blending it into the A1 Microfill, making sure there is no visible margin.
► Shape and Contour using course and medium FlexiDisks
and ET burs.
► Use FlexiPoints or FlexiCups to add characterization to labial
surface, and polish using Fine and SuperFine FlexiDisks.
► Polish to high luster with Enamelize and FlexiBuffs.
Cosmedent, Inc.
401 N Michigan Avenue - Suite 2500
Chicago, IL 60611 (800) 621-6729
www.cosmedent.com
© 2008 Cosmedent, Inc.
All Rights Reserved
Interactive Seminar
Questions to Ask When Selecting
a Composite Resin System
1.
How does the material handle?
2.
Does the finished material truly match its selected shade guide?
3.
Does the system make color matching or color development easy?
4.
Is the finished product color stable over time ( 15 to 20 years )?
5.
How easy is it to polish, and will the composite hold the polish
over time?
6.
How strong is the restoration?
7.
What are the translucency and opacity characteristics
of the material?
8.
When finished properly, are the composite and gingival tissues
biocompatible?
9.
What material has adequate strength for the purpose of use?
10. What material is more wear resistant?
Why?
Reprinted with Permission by Dr. K William “Buddy” Mopper, DDS, MS,
from Dentristy Today, October 2008 Issue - Aesthetics
Cosmedent, Inc.
401 N Michigan Avenue - Suite 2500
Chicago, IL 60611 (800) 621-6729
www.cosmedent.com
© 2008 Cosmedent, Inc.
All Rights Reserved
CONTINUING EDUCATION
INSIDE
ESTHETICS
RESTORATIVE
IMPLANTS
Contouring, Finishing, and
Polishing Anterior Composites
The key to beauty and biologic integrity of long-term restorations lies in the final
steps of the procedure.
By K. William Mopper, DDS, MS
O
ne of the most important steps in
successfully creating bonded restorations is contouring, finishing,
and polishing.
Proper finishing and polishing greatly
increase esthetic results, maximize patients’ oral health,1 and increase the longevity of restorations.2 Unfortunately,
the proper sequence of polishing steps
necessary to achieve optimum results is
often overlooked.3 The purpose of this
article is to describe a technique that
will help achieve maximum esthetics
and biological success when contouring,
finishing, and polishing anterior restorations (Table 1 and Table 2).
Finishing and polishing anterior
composite restorations is a sophisticated art form. However, proper technique
is actually quite simple and extremely
efficient once the practitioner understands the concept behind the finish
and polishing process.6,7
Step 1: Material Selection
The ability to achieve a good finish
and polish on anterior composites is
determined by two very important factors—access to the right materials and
the artistic ability of the dentist. Having
access to the right materials, however,
does not mean simply polishing discs
and strips. The dentist must also realize
that the type of composite(s) used will
have a large impact on the restoration’s
longevity, durability, polishability, and
wear-resistance. Achieving a good understanding of the materials available,
and grasping their impact on overall results will maximize restorative success.
Composites
In terms of color stability and polishability, in the author’s opinion microfill
is the only composite material that really stands the test of time. A microfill
must be used as the final layer in order to
obtain the best polish, surface smoothness, and long-term wear resistance.
Nanohybrids or nanofills can also be
used to replace the enamel layer in composite restorations. These materials initially provide a relatively good surface
smoothness and high shine. Over time,
however, nanofill composites lose their
luster and are less wear-resistant than
microfill composites.8 Microhybrids are
the least polishable of the three main
composite types. Used as an anterior
enamel layer, microhybrids rapidly lose
polish and are more susceptible to staining. To achieve a beautiful, long-lasting
polish, a microfill composite must be
used as the final layer.
Finishers and Polishers Overview
K. WILLIAM MOPPER,
DDS, MS
Private Practice
Glenview, Illinois
Member and Fellow
American Academy of
Cosmetic Dentistry
62
Where do polishers best fit into a practice’s current procedures? One- or twostep polishers can certainly be used
when polishing composite restorations
quickly. But, if the goal is to achieve the
best long-term polish, then it is more
desirable to use a comprehensive polishing system.
INSIDE DENTISTRY | March 2011 | www.dentalaegis.com/id
Different types of composites call for
different polishing techniques, depending on the type of restoration and the
dentist’s ultimate goals. As a reference,
diamond impregnated polishers should
be used, followed by an aluminumoxide polishing paste when polishing
nanofill and microhybrid composites.
When polishing microfill composites,
aluminum-oxide polishers should be
used, followed by an aluminum-oxide
polishing paste.9
Polishing Materials
Thorough and complete finishing and
polishing requires the use of a sequential series of finishing and polishing
burs, discs, strips, and pastes. Following
the proper sequence of materials ensures the long-term health and polishability of restorations. If a part of this
process if skipped, the tooth will often
be left rough and susceptible to plaque
and staining. Either multi-fluted carbides or fine diamonds for gross contouring can be used to begin finishing
the restoration.
Discs
Discs can be used for the contouring
of all tooth surfaces as well as bulk
reduction of excess material. Discs
will help contour and finish curved
surfaces such as labial proximal line
angles, lingual marginal ridges, cervical areas, incisal edges, shaping and
finishing of incisal corners, plus finishing and polishing of labial surfaces.
They are also excellent for contouring
and finishing of posterior marginal
ridge areas, and for lingual and buccal surfaces.
TABLE 1
Why is Finishing and Polishing So Important?
Proper finishing and polishing is important for several reasons, such as:
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INSIDE
ESTHETICS
Four-Disc Grit Sequence:
Aluminum-Oxide Discs
The author is an advocate of the fourgrit disc sequence, which is designed to
gradually reduce the amount of roughness caused by initial abrasion until a
smooth glossy tooth surface is achieved.
To provide maximum control for the
operator, composite finishing should
be done under low-speed/high-torque
(speed from 0 rpm to 30,000 rpms).
Coarse—The coarse grit is the stiffest of
all the discs. This grit is used in conjunction with multi-fluted finishing burs for
gross contouring and shaping. When
used with pressure, the coarse disc
makes it easy to blend the composite
into the tooth surface, eliminating the
white line and raised margins.
Medium—The medium grit should be
used to continue smoothing the restoration surface. Medium grits remove any
remaining imperfections and marks.
Fine—This part of the grit sequence
is where polish really starts to shine
through. The fine grit helps remove the
smallest imperfections while adding a
nice luster to the restoration.
Superfine—The superfine grit further
refines the surface smoothness attainable to create a highly polished
restoration.
FIG. 1
Diamond Strips
Diamond strips help start the interproximal finishing process while
maintaining the integrity of the interproximal contact. A larger-grit (45-µm
strip) should be used for interproximal
stripping of natural teeth or for gross
removal of material, and smaller grits
(15 µm and 30 µm) should be used to
start interproximal polishing.
Aluminum Oxide
Strips should be used to contour and
polish interproximal areas. Use of a
high-quality strip will remove tenacious
stains and create a high polish at the interproximal without damaging the soft
tissue. It is important that the strip is
FIG. 2
thin and will stay intact as it is drawn
through the interproximal contact areas.
Oxide Cups and Points
Aluminum-oxide cups should be used
to polish gingival margins, achieve labial characterization and anatomy, and
effectively reach areas such as the gingival third and the gingival margins of
anterior teeth. Aluminum-oxide points
should be used to create labial grooves
in veneers, to finish and polish occlusal
surfaces of posterior teeth, and on lingual surfaces of anterior teeth.
An aluminum-oxide polishing paste
should be used as the last step in the finishing and polishing process. Polishing
paste with felt discs and points can be
FIG. 3
FIG. 4
FIG. 5
FIG. 6
FIG. 7
FIG. 8
FIG. 9
FIG. 10
FIG.11
FIG. 12
FIG. 13
FIG. 14
FIG.15
SCULPTING AND CONTOURING, REFINEMENT AND FINISHING (1.) Class III restoration preoperative view (note the long bevel). (2.) Lingual view of the
preparation. (3.) Application of Renamel NANO Shade A1 (Cosmedent, www.cosmedent.com) using Cosmedent’s 8A Composite Polishing Instrument. (4.)
Lingual sculpting and shaping of Renamel NANO using Cosmedent’s IPCT Composite Polishing Instrument. (5.) Addition of a small amount of Renamel NANO
to blend onto the long bevel. This completed the block-out of shine-through and acted as an opaquer. (6.) Addition of the nano-hybrid composite is complete. Notice there is still enough room to apply Renamel Microfill (Cosmedent). (7. AND 8.) Sculpting and contouring of Renamel Microfill to proper shape and
contour. (9.) A Brasseler ET-9 bur was used for for labial reduction. (10.) A Brasseler 0S-1 bur was used for lingual reduction. (11.) A Brasseler 8392-016 bur was
used to refine the lingual and labial embrasure spaces. (12. THROUGH 15.) A disc system (FlexiDisc System by Cosmedent) from coarse to superfine was used to
achieve a high polish and invisibly blend composite into the tooth structure. Note the high flex and resilience of the discs.
66
INSIDE
ESTHETICS
used to bring out the final beautiful polish of composites, metals, porcelain, or
natural dentition after prophylaxis.
Step 2: Conceptualization
Before finishing and polishing, the
dentist must conceptualize the desired
end result. The dentist will not have to
work as hard to obtain lifelike results if
the restoration is pre-contoured to the
correct shape and form before polishing.
