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SMILE DESIGN, ESTHETIC MATERIALS, BONDING

UPDATE

GEORGIA DENTAL COLLEGE

All-Ceramic Crowns, Veneers & Bonding Update

Techniques and principles reviewed in this all-dayprogram are derived from my personal teaching

and clinic experience.

They do not constitute a guarantee for success,the attendees should form their own opinion.

Gerard Chiche L.L.C.

DISCLAIMER

I

ESTHETIC DESIGN

Upper Lip Line

Lower Lip Line

Treatment Plan from Incisal Edge Up

ESTHETIC PRIORITIES ESTHETIC CHECKLIST

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1. PROPER LENGTH

2. INCISAL PROFILE

3. SMILE LINE DESIGN

4. TOOTH PROPORTIONS

Kinetics of Anterior Tooth DisplayVig , Brundo 1978

Dynamics of the Maxillary IncisorDickens , Sarver, Proffit 2002

I. Pleasing Display

1. Male Pt. 0.5 - 2 mm.

2. Female Cons. 2.0 - 3 mm.

3. Female Spark. 3.5 - 4.5 mm.

Treatment PlanFrom Incisal Edge UP

Central LengthShort Face: 10.0 mm.Medium Face: 10.5 mmLong Face: 11.0 mm & up

WAX-UP at KNOWN LENGTH

Diag. Cast 1 Diag. Cast 2 II. Incisal Profile

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TEAM FOUNDATION

VERIFY INCISAL LENGTH & PROFILE

CONVEX

FLAT

CONCAVE

TOO CONVEX

Amy & AramIII. SET SMILE LINE

CONVEX

FLAT

CONCAVE

RECORD LOWER LIP SHAPE !

CANINES & BICUSPIDS DESIGN

Dr B. Kadashta & Mr V. Tran

Eliminate Lateral Working Interference

1. Shorten Cusp Tip

2. Steepen Canine Guidance

3. Group Function

4. Move Cusp Tip Laterally

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MOVE BUCCAL CUSPS LABIALLY = LESS INTERFERENCES LESS INTERFERENCES, MORE LENGTH,UPRIGHT BICUSPIDS = LESS WEAR

IV. SET PROPORTIONS

10 mm. L

7.5-8.0 mm

11 mm. L

8.5-9.0 mm

Rule: When Set Proportions

Optimize Canine Guidance Patient’s Expectations – Reduce Gummy Smile & Porcelain Veneers

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Priorities

• CEJ Location Veneer Extent.

• Gal Margin – Bone Crest Gingivectomy > 3 mm.

• Root Length Bone Resection.

1. WHERE IS THE CEJ ?

Priorities

• CEJ Location

• Gal Margin – Bone Crest

• Root Length

3 mm RULE

GINGIVECTOMY : ONLY if > 3 mm. Preop.

LOW PREP VENEERS

Intrusion vs. Crown Lengthening

1. CEJ Location 2. Root Length 3. Type of Restoration

EX3CEJ Level = Maximum Veneer Extent

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8 and 9 : 8.5 mm.7 and 10 : 6.5 mm.6 and 11 : 7.5 mm. *

S. Chu2007

54 patients16-72 years

Relative Width Mesial of CaninesCompensates

Dr M. Tadros & Mr. S. Im

GINGIVAL ALTERATIONS ALTER ABUTMENT CONTOURS

1.5 mm.

M. Redmagni et alSoft Tissue Stability with ImmediateImplants and Concave AbutmentsEuropean J. Esthet Dent 2009: 4 - 4

H. Su et alConsiderations of Implant Abutment and

Crown Contour: Critical & Subcritical ContoursInt J. Perio Restorative Dent 2010: 30 - 335

I. SET INCISAL LENGTH

II. SET INCISAL PROFILE

I. SET INCISAL LENGTH

II. SET INCISAL PROFILE

RULE: MAXILARY INCISORS CONTROLMANDIBULAR INCISORS POSITION

Interdisciplinary Treatment

Axial Inclination

Rule: Maxillary Incisors Set-up Dictate Mandibular Incisors Plan

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Implant Restorations Goals

1. Proper Sagittal Inclination

22. Incisal Porcelain Thickness

3. Moderate Anterior Guidance

INCISAL EDGESUPPORT

INCISAL EDGESUPPORT PASSIVE FIT !Dr M. Tadros & Mr A. Torosian

If Cut-Back Must Support All Incisal Edges

All Zirconia & Emax Cases

Dr. A. Orta & Mr. A. Torosian

0

40

80

120

160

200

Zirconia Enamel Nano comp.

polished

Ghanta H, Ozer F, Yi Y, Irmak O, DiRienzoJ, Blatz MB.Effect of wear on bacterial adherence to material surfaces.

