Dental Procedures PDF

But remember, in terms of block temp, there's only one material that can be used as a block temp. Remember, bicycle materials do not go through a doughy stage. If it doesn't go through a doughy stage, you can't make a block of it and you can't position it over a tooth. All right, so bicycle material...

But remember, in terms of block temp, there's only one material that can be used as a block temp. Remember, bicycle materials do not go through a doughy stage. If it doesn't go through a doughy stage, you can't make a block of it and you can't position it over a tooth. All right, so bicycle materials are really only for using either a putty matrix or a vacuum form. A vacuum made matrix. I'll describe both of those in just a few minutes. All right. So I mixed up the the methyl methacrylate. Like I mix it up to the proper consistency and I don't immediately put it on the tooth. Why. Because it's still in the first stage. It's still in the sticky, liquidy stage. And it will stick to your fingers, stick to your glove fingers. So as soon as it moves from the liquid slash sticky stage to the doughy stage, that's when you pick it up. Mold it. Now, a common problem, especially for little inlays, is making a big wad of acrylic and then putting it over that like five teeth. Remember, for a little mo inlay or an mo d l only, all you need is a little bit more than what you think you're going to need. So again, don't don't put a huge wad of acrylic when you're only doing a single unit. And then as soon as it goes into the doughy stage where it's stopping, it's not sticking to your fingers anymore. Then you bring it to the mouth. Now, should the tooth be lubricated? And the answer is, if it's a type, don't. Yes, you want to lightly lubricate it. But in the real world, saliva, the patient saliva is the best lubricant. So just you actually want it wet. You don't want to blow it dry because it may stick not only to your preferred tooth, but also the adjacent teeth. So you want a little bit of, of lubricant, just a little bit of the patient saliva covering covering the teeth. And then you seat it properly. And what's really critical is two things. One is that makes it into the patient, bites down into a normal MIP and stays there until you say, open your mouth because you want the patient to bite into MIP. And if they're not fully into MIP, you're going to have a lot of adjusting to do. All right. So you want the patient to bite down into MIP. Stay there until you give the patient the instructions okay. And then usually after about five to 10s I'll have the patient open again and push it a little bit from the buckle and lingual. This is especially true on the lower because patients have a tendency to use their tongue to play with it, because remember, their tongue is probably numb on that side of their mouth. All right. So a common tendency by patients is to try to dislodge it or put too much pressure on it with their big fat tongue. So so watch it carefully that it is in fact fairly well adapted to the tooth. Now, the next thing you need to do is watch it carefully for when it's going to go from the doughy stage to the rubbery stage. Remember, the doughy stage is still very flexible and still very moldable in the rubbery stage. It's not. It bounces back like rubber. That's why it's called a rubbery stage. All right. But again this is it. When it's sitting on the tooth, having the patient having bitten down in the proper position. And you'll notice that there are highs and lows on this surface. Now this is a full on lay. So it's very similar to a full gold crown or a full full crown. And the low points are going to be come as long as you carve it properly or you finish it properly will be the central holding. That's going to be the central fossa, that's going to be close to the marginal ridge. The high points are going to be the cusp tips. Okay. What about over here. Those are the non working custom. There's really nothing occluding with them unless the patient is in a cross bite which really changes everything. All right. So usually the the the non working cuts are going to be way too hot. And that's fine simply because there's nothing occluding with the non working cusp. So you're going to have to carve in or drill in all of the anatomy. One of the fun things about about block temps is it really forces you to know anatomy. You need to know the anatomy of the tooth. And you need to assess that particular patient. Because remember, a young patient has lots of ups and downs. An older patient might have a fairly worn down occlusal surface. So you want to match the patient's, you know, proper anatomy. All right. Now again when it goes watch it carefully. Don't leave this patient because again you don't want to set too much when it goes from the doughy stage to the rubbery stage. Then you very carefully tease it off. Okay. And this is going to require a lot of skill in all ten of your little fingers to be able to tease it off. And frequently it website. This remote has the buttons and the different place. See over here the adjacent tooth. It frequently gets stuck to this, especially if it's a restored tooth, especially if it's a little scratchy. All right, so you want to make certain that when you're teasing it off, it doesn't stick to these these teeth. And you want to try as best you can to tease it off with. No. Distortion, which is difficult, okay, especially for a tiny little inlay, because again, it's hard to grab on to a tiny little inlay. All right. So the internal surface has pretty good detail, and you should be able to pick up almost everything. But realize that for an on lay like this, you're going to have to realign it. And I stressed that last week. If it's a small little inlay, you frequently don't need to realign it. And again, towards the end of last week's lecture, I described that if you careful at removing it because it's so small, the distortion and the shrinkage don't contribute too much to dimensional change. So you may not need to realign a little inlay, but this is going to have to be realigned simply because it's so big. And it's highly likely removing a big restoration like temporary restoration like this. You probably did cause some distortion. So this is going to have to be reamed out. But don't ream it out now because it's still in the rubbery stage. This now goes in a little bit of water okay. Now it doesn't have to go in water, but it's better if it goes in a little cup of hot water. And I typically have instant hot that can be really hot, almost boiling hot. That's where I plop the the temporary for two reasons. One is that it will set faster if it's put in some nice hot water, and two, if it's in a cup like this, you're not going to lean on it or