Many practitioners lose the shape of the
restoration because of a lack of attention
to the material application phase. Many
dentists have a tendency to over-bulk
the composite, and end up losing the
intended shape. It is much easier to obtain the desired result if the composite is
initially placed into the correct anatomical form and only slightly over-contour
Step 3: Action
A realistic tooth form should be developed before the pre-contouring phase
begins. Now it is time to apply the correct technique during the final phases
of the restoration.
Handpiece
Finishing and polishing should be
achieved with a low-speed, high-torque
handpiece, typically anywhere from
7,000 rpm to 30,000 rpm. A high-speed
handpiece may be used to pre-contour,
but using anything over 30,000 rpm
during finishing and polishing is too
high. Low-speed, high-torque is preferable, because it gives the operator
complete control.
The best finishing and polishing
technique depends on the type of restoration the dentist is presented with.
When polishing a Class IV restoration, for instance, the dentist should
rely mainly on discs. However, cups
and points will help develop more realistic characterization when polishing a veneer. A step-by-step guide to
polishing on various restorations is
outlined below.
Class III, IV, and
Diastema Closures
Starting with a coarse disc or a carbidefinishing bur, the restoration can be
completely contoured moving from
restorative material to tooth surface,
similar to burnishing metal. This can be
done in a wet or dry field. The material
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PRODUCT
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Composite
Finishing and Polishing
should be extended well past the long
bevel, and the dentist should not come
back to the beveled margin. The final
restoration should be feather-edged
onto the tooth surface past the beveled margin. If done properly, any
white line or raised margin will completely disappear. At this stage, the
disc should be flexed for maximum
finishing potential.
FIG. 16
FIG. 17
FIG. 18
FIG. 19
FIG. 20
FIG.21
FIG. 22
FIG. 23
FIG. 24
FIG. 25
FIG. 26
FIG. 27
FIG. 28
68
from the facial aspect.
FIG.29
FINAL POLISHING (16.) Gingival torquing opened the contact to start the
interproximal finishing. (17. AND 18.) Use of both wide and narrow superfine
diamond finishing strips (Cosmedent’s FlexiDiamond Strips). Running these
strips once or twice through the contact will smooth the contact area. (19.)
This view shows that there is still more finishing and polishing to be done to
further refine the embrasure space. (20.) Further refinement of the mesial–labial line angle to further refine embrasure space and create symmetry of both
centrals. Here, the use of the medium-grit (FlexiDisc) is preferred. (21.) Continuing the polishing with a fine disc. (22.) Polishing with a superfine disc. (23.)
Polishing the lingual surface with diamond polishers (Cosmedent’s nanohybrid
composite polishers). (24.) Polishing the lingual surface with a superfine cup.
(25.) Finishing and characterizing the labial surface with a superfine point. (26.)
Application of an aluminum-oxide polishing paste (Enamelize, Cosmedent)
with a felt buff (FlexiBuff, Cosmedent). (27.) Polishing the lingual surface with
Enamelize and Felt FlexiPoint (Cosmedent). (28.) This is the incisal view of the
finished restoration. Note the symmetry of the labial surfaces, the contour at
the embrasures surfaces, the contact, and the beautiful blend of the polished
material into the tooth surface. (29.) Labial view of the finished restoration.
INSIDE
ESTHETICS
The different grit sizes—medium, fine,
and superfine—should be continued
through in succession. An enamel-like
luster rapidly appears. The interproximal
process should be started with diamond
strips to maintain the integrity of the contact. One or two times through the interproximal should be sufficient, followed
with the fine-superfine aluminum oxide
strip on dry surface until no resistance
is felt, and a smooth surface is apparent.
For the final polish, an aluminum oxide
polishing paste with felt discs and points
should be used. This is the step that really
brings out the amazing final polish.
Class V
On occlusal or incisal margins, 5/8” or
1/2” coarse disc should be used past the
long bevel. Discs are always preferred on
exposed margins. To start finishing from
restoration to tooth surface, a coarse disc
is used, followed by medium and then
fine; finishing with the superfine disc to
achieve maximum polish. The 3/8” disc
should be used at the gingival margin.
Although this is a small diameter, the 3/8”
disc can be flexed to gain access to hardto-reach areas. The gingival half of the
restoration can be polished nicely using
flexible cups, but rubber must be kept off
the occlusal and incisal margins.
If Class V restoration invades the proximal surfaces, the diamond strips and
aluminum oxide strips should be used
in the narrow width for polishing these
surfaces. An aluminum-oxide polishing
paste with felt discs and points is recommended for the final polish.
and down the tooth surface. Blunting
off sharp edges on a green stone prior
to characterizing prevents scarring and
over-characterization.
After a grooved surface has been
developed, augmenting with rubber
points highlights the grooves. Polishing
the surface is completed with fine and
then superfine polishing discs. To polish the interproximal surfaces, diamond
and aluminum-oxide strips are used as
previously described. For the final polish, an aluminum-oxide polishing paste
with felt discs and points is used.
Quick Tips
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Full Resin-Bonded Veneer
The coarse disc or contouring bur is
used to start contouring and finishing.
The coarse and medium discs can be
used to complete the contouring of the
veneer. It is desirable to maintain the
character and anatomy placed in the
facial surface. This cannot be done with
discs, but cups and points are very useful for this purpose. To characterize, the
cup is placed flat on the tooth surface,
flexed slightly, and run with pressure up
TABLE 2
Maintenance of
Composite Restorations
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Excessive staining is removed in the
usual fashion. A small amount of aluminum-oxide polishing paste is then
applied to each surface and polish. To
remove interproximal staining, each
interproximal should be packed with
polishing paste, and a wide, fine/superfine polishing strip is used to polish
the surface.
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INSIDE DENTISTRY SWEEPSTAKES
Enter to win an
Odyssey® Navigator™ Diode Laser!
It’s simple—just use one of the three options below and follow the instructions to
enter. The contest runs for the next 2 issues and there are 4 unique entry boxes
in each issue. With 9 unique ways to enter in each issue, look for all the boxes
and enter often to win. One winner will be selected by random drawing and
featured in the June issue. Good luck!
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The proper contouring, finishing, and
polishing of anterior restorations is a
key component to the long-term success of bonded restorations. This article outlines the importance of three
different phases in the finishing and
polishing process. First, the appropriate restorative materials, from composites to polishers, must be carefully
selected to help get the job done right.
Then, the dentist must conceptualize
the desired end result, and set up the
restoration accordingly. And, finally,
the proper finishing and polishing
technique must be executed in order to
achieve maximum restorative success.
For a clinical example of the technique
described, the author provides a complete case pictured in Figure 1 through
Figure 29.
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The author is part owner of Cosmedent.
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* Contest is open only
to dentists practicing
in North America.
70
Conclusion
References
1. Jefferies SR. Abrasive finishing and polishing
in restorative dentistry: a state-of-the-art review. Dent Clin North Am. 2007;51(2):379-397.
2. Turkun LS, Turkun M. The effect of one-step
polishing system on the surface roughness of
three esthetic resin composite materials. Oper
Dent. 2004;29(2):203-211.
3. Mopper KW. How do composite resins stand
the test of time? Dent Today. 2004;23(5):74-79.
3%0$ƫ0$!ƫ1/!ƫ+"ƫƫ %)+* ƫ
,+(%/$%*#ƫ,/0!Čƫ"+((+3! ƫ
5ƫ0$!ƫ1/!ƫ+"ƫ*ƫ(1)%*1)ġ
+4% !ƫ,+(%/$%*#ƫ,/0!ƫ3%0$ƫ
"!(0ƫ3$!!(/ƫ* ƫ"!(0ƫ,+%*0/ċƫ
4. Ikeda M, Martin K, Nikaido T, Foxton RM,
et al. Effect of surface characteristics on adherence of S. mutans biofilms to indirect resin
composites. Dent Mater J. 2007;26(6):915-923.
5. Kantorski KZ, Scotti R, Valandro LF, et
al. Adherence of Streptococcus mutans to
uncoated and saliva-coated glass-ceramics
and composites. Gen Dent. 2008:56(7)740-747.
6. Mopper KW. Let’s talk composites! Dent
Today. 2008;27(10):120-122.
7. Craig RG, Ward ML (eds). Restorative Dental
Materials. Mosby, St. Louis, 1997,p263.
8. Barucci-Pfister N, Gohring TN. Subjective
and objective perceptions of specular gloss and
surface roughness of esthetic resin composites
before and after artificial aging. Am J Dent.
2009;22(2):102-110.
9. Takanashi E, Kishikawa R, Ikeda M, et al.
Influence of abrasive particle size on surface
properties of flowable composites. Dent Mater
J. 2008:27(6):780-786.
10. Cenci MS, Venturini D, Pereira-Cenci T, et
al. The effect of polishing techniques and time
on the surface characteristics and sealing ability of resin composite restorations after oneyear storage. Oper Dent. 2008;33(2):169-176.
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uick Tips
Pink Opaque for Stained Dentition
K. William Mopper, DDS, MS
Co-Founder and Chairman
Cosmedent, Inc.
Chicago, Illinois
Director
Center for Esthetic Excellence
Chicago, Illinois
Private Practice
2601 Compass Road, Glenview, IL 60026
Phone: 847.729.6080 Fax: 847.441.6082
moppers@ais.net
arkly
stained
teeth have always been difficult to treat cosmetically. Tetracycline-stained
dentition and the single, nonvital tooth are
among the most difficult
teeth to treat esthetically
with minimally invasive
D
procedures such as composite resin veneers or porcelain laminates.