IADR 2015 Abstract 2150.

Me

an

ba

cte

ria

co

un

t

Bacteria countbefore and afterdual axis wear with220,000 cycles at 49 N

S. gordonii on polished surface

S. gordonii on worn surface

Enamel highest bacteria count to both surfacesZirconia lowest bacteria count

B A C T E R I A LA D H E S I O N

Need Polished Subgingival Zirconia

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V. PERFECT vs NATURAL

1. POINTED CANINES

2. ASYMMETRIC LATERALS

3. INCISAL EMBRASURES

4. COLOR GRADIENTS

PERFECT vs PERSONALIZED

• 1 Emax (No Discoloration)

• 2 Lower Incisors

• 3 Thin Teeth, Large pulps

• 1 Zirconia (Layered)

• 2 Emax Discoloration ++

• 3 PFM

Glass Ceramics• 1 Best Translucency

• 2 Reduced Facial Thickness

• 3 Convenient & Versatile

• 4 Combines with Veneers

• 5 Plan Masking Strategy

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Crowns

Onlays

VeneersDr S. Dang & Mr A. Torosian

26.8

33.6

SB Univer UnetchedSB Univer etched

Single Bond Plus

Significance difference in enamel shear bond strength (p.<05) with SB Universal

SB Universal NO ETCH SB Universal WITH ETCH

SINGLE BOND PLUS WITH ETCH

Courtesy Dr. John Burgess

SELECTIVE ETCH

1. Diastema2. Proximal Composites3. Space Management4. Rotated Teeth / Crowding5. Black Hole / Short Papilla

4. Anterior ¾Veneer

BEST Veneer Prep if Black Holes and SHORT Papillae

Anterior ¾Veneer

5. Labial Extension Onlay

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Labial Extension Onlay

NO ENAMEL PERIPHERY = NO ONLAY

Lower 1st MolarMost Severe

Soda-Swishing

Cupping/Cratering

Smooth Lingual Wearof Upper Anterior

Regurgitation

Abrahamsen TC, Inside Dent 2011;10:38-50

Erosion

Even Posterior WearUpper & lower

Fruit-Mulling

Cupping/Cratering

Chewable Vit. CAsthma Spray

Chlorine

Less Frequent

Safety of Increasing Vertical Dimension of Occlusion: a Systematic ReviewJ. Abduo. Quintessence Int 2012

• Magnitude Maximum 5.0 mm. Meas. Anteriorly. Gough, Dahl, Ormanier.

• Patient Adapts Resolution 1-2 weeks (2 days - 3 mo.) Carllson, Rivera, Abekura, Tryde

• EMG Activity Back to pre-treatment levels 2 -3 mo. Carllson, Dahl, Gough, Manns.

• Relapse Unknown, Relatively Stable. Gough, Dahl, Ormanier.

EMAX REQUIRED OCCLUSAL THICKNESS1.5 mm. Minimum Adequate if Luted (RMGI)

M. Kern et al. JADA 2012 143; 3: 234

Fracture Strength of All-Ceramic Restorations after Fatigue LoadingB. Baladhandayutham, P. Beck, M. Litaker, D. Cakir, J. Burgess.

AADR 2012 Abstract # 24

REQUIRED OCCLUSAL THICKNESS

1465

2025

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Dr S. Aimplee & Mr A. Torosian

EMAX REQUIRED OCCLUSAL THICKNESS1.0 mm. Sufficient if Adhesively Bonded

(Ivoclar – Vivadent 2016) “One Wing”

AlvaroEsthetic Fellow

Cantilever Connector SizeLiSiO2 H. 4.0mm X 2.0 mm Tsitru 2012

LiSiO2 H. 3.6 mm X 2.8 mm Sun 2013

Emax Connector Size

4 X 3 = 12 mm² Total Size Kern 2012

Dr S. Dang & Mr S. Im

Glass Ceramics

• 2 Reduced Facial Thickness

• 3 Moderate Discolorations

• 4 Bonded Crowns, Veneers, Onlays(Occasional FPD’s)

• 1 Best Translucency

Glass Ceramics

• 2 Reduced Facial Thickness

• 3 Moderate Discolorations

• 4 Bonded Crowns, Veneers, Onlays(Occasional FPD’s)

• 1 Best Translucency

Maximum Translucency

BONDED1. CROWNS2. VENEERS3. ONLAYS(Occasional FPD)

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MicrostructureLi2Si2O5

• The microstructure of the pressable lithiumdisilicate material consists of approximately70% needle-like lithium disilicate crystalsembedded in a glassy matrix. These crystalsmeasure approximately 3 to 6 µm in length.

