Dear Dr. DiTolla,
Thanks for another great edition of Chairside!
When the magazine arrived, we were
all eager to see which GL we missed in the
last photo hunt contest (of course, the one
at the base of the palm tree in the center
— we will settle for second place). Before I
could turn around, my front desk staff was
working hard on the new photo hunt, and
she's doing pretty good so far! I can honestly
say this is the only magazine that I really
read from cover to cover.
Clinical note: I have become a very big fan
of the BruxZir® crown. Any second molar
crown in my practice gets BruxZir, along
with some first molars (heavy grinders or
previously chipped porcelain). I have found
that many of the cases come back with a
small rim around the margin, as if there was
a minute bevel around the entire prep. Many
times it is insignificant, but last week I had
a case where I was able to feel a significant
step/overhang that needed to be trimmed
back. Is this a result of the processing nature
of these crowns? I don't seem to have the
same issue with Prismatik CZ™ crowns.
Thanks once again for the great lessons of
dentistry that I have put into my everyday
practice.
- Robert M. Lieder, DDS
Baltimore, Md.
Dear Robert,
Thanks for the kind words about
Chairside! Regarding BruxZir crowns,
what you are seeing is a design issue
in the software where it bulks up an
otherwise thin margin to keep it from
chipping during the milling process
when a doctor has prepped a very fine
feather-edge margin. This is one of the
reasons why I like a deep chamfer
margin; it designs better, mills better
and is most likely going to be stronger.
- Mike
Dear Dr. DiTolla,
Is Silent Nite® sl as comfortable to wear
as a hard/soft nightguard? A patient said
she needs a nightguard, and she snores at
times. Which would be her choice? Could
I just send you upper and lower models to
make a Silent Nite sl? Can the patient just
use the upper or lower part of the Silent
Nite sl as an occlusal nightguard and also
as an ortho retainer? Please reply as soon
as possible, as there is an urgent decision
to make. Thank you!
- Stephen C. Hsu, DMD
Fort Washington, Pa.
Dear Stephen,
Good questions! In my experience,
the Silent Nite sl is the more comprehensive
device because it stops snoring
and bruxism. The upper and lower
trays of the Silent Nite sl are made
from the same material as the bite
splints, so there really is no difference
in comfort, save for the fact that the
Silent Nite sl has an upper and a lower
portion as opposed to a single-arch
nightguard.
Unlike previous generations of Silent
Nite appliances, with the Silent Nite sl,
the patient can actually take it apart
on their own and simply wear one half
— although that would require the
patient to correctly predict the nights
on which they were going to snore so
they could wear both.
To answer your final question: Yes, you
can send us upper and lower models
to fabricate the appliance; however, it
is more helpful if we have a protrusive
bite utilizing the sl-protrusion gauge,
which you can get from our lab.
Hope that helps!
- Mike
Dear Dr. DiTolla,
I'm placing my first two minimal-prep veneers
on tooth #7 and #10, with Captek™
PFMs (Argen; San Diego, Calif.) on tooth #8
and #9. Glidewell did the diagnostic waxup
and is now finishing it. Could you suggest,
A to Z, the try-in and delivery of these
veneers, including materials necessary?
As these are minimal prep, please advise if
I should use a bonding agent or straight
cement, as well as the specific silane, acid
and cements. Thank you.
- Lee G. Taylor, DDS
Havertown, Pa.
Dear Lee,
I would try in the units one at a time
without any try-in cement to check
marginal fit. I would try in the crowns
on tooth #8 and #9 together to verify
the contacts are correct and are not
keeping them from seating. I would
then load the veneers on tooth #7 and
#10 with try-in cement to verify they
will seat while tooth #8 and #9 are
seated.
I always seat tooth #8 and #9 first, and
since they are Captek crowns, I would
use a resin-reinforced glass ionomer
like RelyX™ Luting Plus cement (3M
ESPE; St. Paul, Minn.) or GC Fuji Plus™
(GC America; Alsip, Ill.). Once those
have been cemented and the excess
cement has been cleaned, it's time to
move on to the veneers.
You should rinse the water-soluble
try-in paste out of the veneers for tooth #7 and #10, and then dry them
to verify you can see the etched internal
surface of the veneers. If you can't,
you should re-etch them with a 6 to 10
percent hydrofluoric acid for 60 seconds,
and then rinse. You would then
place the ceramic silane solution of
your choice (Kerr Silane Primer [Kerr;
Orange, Calif.], for example) and evaporate
it after about 10 seconds. Place a
thin layer of bonding agent (adhesive)
from a two-bottle system (such as
OptiBond® [Kerr]) and air thin.
Because these are minimal-prep veneers,
and by definition confined to
the enamel, etch the enamel surface
with your choice of phosphoric acid
(I use Ultra-Etch® [Ultradent; South
Jordan, Utah]). Rinse after 15 seconds.
We don't need a dentin bonding agent,
so I would use the same bonding
agent we placed in the veneer. For me,
it's the adhesive from the two-bottle
OptiBond system. Air thin that once
you have brushed it onto the tooth,
and load the veneers with your preferred
resin cement. For me, that is
the translucent shade of NX3 Nexus®
Third Generation light cure cement
(Kerr). Seat one of the veneers by sliding
it into place with facial and incisal
pressure. Tack cure it for two to
three seconds to get the cement to its
gel stage, clean the excess, then finish
curing and repeat for the other side.
- Mike
Dear Dr. DiTolla,
An old patient of mine appeared with an
incisal angle fracture on the distal of tooth
#8. He also has a large Class III filling on the
mesial of #8. Tooth #9 is in good condition.
I would like to place two no-prep veneers
on #8 and #9. How do you treat the old
fillings that are in #8? They have been in
place for many years. Is it best to take them
out, and replace them with nice clean fillings?
The reason I am thinking of no-prep
veneers is that the patient has a rare blood
problem, and his physician does not want
any bleeding at this time. Both #8 and #9
are extremely thin and worn, and the patient
wants a nice improvement.
Thanks always for your help.
- Anthony Badalamenti, DDS
New York, N.Y.
Dear Anthony,
I have placed no-prep veneers on top
of old composites many times, especially
if the shade is not radically darker
than the tooth structure around it.
Prior to placing the veneers, I pumice
the teeth and the composites to
make sure I have a clean surface for
the phosphoric acid. Then I etch the
composites while I etch the enamel,
and for the same amount of time (15
seconds). Finally, I rinse the etching
and place adhesive on the enamel and
composite, etc. So if there is no recurrent
decay around the composites, and
they are not too low in value, there's
no need to replace them.
- Mike