Over the years, ceramic technicians have used pink to warm up cold,
unesthetic grayish discoloration.1,2 Cosmedent®, Inc., has developed a
new pink opaque that treats the darkly stained dentition reliably and with
natural results. Using pink opaque before applying the composite
restorative material neutralizes gray tetracycline stains and results in a
warmer, more natural color. Using other opaques, such as white, A1, or
A2, and then overlaying with the composite will usually result in a
decrease in value. Even when the color is correct, the result will still
have a gray cast.
Figur e 1—Prepared tooth showing dark band of color.
Figur e 2—Application of pink opaque with No. 1
Cosmedent® brush.
Figur e 3—Blending opaque to the tooth structure.
Figur e 4—Opaque after polymerization.
Figur e 5—Light application of more opaque to block
and blend the dark areas that remained after polymerization.
Figur e 6—Continued application and blending.
40
CONTEMPORARY ESTHETICS AND RESTORATIVEPRACTICE
Quick Tips continued
Figur e 7— A pplication of
pink opaque completed on
the upper left central incisor.
A ll undesirable color has
been neutralized without
overopaquing.
R E NA M E L
Figur e 8—The four completed incisor veneers
immediately postoperatively.
R EFERENCES
tooth, or teeth with metal posts
and cores. Pink opaque is also
effective in repairing the dark
gingival discoloration often seen
with porcelain and metal restorations. I
A MUST
FOR
1.
2.
Nixon RL: Masking severely tetracycline-stained teeth with porcelain
veneers. Pract Periodontics Aesthet
Dent 2(1):14-18, 1990.
Nixon RL: Masking severely tetracyline-stained teeth with ceramic laminate
veneers. Pract Periodontics Aesthet
Dent 8(3):227-235, 1996.
Pi n k O PA Q U E
EVERY RESTORATIVE DENTIST
N
OW YOU CAN NEUTRALIZE DARKLY
STAINED TEETH AND CREATE A BRIGHT,
LIFELIKE RESULT WITH COMPOSITE RESIN OR
PORCELAIN .
N EW
PINK OPAQUE TREATS THE
DARKLY STAINED DENTITION RELIABLY AND
WITH NATURAL RESULTS .
P R E PA R E D T E E T H
U SE
T ECHNIQUE
When using pink opaque as
part of the Renamel® Restorative
System (Cosmedent®, Inc.), follow these steps:
1. Prepare, etch, wash, and apply
the bonding adhesive.
2. Apply a thin layer of Creative
Color™ (Cosmedent®, Inc.)
clear liquid resin to the entire
veneer surface, gently air-thin,
and polymerize. The creation
of a smooth surface makes it
easier to apply the opaque.
3. Apply pink opaque in a thin
layer and polymerize.
4. If dark areas shine through,
gently add opaque to these
areas to block it out. Apply
just enough to do the job, and
avoid overopaquing.
5. Apply a thin layer of Renamel® hybrid. The color
should be preselected to match
the existing teeth or the new
shade of the teeth.
6. After the hybrid is placed and
polymerized, slight opaquing
may be required. Use the color
of opaque that corresponds to
the hybrid chosen.
7. Overlay with Renamel® body
PINK OPAQUE TO NEUTRALIZE ULTRA
DARK STAINS ASSOCIATED WITH DEFECTS SUCH
and incisal microfill.
8. Finish and polish.
AS TETRACYCLINE STAINS , THE UNSIGHTLY
NON - VITAL TOOTH AND THE GREYNESS OF METAL
SHINE - THROUGH .
sing pink opaque
before applying
the composite
restorative material
neutralizes gray
tetracycline stains and
results in a warmer,
more natural color.
U
T HESE
ARE AMONG THE MOST
DIFFICULT PROBLEMS TO TREAT ESTHETICALLY
A P P L I C AT I O N O F
P I N K O PA Q U E
WITH MINIMALLY INVASIVE PROCEDURES .
T HIS
AMAZING NEW OPAQUE WILL BLOCK OUT:
•
DARKLY STAINED DENTITION
•
GREYNESS OF METAL SHINE - THROUGH
•
UNSIGHTLY DEVITALIZED TEETH
•
DARK GINGIVAL DISCOLORATION
•
ENDO AND IMPLANT ACCESS HOLES
F I N I S H E D R E S T O R AT I O N
C ASE A PPLICATION
The case shown in Figures 1
through 8 graphically illustrates
the application of pink opaque
before composite application. The
neutralization of the dark stripes
can be easily observed.
BEFORE
Solves the Problem
o f D a r k l y S t a i n e d Te e t h
O THER A PPLICATIONS
The same procedure can be
used for preopaquing after preparation and before placing porcelain veneers on tetracyclinestained teeth, a gray nonvital
DIRECT
1.800.621.6729
www.cosmedent.com
to order call
or visit
AFTER
CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE
41
www.dentistry.co.uk
Clinical
Correct use of composite resins
William
Mopper
DDS,
MS,MS,
K. William
Mopper,
DDS,
explains his protocols for
choosing anterior and
posterior composite resin
materials in aesthetic
restorative dentistry
Figure 1: Maxillary anterior composite restorations at 22.5 years
postoperatively. Only minimal chipping and slight recession can
be seen. Note the highly polished surface of the microfill
composite resin material (Renamel Microfill, Cosmedent)
William
‘Buddy’
K.William
‘Buddy’Mopper
Mopper,DDS,
DDS,MS,
MS,isisinin private
private practice
practice in
Winnetka, Illinois, where he has been involved with creating
dental aesthetics for 42 years. He is an internationally
renowned lecturer in aesthetic dentistry with an emphasis on
composite bonding using direct application techniques. He
co-authored, A Complete Guide to Dental
co-authored,
A Complete
Dental
Bonding, which
was the Guide
first to
definitive
Bonding,
wasprofession
the first describing
definitive
book for which
the dental
book
for techniques.
the dental profession
describing
bonding
He is a member
of
bonding
techniques.
He
is
a
member
the Academy of Esthetic Dentistry, andofa
the
Academy
Esthetic Dentistry,
andofa
fellow
of theof American
Academy
founder
fellow of
the American
Cosmeticand
Dentistry,
diplomat
of the
Academy
Cosmetic
Dentistry,Dentistry,
diplomat
AmericanofBoard
of Pediatric
of
American
Board
of Pediatric
Dentistry,
and aHe
fellow
of
andthe
a fellow
of the
American
College
of Dentists.
taught
the
American
College
of
Dentists.
He
taught
direct
resin
direct resin bonding at many major Universities including the
bonding
at many
major Universities
including theofUniversity
of
University
of Minnesota,
State University
Iowa, the
Minnesota,
State
University
of Iowa,
the University,
University the
of
University of
Nebraska,
Louisiana
State
Nebraska,
Statethe
University,
theofUniversity
of Illinois
University Louisiana
of Illinois and
University
Kentucky. He
is the
and
the University
of Kentucky.
He is the
recipient Dentistry
from the
recipient
from the American
Academy
of Cosmetic
American
of Cosmetic
Dentistry
of an Excellence
award for
of an awardAcademy
for ‘Lifelong
Commitment
to Providing
‘Lifelong
Commitment
Continuing
in Continuing
EducationtoinProviding
CosmeticExcellence
Dentistry’ in
and
an award
Education
in Cosmetic
Dentistry’
and anDentistry.
award ’ for
for ‘Outstanding
Contribution
to Cosmetic
He
‘Outstanding
Contribution
to Cosmetic
Dentistry.’Irwin
He
received the New
York University
College of Dentistry
received
the New
University
Collegeand
of Dentistry
Irwin
Smigel Prize
in York
Aesthetic
Dentistry,
the Lifetime
Smigel
Prize
in
Aesthetic
Dentistry,
and
the
Lifetime
Achievement Award from GenR8TNext seminars. He is
Achievement
Award for
fromtheGenR8TNext
seminars.
He is
director of education
Center for Esthetic
Excellence
director
education
for theand
Center
for Esthetic
Excellence
(Chicago)ofand
is co-founder
chairman
of Cosmedent,
Inc.,
(Chicago)
is co-founderfor
anditschairman
of Cosmedent,
where heand
is responsible
educational
programs Inc.,
and
where
is responsible for Mopper
its educational
programsat and
producthedevelopment.‘Buddy’
will be speaking
the
product
development.
‘Buddy’
will–be
speaking13atJune
the
World Aesthetic
Congress
onMopper
Friday 12
Saturday
World
Aesthetic
Congress
on
Friday
12
–
Saturday
13
June
2009 in London. For further information and to book your
2009
London.
further information
to book
your
places,inplease
call For
Independent
Seminars onand
0800
371652
or
places,
please call Independent Seminars on 0800 371652 or
visit www.independentseminars.com/wac.
visit www.independentseminars.com/wac.
Figures 3a and 3b: A shallow labial prep is placed ranging
from 0.8 mm at the incisal to 0.4 mm at the gingival. The
gingival margin is placed 0.3 mm below the free margin for
aesthetics. The application of Complete (Cosmedent) bonding
adhesive after a total-etch technique was performed
Figure 2: Microfills are exceptionally color stable and wear
resistant. Note the excellent color match of the restoration to
the shade tab (VITA Classical, Vident) after 22.5 years
Figures 4a and 4b: Lingual surface of tooth six is reduced
about 0.5 mm across the entire incisal third, allowing a
complete labial-lingual wrap of incisal edge, creating better
fracture resistance/retention form. The first application of
Renamel NANO A2 is placed lingually to establish canine rise.