When do we Cement?1. Retentive Preparation2. Sufficient Occlusal Thickness3. Porcelain is Strong Enough

When do we Bond?1. Lack of Retention - Resistance2. Thin Occlusal – Lingual Area3. Need to increase Strength

BURGESS

Full Strength (3Y-TZP)

Dr. S. Arias & Mr. A. Torosian

CEMENTED1. SINGLE UNITS2. FPDs3. SCREW-RETAINED

ZenoStar MO Zirconia

MAXIMUM BITE FORCE

• 500 N

• 700 N

• 1000 N

Monolithic Zirconia Crowns

Thickness Fracture StrengthThickness Fracture Strength

0.8 mm. J Lee 2007 (N/A)

1.0 mm. G Jang 2011 (3216 N)

1.0 mm. S Jang 2013 (1780 N)

1.0 mm. C Johanson 2013 (2795 N)

1.0 mm. S Ting 2014 (2429 N)

Thickness for Safety 1.0 mm. and aboveTooth Reduction 1.0 to 1.5 mm.

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When do we Cement?1. Retentive Preparation2. Sufficient Occlusal Thickness3. Porcelain is Strong Enough

When do we Bond?1. Lack of Retention - Resistance2. Thin Occlusal – Lingual Area3. Need to increase Strength

Monolithic Zirconia High-Strength Minimum Thickness

Margin of Safety: 0.8 mm. Acceptable, 1.0 mm. Ideal

a

Courtesy Dr. J. Burgess

Monolithic Zirconia High-Strength Minimum Thickness

Margin of Safety: 0.8 mm. Acceptable, 1.0 mm. Ideal

Courtesy Dr. J. Burgess

Consecutive Case Series of Monolithic &Minimally Veneered Zirconia

Restorations on Teeth & ImplantsUp to 68 Months.M. Moskovich 2015

Long-Term Retrospective Dental Laboratory Survey of Zirconia-Based CrownsIADR 2010 Abstract # 148370, 2011Raigrodski A., Dogan S., Englund G.

Performance of Zirconia Based Crowns and FPDs in Prosthodontic PracticeIADR 2010 Abstract # 40705, 2010

Nathanson, Chu, Yamamoto, Stappert,C.

Clinical Comparison of Zirconia, Metal, Alumina Fixed-Prosthesis FrameworksVeneered with Layered or Pressed Ceramics: A Three-Year Report

J. Am. Dent. Assoc. 2010;141;1317-1329R. P. Christensen, B. J. Ploeger

Clinical survival of posterior zirconia crowns in private practiceIADR 2010 Abstract# 134121

Blatz M, et al

Recommended Body Firing Temperature

Cerabien CZR 930 – 940 Deg. CVita VM9 910Wieland Zirox 900 – 930

“…CZR Press veneer ceramic for zirconia was theexception with a performance comparable with

that of veneer ceramics for metals…”Courtesy Dr. J. Burgess

Gloss of Polished Zirconia

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Best diamondcutting

measured

Komet ZR 6881

Courtesy Dr. J. Burgess

Particle Size

Fonseca, R.G., Abi-Rached, F.O., Reis, J.M.S.N., Rambaldi, E., and Bldissaram P. (2013). Effect of particle size on the flexural strength and phase transformationof an airborne-particle abraded yittria-stabilized tetragonal zirconia polycrystal ceramic. Journal of Prosthetic Dentistry, 110, 510-514.

Song, J.Y., Park, S.W., Lee, K., Yun, K.D., Lim, H.P., (2013). Fracture Strengthand microstructure of Y-TZP zirconia after different surface treatments.

Journal of Prosthetic Dentistry ; 110: 274-280.

Full-Strength Zirconiafor

All Fixed Partial Dentures

Katana HTML / CZR

Dr. M. Silva & Mr. S. Im

9.0 mm² Post. FPD 1 Pontic7.0 mm² Ant. FPD 1 Pontic

12.5 mm² Post. FPD 2 Pontics

6.0 mm² Ant. Cantilever

Tsitru, 2012, Kern 2012, Sun 2013

Zirconia Connector Size

Raigrodski, 2006, Larrson 2007, Studardt 2007, Zasse 2012,

Edentulous Maxilla - Fixed Restorative Options

1. Fixed Hybrid: Economical, Practical, Versatile.

2. Full Zirconia: Additional Strength for Bruxer.

More Esthetic.