(Note this material’s no-slump, no-stick properties allow easy
sculpting/shaping of the incisal tip)
Today, in an attempt to replicate lifelike tooth structure
aesthetically, there are a multitude of anterior and
posterior composite resin materials from which to
choose.
As a result, dentists face a dilemma in deciding what
product to use, and when. This article will explain the
protocol that I follow and will also help readers identify
and utilise the ideal product for a specific use that they
may have in mind.
In my experience, there is no other dental material as
versatile and useful as this category of restorative
products. There are many advantages to understanding
and using direct composite resins regularly in your
practice (Table 1).
When one truly understands how to properly use
these materials, long-lasting, truly aesthetic results are
easily achievable. Composite resin can help you produce
invisible aesthetic restorations of all types. I know this
from my personal, long-time clinical experiences with
this class of dental materials and their associated
techniques.
I have been using light-activated direct composite
resin restoratively for more than 35 years, and for the past
20 years my practice has been limited to producing
Table
Table 1:Advantages
1: Advantagesofofdirect
directcomposite
compositerestorations
restorations
Aesthetics:
When
done
properly,
of the
most
aesthetic
Aesthetics: When
done
properly,
oneone
of the
most
aesthetic
restorations
restorations attainable
attainable
Timesaving:
Placed
in one
practice
Timesaving: Placed
in one
practice
visit visit
Control:
Aesthetic
functional
results
your
hands
Control: Aesthetic
andand
functional
results
areare
in in
your
hands
Minimally
invasive:
Theconservative
most conservative
restorative
Minimally invasive:
The most
restorative
material
material
choice available,
helping
ensure long-term
of
choice available,
helping to
ensuretolong-term
health ofhealth
the tooth
the tooth
Biologically compatible: Extremely compatible with the gingival
Biologically compatible: Extremely compatible with the
tissue, when properly placed and polished
gingival tissue, when properly placed and polished
Wear: Will not wear the opposing dentition
Wear: Will not wear the opposing dentition
Handling properties:
Easy toEasy
handle,
manipulate,
and control
Handling
properties:
to handle,
manipulate,
and
control
Creative: Maximum creativity according to choice, technical and
artistic abilities
Creative:
Maximum creativity according to choice, technical
and
artistic abilities
Reparability:
Easy to repair and can also be used for all-ceramic
and
PFM
repairs
Reparability: Easy to repair and can also be used for allceramic
and PFMstrength:
repairs Modern chemistry (research on
Long-lasting/high
particle size and filler content)
has increased
the strength and
Long-lasting/high
strength:
Modern chemistry
longevity of
(research
oncomposite
particle sizerestorations.
and filler content) has increased the
strength and longevity of composite restorations.
Article reprinted by permission of Dentistry Today, c2008 Dentistry Today
21282.indd 1
8/18/09 10:35:46 AM
Clinical
www.dentistry.co.uk
aesthetic changes using only composite resin. Although
my practice is all encompassing, with my partners doing
indirect restorations of all kinds, I have limited my
practice to direct placement restorative techniques.
Procedures that I use direct composite resins for include:
• Class I restorations
• Class II restorations
• Class III restorations
• Class IV restorations
• Class V restorations
• Tooth shaping
• Tooth alignment
• Diastema closure
• Repair of intraoral defects
• Veneering for colour change
• Veneering mutilated dentitions
• Tooth lengthening
• Incisal edge reinforcement
• Composite and porcelain repairs.
Composition of composite resins
What categories of composite resin materials are available
to us for use in our clinical armamentarium? Let’s
examine them by discussing their properties and seeing
where they fit into our clinical techniques.
Microfills
Microfills are important if you want to create truly
aesthetic, life-like restorations. This class of composite
resins offers the highest level of aesthetics because they
most closely simulate the actual enamel surface of a
tooth. Since microfills have the smallest average particle
size (0.04 microns) of direct composite resins, they
polish to a higher lustre than any other material on the
market. They also hold their polish over time and
exhibit better wear characteristics than other types of
composite resins. Microfills are also more stain and
plaque resistant, making them more biologically
compatible with the gingival tissue. In addition, they
have the highest refractive and reflective index of any
composite resin category, producing the most realistic
translucency.
However, microfills are less filled than other
composite resins. As a result, they will not exhibit the
same strength-properties as microhybrid or nanofill
composites. Because of this, I use a layering technique
placing an ‘enamel’ layer of microfill composite resin
(Renamel Microfill, Cosmedent) over a stronger, ‘dentine’
layer composite. For the ‘dentine’ layer(s) I use either a
microhybrid or nanofill composite (Renamel Microhybrid
or Renamel NANO, Cosmedent). Restorations built in
this way exhibit optimal aesthetics and wear resistance
due to their outer microfill ‘enamel’ layer.
Microhybrids
Microhybrids are able to most closely simulate the
dentine of natural tooth structure. Because of their
higher strength and greater opacity, microhybrids are
perfect for supporting the microfill ‘enamel’ layer.
Microhybrids have a larger particle size than the nanofill
and the microfill composites, resulting in higher-strength
properties. Since microhybrids are the most opaque of
the three composite types, they are also great for masking
out unwanted colour and achieving extreme colour changes.
Microhybrids are also less polishable, more difficult to
marginate, and will wear faster than microfill resins. As
microhybrids most closely simulate the dentine of tooth
structure, they will not obtain the same aesthetic results
for an ‘enamel’ layer as a microfill resin. In my practice, I
use microhybrids as the substructure under microfills in
areas that require high strength.
Nanofills
Nanofills
The incorporation
incorporation of nanofill technology into composite
The
resins is
is an important advancement in the field of
resins
aesthetic dentistry. Nanofill composites combine
aesthetic
conventional-filler technology with nano particles to
conventional-filler
achieve both
both strength and aesthetics in one material.
achieve
Currently, there are two distinct types of nanofill
Currently,
composites in the marketplace: completely nanofilled
composites
resins and
and nano-hybrids (i.e. Renamel NANO,
resins
Cosmedent).
Cosmedent). Completely nanofilled resins contain
nanometer-sized particles throughout the resin matrix.
nanometer-sized
Nano-hybrids, on the other hand, consist of larger
Nano-hybrids,
particles surrounded by nanometer-sized particles.
particles
Although these nanofill materials vary in composition,
Although
the goal
goal is
is the same, creating a ‘universal’ dental composite.
the
As previously mentioned,
As
mentioned, nano-hybrids
nanohybrids contain
nanometer particles combined with more conventional
nanometer
21282.indd 2
Figures 5a and 5b: After polymerisation of the incisal tip,
Renamel NANO (Cosmedent) was used on the mesial
proximal to add to the width of the cuspid to match the
other side of the mouth. Note the space between cuspid and
laterals is not fully closed because it would have delivered a
disharmony in size. Proper morphology of each tooth is
completed making finishing and polishing much easier
Figures 6a and 6b: Addition of facial NANO A2 and the use
gloved finger (no powder and clean and dry) to manipulate
material into place. Apply light pressure with a tapping
motion to allow for rapid and easy placement and precontouring
Figures 7a and 7b: Use of titanium-coated instruments ensures
easy placement of nanofills without sticking. Similar to buttering
bread, the composite is spread and thinned simultaneously. A G3
instrument (Cosmedent) allows for easy placement on facial
surfaces. An IPC Carver (Cosmedent) cleaves excess material
interproximally and at gingival margins. Morphology and
contours are achieved, but the material has not yet been
polymerised
Figures 8a and 8b: After polymerisation of facial surface,
Renamel NANO (Cosmedent) Medium Incisal shade is placed
with a Multipurpose instrument (Cosmedent) into the incisal
areas to enhance the overall lifelike appearance of the
finished veneer (Note colour and translucency of this
material). The G3 instrument is used along with finger
pressure to aggressively compress incisal material into the
pre-formed incisal grooves
Figures 9a and 9b: Incisal material in place and polymerised
(note the translucency difference between the incisal edge
and the body material). When gingival margins are involved,
apply a small amount of Renamel Microhybrid (A2)
(Cosmedent) material and sculpt with the IPC instrument to
completely seal gingival and proximal margins
Figures 10a and 10b: The G3 is used to smooth/sculpt
subgingivally to completely seal margin. Material application
and morphology is complete (note how much attention is
given to properly sculpted tooth form). Then the material is
light-cured for 60 seconds
filler technology. These large particles provide similar
strength properties to hybrid materials while exhibiting
higher polishability, as seen with the microfill resins.
Unlike microhybrids, nanofill composites have a lifelike
opacious translucency that is very natural in appearance.
It is important to note that these materials will not hold
their polish as long as microfill resins and, as a result,
may be more susceptible to plaque and staining over
time. However, when compared with conventional
microhybrids, nanofill composite resins will maintain
better surface smoothness and are thus great for the
single-product user.
Where should you use nanofill composites? Although
you can really use nanofill materials to create cosmetic
dental restorations of all kinds, I have identified a few key
areas where nanofill composites fit into my dental
practice. They are as follows:
• Posterior restorations
• Veneering lower anteriors
• Building up incisal edges
• The classic class IV restoration
• When restoring or increasing cuspid rise.
They can also be used when the dentist wants to use
only one material, instead of layering a microfill over a
microhybrid; as a support material for Class IV
restorations; any tooth lengthening; adding cusps to
worn molars or bicuspids; and for veneering mandibular
anterior teeth (when strength is a concern); and posterior
restorations.
Opaquers and tints
Opaquers and tints are key ingredients to creating
beautiful invisible restorations. During the restoration
procedure, opaquers allow you to block-out unwanted
colour while tints help you bring the desired colour back
into the tooth. The use of both is where your creativity as
a dentist can really shine! However, opaquers and tints
should always be used sparingly. Also, be careful when
choosing them as some manufacturers make these
materials too opaque. Let’s examine the difference
8/13/09 10:49:34 AM
Clinical
www.dentistry.co.uk
Figure 11: Final right cuspid
composite resin veneer
(tooth 6) after finishing and
polishing. (Figures 13-15
demonstrate finishing and
polishing steps on tooth 11)
between these two materials.
Opaquers: The main advantage of opaquers is that they
produce opacity and block light transmission. Use them
anywhere you would like to produce opacity in your final
restoration. Since opaquers increase the value of a
restoration, they are great for masking out metals and
dark stains.
Tints: Tints are used to help increase the hue and
chroma of your restoration. Since tints transmit light,
they are great for adding translucency back into your
restoration. Unlike opaquers, tints decrease value. I use
them to help develop a realistic-looking enamel surface
from within.
System advantages
To excel in direct composite resin techniques, you should
find a system that gives reliable and long-lasting results
— then stick with it! Ask yourself the following question:
How many composite materials have I shelved because
some guru says another product is better — only to be
disappointed once you have used it? When you are
looking for a system, you should consider certain criteria
(Table 2).
Application technique
First, one should understand that no material in itself will
deliver the ideal restoration. This is because material
selection is only one part of direct resin bonding. Second,
one must consider the dentist’s technical ability. Proper
technique involves many components including the
following: proper preparation technique for each
procedure; method of material placement — this involves
complete understanding of tooth morphology and
sculpting techniques necessary to achieve it; knowledge
of layering and how to use various materials in
combination to enhance the overall physical, aesthetic,
and biologic results of each procedure (i.e. when to use
microhybrid, nanofill, microfill, tints, and opaquers); and
using the proper finishing and polishing techniques to
achieve the most lustrous, plaque resistant, stain resistant
and wear resistant finished result. One must understand
when and how to use finishing burs, discs, rubber
impregnated points, and polishing paste to obtain the
desired result. (Note: knowledge and technical abilities in
Figure 12: Upper left cuspid (tooth 11). Composite application
complete and polymerised prior to finish (note the two most
important views when finishing and polishing are from the
incisal and profile. Incisal view: Sets up incisal gingival
contours, mesial distal contours and labial lingual relationships.
It also helps to visualise embrasure space development. Profile
view: Helps to silhouette one tooth against another to establish
the alignment and emergence profile)
Figures 13a and 13b: Use of discs to contour the labial
surfaces and to properly contour line angles and to develop
embrasure surfaces. Note retraction with an 8A instrument to
protect gingival tissue and an 8392-016 diamond (Brasseler,
USA) while trimming and defining the gingival tissue
Figures 14a and 14b: Further define tooth and pre-polish with
a fluted ET6 bur (Brasseler USA). A diamond-impregnated
point (Diamond Polisher Medium, Cosmedent) is used to
form/polish mesial and distal grooves and further develop
central lobe on cuspid
Table 2: Key questions when selecting a composite
resin system
1. How does the material handle?
2. Does the finished material truly match its selected shade
guide?
3. Does the system make colour matching or colour
development easy?
4. Is the finished product colour stable over time? (15 to 20
years?)
5. How easy is it to polish, and will the composite hold the
polish over time?
6. How strong is the restoration?
7. What are the translucency and opacity characteristics of the
material?
8. When finished properly, are the composite and the gingival
tissues biocompatible?
9. What material has adequate strength for the purpose of use?
10. What material is more wear resistant? Why?
all the above-mentioned areas can be greatly enhanced by
an excellent hands-on workshop experience. I would
recommend that you consider this if you have not already
done so.)
Case report:
direct composite resin technique
Many years ago, I placed direct composite resin veneers
on my son’s maxillary anterior teeth (6 to 11) to close
spaces using only a microfill (Renamel Microfill,
Cosmedent). Over considerable time, Robert had some
chipping due to aggressive eating habits. These defects
were easily repaired. Photos, taken at 22.5 years
postoperatively, show minimal chipping of the composite
material and excellent color stability of the material
(Figure 1). As mentioned previously, microfills hold their
polish long-term better than any other type of composite
resin material, especially when the right dentifrice and
toothbrush are used (Figure 2).
I made the decision to redo Robert’s case in autumn
21282.indd 3
Figure 15: Fine and superfine
disks (FlexiDiscs, Cosmedent)
are used to achieve a high
lustre while maintaining facial
anatomy. This is followed with
a buffing procedure (FlexiBuff
and Enamelize polishing paste,
Cosmedent) to achieve
exceptionally smooth surface
and immediate high polish. A
Felt FlexiPoint (Cosmedent)
and Enamelize polishing paste
are used to enhance the
mesial and distal grooves
Figure 17: Completed case: tooth numbers 6 and 11 were done
with Renamel NANO A2 Body and Medium Incisal. Tooth
numbers 7 and 8 were done with Renamel NANO and overlaid
with Renamel Microfill A2 Body and Medium Incisal. Tooth 9
was not veneered, but the mesial and distal diastema closures
were done using only Renamel Microfill
Figure 16: Note the excellent
colour match of the
completed veneer to an A2
shade tab (Vita Classical,
Vident)
2007. The treatment goals were to achieve great
aesthetics while establishing proper disclusion by
improving his canine rise. Therefore, the new aesthetic
restorations were done by utilising both nanofill and
microfill composites.
Let me take you through the reasoning involved in the
proper material-selection thought process. I could have
done the entire case using a nanofill and achieved
excellent results, but I wanted the best of both worlds,
both strength and aesthetics. I wanted a microfill surface
because of its long-term polishability and optimal,
life-like aesthetics. I used a nanofill to complete the
functional portion involving the right and left cuspids.
This would give me the strength required on a support
tooth, along with great aesthetics and an excellent colour
match to the laterals and centrals (the technique is shown
in detail in Figures 3-16). Now, many would ask, why not
Figure 18: Completed case at three-week post-op (note the
accurate color match)
porcelain veneers? And, I would ask, why
porcelain veneers? What did we achieve with my son
after 23 years? We achieved long-lasting results with
minimal preparation. We observed only minimal (nonpathologic) recession due to material biocompatibility
(and good oral hygiene habits); total colour stability with
excellent aesthetics; complete and intimate bond of the
composite-to-tooth surface (no cementation); and
easy-to-repair restorations (Figures 17 and 18). Oh, and
by the way —Robert still eats ribs!
7/31/09 5:22:28 PM
GIVE BACK A SMILE™
My Turn to Give Back
A Great Smile is an Eye Opener
Buddy Mopper, DDS, MS, FAACD
Introduction
Over the years I have seen what great work the AACD’s Charitable
Foundation has done for survivors of domestic violence. Their
Give Back a Smile™ (GBAS) program encourages AACD members
nationwide to volunteer their time and “give back a smile” to survivors
of domestic violence with missing or damaged teeth. The impact a
smile can have on a person’s appearance, confidence, and happiness
is profound. Working with this patient reinforced how important a
smile is to a person’s overall appearance and well-being.
Patient History and Findings
“Diane” presented in early 2010 with a missing maxillary right central
incisor, fractured left central incisor, fractured right lateral incisor, and
a semi-closed eyelid where her eye had been replaced (Figs 1-3).
Diane was violently attacked by her ex-boyfriend in 2000. The
blows to her face were so vicious she lost her upper right central,
fractured her right lateral and left central incisor, and suffered such
severe damage to her eye it had to be removed.
After meeting Diane and hearing her story of domestic abuse, I was
anxious to start treatment as soon as possible.
The impact a smile can have on a person’s
appearance, confidence, and happiness is
profound.
Treatment Planning
When Diane came to my office she was a very sad woman, and understandably so. At the time of the consult I was able to show her,
through the use of a direct composite mock-up (Renamel Nano, Cosmedent; Chicago, IL), what she would look like when she was finished. By the end of the mock-up she was so happy with her new
smile she started to cry.
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Spring 2011 • Volume 27 • Number 1
The treatment plan was as follows:
1. Repair both fractured incisors.
2. Add enough material to both incisors to allow for proper contouring, spacing, and complete symmetry of both central incisors.
3. Construct a resin retained bridge.
a. Trough lingual surfaces of left central incisor and right lateral
incisor to allow for the placement of dental fiber reinforcement
(Ribbond; Seattle, WA) internally, which would help support
the construction of the missing right central incisor.
b. Cover exposed Ribbond and properly contour the lingual surfaces of both incisors with the use of nano-fill composite.
c. Create a freehand matched right central incisor with proper
bonding techniques.
In my opinion, this type of bridge is conservative and more predictable for longevity for the following reasons:
• Lower modulus of elasticity, which allows for the flex of natural
dentition and therefore actually becomes less likely to break.
• When fabricating a restoration of this type, you will not see wear
on the lower incisors.
• I have found composite resin to give a more predictable esthetic
outcome than does porcelain. If the bridge should fracture at the
connector site or any other place, it is far easier to repair.