More Color Stable.

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PROVIDE OCCLUSAL GUARD !

Drs J. Kim, J. Londono, C. Susin & Mr A. Torosian

PROVIDE OCCLUSAL GUARD

OPPOSING EDENTULOUS MANDIBLE = METAL-ACRYLIC HYBRIDDr A. Blasi & Mr A. Torosian

INCISAL EDGE DESIGN

Dr A. Blasi & Mr A. Torosian

88

zirconia

copy-mill

All Incisal Edges in Zirconia At Least 2 mm. ZirconiaAround Screw Channel

PROTECTION DESIGN

1. Zirconia Functional Areas & Inc. Edges.

2. Occlusal Guard Mandatory.

3. Mandibular Opposing Hybrid.

4. Min. 2 mm. around Screw Channels.

5. Maximize Incisal Edge Thickness.

6. Provide Shallow Anterior Guidance.

7. Maximum Cantilever Length 7-9 mm.

DJ. Londono & Mr A. Torosian

• 1. Esthetics with More Strength i.e. Bruxer.

• 2. Cement versus Bonding for Simplicity, Esp. if gingivitis or deep margins.

• 3. Monolithic and milling reduce Cost.

The Journal of Cosmetic Dentistry April 2016

Translucent Zirconia(Maximize Thickness, Case selection)

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Translucent Zirconia Brands Vary in StrengthCourtesy Drs. N. Lawson & J. Burgess

1. Type of Zirconia - Not High Strength

2. No Passive Fit - No Verification Jig

3. Working Contacts - Group Function

FRACTURE CAUSES

4. Zirconia Thickness around Screw Channel

Alumina Yttrium to stabilize cubic phase

Cubic phase Content does not TransformTetragonal ZrO2 Resists Crack Propagation

Tetragonal ZrO2

1170°C-2370°C

Cubic ZrO2Above 2370°C

From : Zirconia as a ceramic biomaterial C. Piconi, G. Maccauro Translucent Zirconia

Zirconia classified - 3, 4, 5 mole% yttria continuum (Courtesy Dr. J. Burgess)

Opaque-3%-1000-1400 Mpa Less opaque- 4% Translucent - 5%

Lava Frame (3M) Lava Plus Lava Esthetic

Katana HT ML(Kuraray) Katana STML Katana UTML

Bruxir (Guidewell) Bruxir Anterior

ZirCAD LT & MO (Ivoclar) ZirCad MT Multi & MT

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•

Kwon, D N. Lawson, E. McLaren, A. Nejat J.O. Burgess 0.8mm thickness,

1194

737 688460

Katana HT Katana ST Katana UTML e.max0

200

400

600

800

1000

1200

1400

Flexural Strength

Flexural Strength

TRANSLUCENT ZIRCONIA = ESTHETICS WITH MORE STRENGTH

Hybrid Workflow for Monolithic Zirconia

1 2 3

4Overview of Steps: No Pressing, No Layering

Katana STML MonolithicDr. J. Londono & Mr. S. Im

TRANSLUCENT ZIRCONIA: ESTHETICS WITH MORE STRENGTH & MONOLITHIC (Better Lab. Cost)

MARGINAL GINGIVITISDEEP MARGINS

=MORE CONVENTIONAL

CEMENTATION

IF WANT TO CEMENTMEASURE THICKNESS

FIRST

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1. Minimum Wax Up on Occlusal SurfacesUncovered Areas =Vertical Stops 2. Etch Every Other Tooth H3PO4 – HF on Porcelain (W. Hall)

3. Bond and Load Clear Matrix with High-Filler Load Flowable Composite 4. Small Vent Holes Over Lingual Cusps Minimize Excess on Adjacent Teeth

5. Split Clear Silicone Matrix at Mandible to Facilitate Isolation New VDO After Occlusal Refining – Ready for Quadrant Work

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1. Prepare Anterior Teeth 2. Complete & Bond Anterior Crowns 3. Prep. & Complete Posteriors

Composite Buildups Hold VDO Ceramic Crowns Hold VDO

Margin Line Offset - set to .20

Komet94009

NoritakeSD-61

e.max

4-YTZP Translucent Zirconia

Marko Tadros DMD - USA

• Ceramics SelectionTranslucent Zirconia.

• Crown DeliveryCemented 6-11.