• In my experience, this type of bridge has direct apposition of
the composite to the tooth structure, therefore delamination is
almost impossible.
Figure 1: Pre-treatment, full-face image of patient. Notice
semi-closed right eye.
Treatment
Both incisal edges were freshened with the use of a coarse FlexiDisc
(Cosmedent). A long bevel was placed on the labial of the central
and lateral and the lingual surface of each tooth was reduced fivetenths of a millimeter following the end of the long bevel. A chamfer
was placed in the same vicinity on the lingual corresponding to the
end of the long bevel on the labial. After etching (always etch beyond
the long bevel), Cosmedent Complete bonding agent was placed and
light-cured. To build up incisal edges and to give strength and opacity,
Renamel Nano composite was sculpted to the leading edge of each
long bevel and blended just slightly to the middle third of the bevel,
which left room for the Renamel Microfill. Nano was also blended
onto the lingual surface and sculpted to the lingual chamfered margin, creating a smooth intact lingual surface. Microfill was used for
the final layer on the labial surface. It was sculpted past the long bevel
and blended into the tooth surface and polymerized. The restorations were contoured, finished, and polished using the ET bur system
(Brasseler USA; Savannah, GA) followed by FlexiDiscs, FlexiCups,
FlexiPoints, FlexiStrips, Enamelize polishing paste, and felt FlexiBuffs
(Cosmedent). This technique was completed prior to the Ribbond
placement.1-3
Immediately following treatment, I informed the patient that the
restoration might be slightly too light in the gingival third. At her next
appointment, that assumption was confirmed (Fig 4).
At the next appointment, I reduced the microfill layer slightly all
the way to the middle third of the tooth.
Figure 2: Pre-treatment, natural smile view showing damage
from abuse.
Figure 3: Pre-treatment, retracted view.
Journal of Cosmetic Dentistry
23
GIVE BACK A SMILE
Technique Steps
1
After the mock-up.
3
4
Teflon tape was placed over the gingival
tissue to aid in the creation of a smooth
gingival surface for the pontic.
6
Application of nano-fill composite over the
Ribbond to form the dentin layer of the tooth
surface.
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Addition of small amount of flowable
Renamel Microfill.
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Smoothing flowable Renamel Microfill with
Cosmedent #3 brush.
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Creation of cervical chroma.
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Gray tint applied to enhance incisal
translucency.
2
Ribbond cemented in place with Insure resin
cement (Cosmedent) and overlaid with
Renamel Nano (Cosmedent).
5
Application and sculpting of lingual surface
with nano-fill.
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Polymerized flowable creating the artist’s
canvas.
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Gray tint was added to the incisal third.
12
To create the enamel surface, Renamel
Microfill was placed and sculpted to the exact
proximal contour while at the same time
slightly over-contouring from the facial.
15
Prior to finishing, measurements were taken
from the mesial of the lateral incisor to lateral
incisor with a digital boley gauge and then
divided by two, to determine the total width
of space needed for both central incisors.
18
Polishing completed; notice lack of gingival
chroma.
21
What a difference a new smile can make!
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Great attention was given to the proper
formation of line angles and embrasures.
16
Symmetry is accomplished in the “eyes” of
the dentist. Angulation and inclination have
to be done by “eye-balling” it.
19
Notice moist cotton pellet on adjacent central
to prevent dessication to achieve perfect
color match.
14
This technique of sculpting greatly simplifies
the final technique of contouring, finishing,
and polishing.
17
Completed restoration prior to polishing.
20
More gingival tint was added to the cervical
third prior to final microfill; notice the
increased chroma.
22
Finished case, immediately postoperative.
Journal of Cosmetic Dentistry
25
GIVE BACK A SMILE™
I placed a thin moist cotton pellet on the adjacent tooth to keep it
from desiccating, a great trick to help determine correct tooth color.
Because the cotton pellet keeps the tooth moist it is easier to see the
perfect color throughout the procedure. I added a little more tint to
the gingival surface of the pontic in an attempt to create a perfect
match.
Finishing was completed with the Brasseler ET contouring system
and polishing was completed with Flex-discs, Flexi-points, Flexi-cups,
Flexi-strips, Enamelize polishing paste and Felt Flexi-buffs.
Rewards
Figure 4: Postoperative evaluation confirmed that the gingival
chroma needed to be enhanced.
Figure 5: One year after treatment.
Immediately after treatment Diane said, “I now have a beautiful
smile—it has lifted my self-esteem.” One year later, Diane’s self-esteem is at its highest. She says, “It feels good when you can smile and
know that the world is smiling with you (Fig 5). I smile all the time
now, but for 10 years I couldn’t. Whenever I looked in the mirror I saw
a monster; today, I see a beautiful woman. The GBAS program and Dr.
Mopper gave me my life back!”
Diane also recounts the difference having her smile back has made
in her life. She now can go out in the world with her head held high,
and she can look people in the eye without being embarrassed. Her
new smile has had such an impact on her that she now wants to be a
spokesperson against domestic violence.
Diane’s newfound confidence and zest for life reaffirmed for me
how much patients really do appreciate our work; a smile truly is contagious.
What a difference a smile can make. Now Diane smiles not just
with her lips and teeth, she smiles with her whole face (Fig 6)!
Volunteering for the Give Back a Smile program was incredibly rewarding for my staff and me. Restoring Diane’s smile reminded us of
the significance of a smile in a person’s life. If you are not currently
volunteering with GBAS, I strongly encourage you to do so.
Acknowledgment
The author thanks his partner, Dr. Dennis Hartlieb, for his assistance with
this case.
References
1. Radz G. Beyond the Maryland bridge. J Cosmetic Dent. 1996;12(1):18-22.
2. Benjamin G, Kurtzman GM. An indirect matrix technique for fabrication of fiber-reinforced direct bonded anterior bridges. Compend Contin Educ Dent. 2010;31(1):60-4.
Figure 6: One year after treatment—a very happy patient!
3. Piovesan EM, Demarco FF, Piva E. Fiber-reinforced fixed partial dentures: a preliminary retrospective clinical study. J Appl Oral Sci. 2006;14(2):100-4. jCD
Dr. Mopper is in private practice in Glenview, Illinois, and teaches CE in bonding at the University of Iowa and
the University of Illinois. He is an Accredited Fellow member of the AACD and is the recipient of two awards
from the AACD: Award of Excellence in Cosmetic Dental Education and Outstanding Contribution to the Art
& Science of Cosmetic Dentistry. Disclosure: The author is co-owner of Cosmedent, Inc.
26
The Lingerie of the Smile
®
K. William Mopper, D.D.S., M.S. and Dennis Hartlieb, D.D.S.
instructors
OUTSTAN D I N G
C E E F A C U LT Y
The Center for Esthetic Excellence
has one of the most highly regarded
faculty of any continuing dental
education program in the world.
Our faculty members have received
multiple awards and commendations
in the dental industry, and have
served as consultants and teachers
both nationally and internationally.
The CEE faculty will help you take
your esthetic dentistry to a new
level of success.
Dr. Bud Mopper is in private practice in
Glenview, Illinois, where he has been doing
minimally invasive dentistry with composite for
almost 40 years. He is an
internationally renowned
lecturer in esthetic dentistry with an emphasis
on Composite bonding
using direct application
techniques. He coauthored, A Complete
Guide to Dental
William “Buddy”
Bonding, which was the K. Mopper,
D.D.S., M.S.
first definitive book for
the dental profession describing bonding techniques — and he has continued to publish numerous articles on The Art and Science of Direct
Resin Bonding. He is a member of the Academy
of Esthetic Dentistry, Fellow of the American
Academy of Cosmetic Dentistry, Diplomat of
the American Board of Pediatric Dentistry, and
Fellow of the American College of Dentistry.
He teaches direct resin bonding on a
Continuing Education level at many major
universities including the State University of Iowa
and the University of Illinois.
Dr. Hartlieb is a graduate of the
University of Michigan School of Dentistry.
He maintains a full-time practice in the
Chicago suburb of Glenview, Illinois, that
is devoted to
comprehensive
cosmetic and
restorative dentistry.
Dr. Hartlieb is an
Adjunct Associate
Professor at the
Marquette University
School of Dentistry.
Dr. Hartlieb is also an Dennis Hartlieb, D.D.S.
instructor at the
L.S.U. Continuum for Esthetics and teaches
hands-on anterior and posterior bonding
courses throughout the US and in Europe.
As a consultant for many dental
manufacturers, Dr. Hartlieb is influential
in the design of materials for restorative
dentistry. Dr. Hartlieb’s dentistry has been
seen in many dental publications, where he
has contributed articles on his techniques
in restorative dentistry. Dr. Hartlieb is a
member of the American Academy of
Cosmetic Dentistry and a participant of
the “Give Back a Smile” program.
Dr. Mopper is the recipient of two of the
most prestigious awards given by the American
Academy of Cosmetic Dentistry. One for
“Lifelong Commitment to Providing Excellence
in Continuing Education in Cosmetic Dentistry”
and secondly, an award for “Outstanding
Contribution to Cosmetic Dentistry”. He received
the New York University College of Dentistry
“The Irwin Smigel Prize in Esthetic Dentistry”,
and recently received the “Lifetime Achievement
Award” from the World Aesthetic Congress, in
England, for “Outstanding Contribution to
Cosmetic Dentistry”.
He is director of education for The Center
for Esthetic Excellence, in Chicago, Ill., and is
Co-founder and Chairman of Cosmedent, Inc.
where he is responsible for its educational programs and product development.