• AdvantagesBlock Discolorations.

• RequirementsAdequate Thickness.

Dr. M. Tadros & Mr. A. Torosian

ESTHETICS WITH 1. MORE STRENGTH 2. MONOLITHIC 3. MORE CEMENTATION

Relationship between bond-strength tests and clinical outcomesB. Van Meerbeek et alDental Materials 2010

Ca-10-MDP salt

WEBBED PROPHY CUP SMALL PARTICLE ABRASION

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MDP BONDS TO CA & PROVIDES STABLE BOND20 Seconds MILD DENTIN DEMINERALIZATION

“ Ca-10-MDP salt is one of the most hydrolyticallystable salts” (Perdigao 2013)

Emax Bonding

BOND TWO CROWNSAT A TIME

Lithium Disilicate Crowns

FLOSS INTERPROXIMAL FIRSTLIGHT-CURE 1-2 SECOND / Tooth

PEEL OFF & FLOSSLIGHT-CURE 1-2* SECOND

Light Cure 1-2 Sec.

Clean Excess

Floss Interprox.

ASAP

Apply Heavy GlycerineIf Bleeding Finish Flossing

Remove Cord

Verify No Cement Light-Cure

20 sec. +

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SIMPLICITY

ZIRCONIA1. Resin Ionomer2. Resin Cement if Need

More Retention

Courtesy Dr. John Burgess Crown RetentionNewtons

493

431385

411

346

SELF-ADHESIVE RESIN CEMENTS

1. RELYX UNICEM 2

2. PANAVIA SA CEMENT *

2. ABSOLUTE

3. BISFIX SE

3. BREEZE

REALITY RATINGS* November 2013

0.00

5.00

10.00

15.00

20.00

Max Unic Unic Ap BC Pan SA

In vitro comparative bond strength of contemporary self-adhesive resincements to zirconium oxide ceramics with and without air-particle

abrasion.

Clinical Oral Invest 2010;14:187-92.Blatz et al.1. SANDBLAST

Efficacy of silane after thermal-fatigue on bond-strengths degradation to zirconiaJ. Phark et al. Abstract 640, AADR 2012

2. PRIMER

Zirconia S-C-P

Saliva IVOCLEAN MDPSaliva AL-OX MDP

2. ZIRCONIARMGI LUTING Preferred !

zirconia

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6

Abutment Connection 2 weeks 4 weeks 6 weeks

Increase Cervical Profile

Bonding Zirconia = S-C-P

Saliva IVOCLEAN MDPSaliva AL-OX MDP

BONDING ZIRCONIA zirconia

Bonding Zirconia = S-C-P Bonding e.max = HF-P

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PREPARATION SYSTEM

828 - 026 LVS 3 – LVS 4 8392 - 016

I

Classic Preparation

Main AdvantageIntra-enamel Most of Times

0.3 mm.

0.5 mm.0.6 mm.

R. Winter 2011 NO DISCOLORATION

0.5 mm.

0.7 mm.0.8 mm.

MODERATE DISCOLORATION

I

Classic Preparation

Potential to Expose DentinWhen Thin Enamel

Or if Need Deeper Prep

Incisor Compliance Following Operative ProceduresRapid 3-D Finite Element Analysis - Micro-CT Data

P. Magne & D. Tan J. Adhesive Dent. 2008

50 N Load50 N Load

100% Removal Facial Enamel = 91% Flexure Increase

Natural Tooth Veneer Preparation

“Low-Prep” Veneers = Undersized + Retrusive Incisors

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Dr A. Camba, E. Bailey & Mr S. Im

Lower Lip Tolerates Additive Treatment

Additive & Low Veneer Preps Advantages.Provides Maximum Enamel!.Increases Veneer Strength.

Precautions.Need Additive Wax-up..Needs Precise Technique..Needs Esthetic Try-in

SILICONE INDEX

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BUR 8392 – 0.16

1

2

3

4V

“Low- Prep” Veneer

Advantages. Minimum / No Enamel Reduction!

Precautions.Need Room for Line Angles.

.Need Room for Labial Embrasures.Needs Esthetic Try-in

Additive Mock-upAdditiveWax-up

Harmony with Lower Lip

Incisor Compliance Following Operative Procedures Rapid 3-D Finite Element Analysis with Micro-CT DataP. Magne & D. Tan J. Adhesive Dent. 2008

100% Removal Facial Enamel = 91% Flexure Increase

50 N LoadLOW Flexure Case

Low Flexure Case

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REALITY RATINGLIGHT/ DUAL CURE

1 . INSURE / INSURE LITE

2 . NX3

2. VARIOLINK II

3. VITIQUE

4. LUTE-IT!

5. CALIBRA

LIGHT CURE ONLY1 . RELY X VENEER CEM.