© 2011 K. William Mopper, DDS, MS
®
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®
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®
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®
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®
Body Microfill: Overlay Inter-Sculpted
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®
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401 North Michigan Avenue, Suite 2500, Chicago, IL 60611-4243
TEL:
312.467.0700 TOLL FREE: 800.837.2321 FAX: 312.467.0776
2011.1609
COSMEDENT is an ADA CERP
Recognized Provider
The Centrals and the Canines:
The Pillars and Posts of the Smile
®
instructors
OUTSTAN D I N G
C E E F A C U LT Y
The Center for Esthetic Excellence
has one of the most highly regarded
faculty of any continuing dental
education program in the world.
Our faculty members have received
multiple awards and commendations
in the dental industry, and have
served as consultants and teachers
both nationally and internationally.
The CEE faculty will help you take
your esthetic dentistry to a new
level of success.
Dr. Bud Mopper is in private practice in
Glenview, Illinois, where he has been doing
minimally invasive dentistry with composite for
almost 40 years. He is an
internationally renowned
lecturer in esthetic dentistry with an emphasis
on Composite bonding
using direct application
techniques. He coauthored, A Complete
Guide to Dental
William “Buddy”
Bonding, which was the K. Mopper,
D.D.S., M.S.
first definitive book for
the dental profession describing bonding techniques — and he has continued to publish numerous articles on The Art and Science of Direct
Resin Bonding. He is a member of the Academy
of Esthetic Dentistry, Fellow of the American
Academy of Cosmetic Dentistry, Diplomat of
the American Board of Pediatric Dentistry, and
Fellow of the American College of Dentistry.
He teaches direct resin bonding on a
Continuing Education level at many major
universities including the State University of Iowa
and the University of Illinois.
Dr. Hartlieb is a graduate of the
University of Michigan School of Dentistry.
He maintains a full-time practice in the
Chicago suburb of Glenview, Illinois, that
is devoted to
comprehensive
cosmetic and
restorative dentistry.
Dr. Hartlieb is an
Adjunct Associate
Professor at the
Marquette University
School of Dentistry.
Dr. Hartlieb is also an Dennis Hartlieb, D.D.S.
instructor at the
L.S.U. Continuum for Esthetics and teaches
hands-on anterior and posterior bonding
courses throughout the US and in Europe.
As a consultant for many dental
manufacturers, Dr. Hartlieb is influential
in the design of materials for restorative
dentistry. Dr. Hartlieb’s dentistry has been
seen in many dental publications, where he
has contributed articles on his techniques
in restorative dentistry. Dr. Hartlieb is a
member of the American Academy of
Cosmetic Dentistry and a participant of
the “Give Back a Smile” program.
Dr. Mopper is the recipient of two of the
most prestigious awards given by the American
Academy of Cosmetic Dentistry. One for
“Lifelong Commitment to Providing Excellence
in Continuing Education in Cosmetic Dentistry”
and secondly, an award for “Outstanding
Contribution to Cosmetic Dentistry”. He received
the New York University College of Dentistry
“The Irwin Smigel Prize in Esthetic Dentistry”,
and recently received the “Lifetime Achievement
Award” from the World Aesthetic Congress, in
England, for “Outstanding Contribution to
Cosmetic Dentistry”.
He is director of education for The Center
for Esthetic Excellence, in Chicago, Ill., and is
Co-founder and Chairman of Cosmedent, Inc.
where he is responsible for its educational programs and product development.
®
1
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Incisal view very important, sets up mesial/distal,
labial/lingual and incisal/gingival relationships.
Note: Areas of excess bulk, facial view.
Cleaving gingival proximal to contour gingival third
to allow for the papillae to help frame tooth properly.
Note: bulk at incisal line angles.
Cleaving of excess bulk to create proper embrasures
and line angles.
2
© 2011 Dr. K. William Mopper, DDS MS
®
Shapley vs. The Chicklet.
1. Great shape.
2. Contact areas and
thickened proximal
walls.
3. Flat to curved.
1. Over-contoured facial:
(too rounded).
2. Bulky at gingival.
The incisal view prior to finishing and polishing.
Medium FlexiDisc — best disc for refining proximal
wall, maintaining integrity of contact areas.
Note: Driven into embrasure area and flexed aggressively to properly define line angles.
Completed restoration — A polish that will be
maintained long-term (years) because the
Renamel NANO, with its strength and opacity, was
overlayed with Renamel Microfill to create the
enamel-like gloss.
Incisal view of the finished case.
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Cosmedent’s multi-purpose instrument is used to
create facial anatomy — grooves and lobes.
Labial surface after polimerization prior to finishing
and polishing.
Brassler Et-9.
Veneer Completed. Note: shape characterization,
line angles, and incisal table.
Cosmedent’s FlexiPoint.
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Note: the beautiful polish and finish of this Renamel
Microfll surface, the reflectivity and the ability to
produce three colors!
8
Application of Material: The Art of Sculpting
Renamel Microfill for Central Incisor — Renamel NANO for Canine.
Cosmedent’s Renamel NANO composite.
Cosmedent’s titanium-coated sculpting instruments.
The clean, gloved finger — one of the most useful
application instruments. Note how light finger pressure rapidly aids in applying the material.
Close-up of placed Renamel NANO composite on
model.
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Application of Material: The Art of Sculpting
Refining shape and form with Cosmedent’s titanium
sculpting instrument.
Cosmedent’s A-8 titanium sculpting instrument.
Refining and contouring interproximal surfaces with Cosmedent’s titanium IPC sculpting instrument.
Material prior to polymerization. Note the almost
perfect shape — only the mesial incisal corner
needs to be refined using an IPC instrument.
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Polymerized veneer prior to finishing and polishing.
The Creation of a Finished Enamel Surface:
The Art of Fnishing and Polishing
The Mopper Composite Preparation, Contouring,
Finishing and Polishing Kit.
Cosmedent’s FlexiDisc System, showing a variety
of diameters and progressively finer polishing grits
of aluminum oxide.
The Top Finisher System includes FlexiPoints,
FlexiCups impregnated with aluminum oxide and
Felt-Flexi polishers.
The NANO/Microhybrid Diamond Polishing System
has diamond-impregnated rubber points in grits
used progressively as Coarse (Grey), Medium (Blue)
and SuperFine (Pink).
Cosmedent’s coarse FlexiDisc (gray) sets the incisal
edge length and taper.
Cosmedent’s coarse FlexiDisc flattens and shapes
the incisal third.
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The appearance after using coarse disc before we
start to refine embrasures.
The incisal view showing the need for refinement of
embrasure spaces.
Taking measurements.
Use coarse disc to taper the gingival third.
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Bringing incisal third into alignment with the adjacent
central with the coarse disc.
®
Coarse disc reduces middle third to bring it into
alignment with the adjacent central.
Develop the labial contour with the Et-9 from incisal
to gingival.
Use the 16-fluted Et-9 to further smooth the surface.
The Et-9 starts to develop grooves and lobes in the
tooth surface.
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Refining the distal line angle by driving disc into the
embrasure space agressively.
Flexing it agressively toward center of the tooth. It
rounds out the line angle, without losing the integrity
of the of the thickness of the proximal walls and the
incisal edge — and at the same time it smooths out
the labial surface.
Repeat the same procedure on the misial line angle and labial surface the same way by flipping the disc.
Refining the incisal edge with the medium grit
FlexiDisc.
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The appearance of the tooth should look like this
prior to the final polish.
®
Start with the medium NANO point used to further
refine the characterization and further smooth the
labial surface.
SuperFine NANO points brings it to a high shine.
FlexiDisc fine will bring it to a higher polish —
especially on proximal areas.
Fine FlexiDisc will not remove material — only
refines polish.
Superfine FlexiDisc will bring a higher gloss.
Cosmedent Flexi-Buff with Porcelize 1 micron diamond paste.
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Cosmedent Flexi-Buff with Porcelize 1 micron
diamond paste and pressure (notice the flex of
the disc).
For Microfill, use Cosmedent’s FlexiBuff with
“ENAMELIZE” (aluminum oxide) for highest
polished surface.
Finished result showing the high polish achieved with Renamel NANO and the Flexi System.
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COSMEDENT is an ADA CERP
Recognized Provider
401 North Michigan Avenue, Suite 2500, Chicago, IL 60611-4243
TEL:
312.467.0700 TOLL FREE: 800.837.2321 FAX: 312.467.0776
Interactive Seminar
Materials List
Cosmedent’s Renamel Restorative System The Renamel Restorative System is the only fully
integrated system of microfills, microhybrids, nanofills, flowable microhybrids, flowable microfills and
opaquers, all color matched to each other and the VITA shade guide. Complementary tints are also
available to greatly enhance your esthetic results.
One shade restorations make the Renamel System predictable and reliable. All composites and opaquers
are matched in color but have different opacities depending on the type of composite you use:
Renamel Microhybrid The most opaque
Renamel NANO Exhibits an opacious translucency
Renamel Microfill Has an enamel like translucency
(All three Renamel composites
have built in fluorescence
which mimic natural dentition)
Where do I use the following materials in my office?
Renamel Microhybrid I primarily use microhybrid to start veneering techniques when I require
both strength and opacity.
• Great for blocking out undercolor because of its high opacity and color density
• Superior tensile strength makes this a great dentin replacement
• Has a flowable consistency that is easy to manipulate and place in thin layers
• Thicker oxygen inhibited layer makes it easy to layer composite if necessary
• Tremendous wetting properties resulting in the best adhesion to tooth surface and bonding
adhesive.