2 . VARIOLINK VENEER

3. DA VINCI

4. ACCOLADE PV

5. CHOICE 2

Clear

White

Clear

White

(Thin Veneers)

THIN VENEERS

(B 0.5 or TR)

THIN VENEERS

(B 0.5 or TR)

VENEER CEMENT SELECTION

2. Tissue Health

Sticky Viscous Cement Da Vinci

Low Viscosity Cement Rely Veneer

1. Thin vs. Thick Veneer

3. Number of Veneers

BONDING PRECAUTIONS

1. Microblast or roughen Dentin

2. Retraction String

3. Cure 5th Gen. Adhesive separately

Cure First Cure First

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BONDING VENEERS

1. Etch 2. Adhesiveon Dentin

LIGHT-CURE 3. Adhesiveon whole prep

SEAT VENEERLIGHT-CURE

THIN ADDITIVE LAYER RECHECK LOWER LIP !

RECHECK HARMONY with LOWER LIP !

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D. Layton2012

G. Gurel2013

S. Rinke2012

A. Walls1995

D. Layton2013

M. Friedman1998

M. Fradeani1998

• Intra-enamel prep. > 80%

• Exposed Dentin Prep. > 50%

Feldspathic 96% 10 yrs93% 15 yrs91% 20 yrs

Pressed 98% 5-12yrs

Feldspathic 86% 5 yrs

Pressed 93% 3 yrs

Flexural Strength

0,0

20,0

40,0

60,0

80,0

100,0

120,0

140,0

Stru

ctur

Premium

Experim

entalProtemp

Acrytem

p

Kan

itemp

Roy

al

Integrity

Fluores

cenc

e

Luxatemp

[MPa]

Relative Fracture Toughness of Bis-Acryl Interim Resin MaterialsKnobloch et al , J. Prosthet Dent 2011; 106: 118

Marko Tadros, DMDJimmy Londono, DDS

A. DIRECT TECHNIQUE – SHRINK WRAP

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Additive Veneer Preparation

Dr M. Tadros & Mr A. Torosian

Limited Treatment – Level I

• Veneer Ceramics Lithium Disilicate

• Bonding Substrate Maintain Enamel

• Available Thickness Augment Labial Volume

• Required Compliance Occlusal Guard

• Difficult Cases Test Drive w. Composites

CONTROL of ONE-ARCH

1. Adjust VDO

2. Gain Space

3. Increase Length

4. Improve Overbite

5. Reduce Anterior Force

Limited Treatment – Level II

For every 100 change in the angle of disclusion, thereis a 35% change in force applied.

L. WeinbergInt. J. Prosthodont. 1998; 11: 55

15 Deg.=

50%

Somkiat & Bin

Emax

Comprehensive Treatment – Level III

• Restorative SpaceMore room – Less Prep

• Reduce Vertical OverlapGenerate Overjet

• Level Occlusal PlaneLess Interferences

• Esthetic ContinuityFront-to-back

po

sto

p

VDO Decision – 4 Questions

Dr. S. Aimplee & Mr. S. Im

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© Bite FX1. Shallow Guidance 2.Adjust Chewing pathway Until Patient Comfortable

Final Guidance Comfortable & Less Steep than Planned …Or

3. Group Function

Drs A. Camba, J. Kim & Mr A. Torosian

Group Function Indications

1. Weak or Mobile Canine

2. Canine Implant

3. Patient Does not tolerate

Canine Guidance

Canines Rule

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DESIGN CANINES UPRIGHT and LESS CONVERGENT

Dr. S. Arias & Mr. A. Torosian

RESTORE CANINE GUIDANCE

with Canines Upright & less Convergent

Parallel to Cheek Planes

Botulinum Toxin Injections Effect on Bruxism

Dr. M. Stevens

• Tinastepe N. Cranio (14) 2014• Long H. Int Dent J (62) 2012• Lee SJ. Am J Phys Med Re (89) 2010• Hoque A. NY State Dent J. (75) 2009• Monroy PG. Spec Care Dentist (26) 2006• Tan EK. J Am Dent Assoc. (131) 2000

Reconstruction Checklist

1. EstheticsOptimize Maxillary Esthetics.Optimize Gingival Levels.

2. FunctionProvide Restorative Space.

Set VDO.