Renamel NANO This is Cosmedent’s universal material. I use nanofill to repair incisal fractures
by itself or with a microfill overlay, for posterior restorations of all types, and as a veneering
substructure in anterior restorations.
• Great Working Properties Virtually no slump making incisal buildup and fracture repairs
much easier.
• Esthetic Has an opacious translucent quality resulting in good esthetics when used alone
or with the other composites.
• Easy to apply
1
Materials List, continued
• Time Saving Because of Renamel NANO’s no slump consistency, you can easily build-up
the substructure of a tooth in one piece.
• Low shrinkage plus increased compressive strength makes it an excellent choice for
posterior restorations.
Renamel Microfill Microfill is the only composite material that truly mimics the enamel surface.
Renamel Microfill has the translucency of natural enamel and can be used as your final layer in
Class III, IV and V restorations, anterior veneers, diastema closures or really anywhere you want to
replace missing enamel either anteriorly or posteriorly.
• Most Translucent Resembles natural enamel better than any other material
• Most Esthetic Easier to polish and retains polish long term better than any other
composite type.
• Most wear resistant of all composites.
• Best refractive and reflective index of all composites.
• The best composite to place over tints. Its increased transparency allows the effects of
incisal and gingival tints to shine through for increased translucency and gingival chroma.
• Built-in fluorescence mimics natural dentition
• Long lasting Long term clinical results show amazing durability and color stability over time.
Renamel Incisal Shades Use incisal shades, dark, medium or light to mimic the intensity of
translucency needed.
Creative Color Opaques Creative Color Opaques help you block unwanted under-color from
shining through to your final restoration. They are used to block out areas that are too translucent,
mask unwanted under-color, and create effects such as white spots and hypoplasia. Use Creative
Color Opaques in between your composite layers. They will also raise the value of your restorations
and can be used to mask metal.
• Both color and value have been matched to Renamel composites so you can easily blend the
corresponding opaquer into the restoration to achieve a more natural result. (Helps to prevent
over opaquing.)
2
Pink Opaque A unique opaquer designed to mask gray colors, non-precious metal, and very dark
stains such as tetracycline stains. Pink Opaque neutralizes color without over increasing value so
results are more natural. It is most often used prior to the placement of your composite layer.
Creative Color Tints Tinting is an invaluable tool that will help you create lifelike effects. Tints
should be placed within the surface not on the surface for the most natural shine-through. Use to:
• Impart incisal translucency and cervical chroma
• Mimic surface artifacts such as pit and fissure staining
• Recreate craze lines, check lines and maverick colors
• Decrease the value of your restoration
Creative Color tints and opaques are microfill based,10% filled, and polishable.
De-Mark This highly radiopaque flowable composite enables you to clearly differentiate your
composite restoration from tooth structure on an x-ray. Because of its extreme opacity this is a great
product for lining posterior preparations.
Quick Tip: Most people under polymerize. As a rule of thumb, double the polymerization time
recommended by the light manufacturer.
Instruments Cosmedent Nonstick Composite Placement Instruments (titanium coated)
• 8A (Long and Short) Used for application and contouring of composite
• G3 Wider version of the 8A. Use this instrument to place and sculpt large amounts of
material.
• IPC (Long, short and off angled) Extra thin and flexible instruments used to refine
margins in interproximal areas, develop line angles, sculpt finite gingival margins, and
refine incisal edges.
• Multi Use Used to mimic areas of incisal translucency and as a posterior placement
instrument
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Preparation, Contouring, Finishing and Polishing
The Mopper System™ (by Brasseler) Anterior / Posterior preparation and finishing kit. Comes in
18 diamond and carbide high speed burs in varying shapes, both regular and micro burs.
Brasseler ET System (Komet ET System) Carbide burs used to start the contouring and finishing
process. Comes in 12, 16, and 30 fluted high speed burs.
Cosmedent’s Top Finisher System is a completely integrated, fully color-coded system for the
contouring, finishing and polishing of nanofills, microfills, hybrids, porcelain, enamel, metal, gold
and natural teeth.
FlexiDisc System Helps you contour, finish and polish restorations of all types. FlexiDiscs are
extra thin, flexible and resilient. Designed to give you more control and an unbeatable final polish.
These discs are available in regular and mini centers and have a vivid color coding to help you
quickly identify the correct grit.
Where Should FlexiDiscs Be Used?
• Blending marginal areas into tooth surface to create invisible margins
• Contouring and finishing of curved surfaces such as labial proximal line angles
• Finishing and polishing of smooth (no anatomy) labial surfaces
• Contouring and finishing of incisal edges, and shaping and finishing of incisal corners
• Contouring and finishing of facial aspects of Class III restorations
• Contouring and finishing of cervically involved areas
• Contouring and finishing of marginal ridges and lingual and buccal surfaces of
posterior restorations.
FlexiCups and FlexiPoints Aluminum oxide rubber polishing instruments. Use to:
1. Enhance characterization and polish labial and buccal surfaces.
2. Polish gingival margins with ease and reliability.
3. Finish and polish lingual surfaces
4. Better polishing of occlusal surfaces.
4
FlexiDiamond Strips Used to start interproximal finishing. The wide strips are for proximal surfaces
and the narrow are used at the gingival crest.
FlexiStrips Aluminum oxide strips are used to complete polishing of interproximal surfaces of
composite. Also available in both wide and narrow.
Enamelize with Felt Points and FlexiBuffs Used for the final polish. Enamelize is an aluminum
oxide polishing paste designed to greatly enhance the polish on all microfill, nanofill and hybrid
composites as well as bring natural tooth structure and metals to a high luster. For the highest shine
use Enamelize with Cosmedent’s Felt Points or Felt FlexiBuffs.
NANO / Microhybrid Diamond Polishers These diamond polishers are designed to quickly and
easily create a beautiful contour and polish on nanofill and microhybrid composites.
The use of high quality magnifying optics will greatly enhance the gingival biocompatibility and
esthetic results of any restoration.
Suggested optics:
1. SurgiTel
2. Designs for Vision
3. Zeiss
My preferred bonding adhesive is Cosmedent Complete, a 5th generation bonding agent with
added features. It has:
1. Dual-cured catalyst – when added in correct proportions can make the light-cured dentin
enamel bonding adhesive either dual-cured or self-cured.
2. It has an unfilled resin that makes durable composite repairs possible.
3. It is a multipurpose bonding agent that will bond to all surfaces — enamel, dentin,
composite, porcelain, metal, acrylic, and core-paste.
5
#1799c 11.19.01
It was a pleasure meeting with you and discussing your restorative and cosmetic dental
needs. We look forward to working with you. The following are some suggestions for
your upcoming visits that should help to make them more comfortable and enjoyable.
*** Important Note ***
Please make sure you have had your teeth thoroughly cleaned
at least 10 days prior to your appointment.
•
Wear comfortable clothes . . . You may want to bring a sweater as the treatment
rooms are kept cool; please note, a blanket is available.
•
Please do not wear any makeup.
•
Feel free to bring an i-Pod, MP-3 player or DVD. The first two hours are usually
completed without a break. After the first two hours, small breaks may be taken.
•
Bring a light, soft snack and drink such as Yogurt, Jell-O, pudding, cottagecheese, crackers, or a light sandwich.
•
While we estimate the length of time required, please be advised that your
appointment may run a little longer than expected. Please keep this in mind when
planning the rest of your day.
Should you have any questions, please do not hesitate to contact us.
Drs. Mopper, Hartlieb & Associates
MAINTAINING YOUR NEW SMILE
It was a pleasure working with you today and creating your new smile. We are
confident that you will enjoy these restorations for many years to come. Brushing
after every meal, or at least twice a day, and flossing at least once a day will help
you maintain good oral hygiene. If you need instructions on how to properly
brush and floss your teeth, please feel free to ask and we will demonstrate the
proper technique. Regarding tooth brushing, we recommend using Supersmile
or Crest plain toothpaste.
The most common question we receive is “Doctor, how strong is the material and
how long will it last?” We can only state that we have been doing bonding for
over 30 years now and most of our original procedures are still intact. The
materials are extremely strong and resistant to breakage.
The following information will help you maintain the longevity of your bonding
procedure:
1. Do not bite your fingernails (this may cause chipping);
2. Do not bite or chew on extremely hard objects (i.e. hard or frozen
candies, ice, rib or chicken bones, hard crusts, shelled nuts, etc.);
3. If you clench or grind your teeth, a night guard is highly recommended
to help prevent wear and tear of the natural chewing surfaces of your
back teeth. The appliance will also help prevent chipping or fracturing
of the edges of your front teeth;
4. If you play contact sports, use an athletic mouth guard (preferably one
we’ve made specifically for you at our office);
5. If you are not a regular patient of our practice, please tell your dentist
about the procedure so he or she can exercise proper care during
cleanings! Because of the bonding we perform, it is often difficult for
even the most experienced hygienist to recognize that there is bonding
material in your mouth, it is that natural looking;
6. We would like to see you six months after your bonding procedure for
a bond polish to make certain the esthetic results have been
maintained and that things are in good order. Thereafter, we will
schedule an appointment with you annually for a bond polish;
7. You can eat normal foods in a normal manner.
Flash your smile and enjoy. We had a great time working with you!
Interactive Seminar

Check List for the Layering Technique

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