throw an instrument on it. You're going to not not going to knock it off the floor. The only thing you have to be careful of is don't drink it. All right. So this get plopped in some hot water and allow it to set. Then when it's fully set, which is stage number four, the fully set stage, now you're ready to turn it back. And again, the best way to do it, especially when you're learning how to make a block temp, is to put a little dot on the highs and lows, because these are areas that you don't want to grind away very much, okay. And obviously as it goes over the adjacent tooth, you're going to have to grind away a lot into the and embraces. You're going to have to grind away a lot. But at this point, you just simply make pencil marks on what will become the central holding tips and the central calling fossa. Okay. And in addition to that, although you don't have a picture of that, I also make a little mark on the two contacts, the medial proximal contact on the distal proximal contact. So I don't want to remove that on the non working. I'm going to remove a lot into some of the abrasions and the line angles. I'm probably going to learn a lot but I remove a lot. But I don't want to remove anything from here. Although I probably will have to remove a little bit when I check the occlusion. Now I strongly recommend, although I know that Dr. Brown doesn't like you to do this, but the best way to do the gross carving here of the grocery model is on a lathe. Much better than holding it on your hand and trying to do with the slow speed handpiece or straight straight attachment. I don't know why Dr. Brown has this aversion to using lathes because it's much safer. First of all, all of the dust is going to be sucked away. There's a dust collector right there that will suck away all the dust. Although the dust collectors collectors in the new SLC a pretty good, much better than our old SLC. So they're they're much better. But the other nice thing about using a lay that you can hold on to this little temporary with two hands, which is really nice for small little temporaries. It's very difficult to hold on to it with just your left hand. If you're doing the grinding away with your right hand with the slow speed handpiece. The other nice thing about using a lathe is you as you probably increasing the lifespan of your low speed handpiece, because when you. I'm sure you know this already right now. But when you trim a temporary with the low speed handpiece, whether you're actually putting a lot of stress and strain, and there's also a lot of dust that's created even with the with using a dust collector. So again, you don't want to clog up your low speed handpiece. You don't want to put a lot of extra wear and tear in your slow speed Tempe, so it'll work out better in the long run if you use a lathe. And I usually in my practice or in my particular case, I'm about ready to stand up and stretch anyways, so I like the idea of having my patient sit up and relax and say, I'll be back in a few minutes and then you can run back to the lab, go to a lathe, and do most of your trimming and most of your stretching, especially when you get a little bit older like me. All right. And again, then you bring it back to the patient. And this is an important part. And you try it in make certain the proximal contacts are pretty good. Although you can add proximal contacts when you when you realign this. Because remember a big, big inlay just like a crown will need to be to be realigned. So try it in and adjust the occlusion. Okay I'm sorry I forgot one important thing I don't have a picture for. Before you try it in, ream out some of the inside and you need to ream out some of the inside, because there has been some distortion and there has been some dimensional change because of the polarization shrinkage. All right. So rim out some of the inside seated on the tooth check and adjust the occlusion. And usually this is done chair side with a straight attachment and acrylic burrs. And then keep doing that until the patient bites down into a normal MIP. And the patient says to you, that's it. That feels perfectly fine. Don't rely on it. If you if you haven't seeded it properly into MIP because you want the occlusion to be right now once it's you've tried it in and you're happy with patients occlusion, remember it's not going to fit intimately simply because it has to be realigned because of the distortion. And you've also reamed out some of the internal surface. So you're really going to capture the intimate detail of your preparation with the re line. Okay. And if your proximal contacts aren't right, you're going to add a little bit of this to your proximal contacts. So now you go back and make another mix okay. But this is a little bit different. The second mix which is the re line mix you want, you don't want to wait till the doughy stage. You want to mix this up. And before it gets to the doughy stage put it into your into your original mix or your original shell. Because what you create the first time is just a shell which you create. The second time is a really nice, provisional or nice temporary restoration that will have all of the margins, all of the intimate detail of your mod XYZ prep like that. All right, so it goes in or the recently mixed I'm sorry, this one right here. The recently mixed methyl methacrylate acrylic then gets put inside the shell. And then you see that immediately and have the patient bite down firmly into MIP okay. So hopefully if the patient bites down nice and firmly then you won't have a lot of or you won't have too much excess removal and you won't have too much trimming and trimming and adjusting after that. Okay. And then patiently wait until not into the rubbery but into the doughy stage. And when it's in the doughy stage, you grab it with a hemostat. Remember, you can't use a hemostat with your original mix because you'll distort it when you squeeze the hemostat. But the external part of this is nice and hard, so you can grab it with a hemostat and then pull it straight up. Okay, now if you remove it too early, it's going to be stringy. So you want to wait patiently until it gets into the rubbery stage before you remove it. And this is going to take a few minutes. And then you inspect it and then your realign mix. You should see everything. So you should have a lot of high expectations on what it should look like. Now, I don't care very much about the first mix because it's going to be realigned anyways, but it's the second mix that really picks up all of the the nice detail, which gives you a really nice, relatively well sealed margin and a lot of intimate fit. All right. And then you take it either to the lathe or you could do this chair side depending upon your personal preference. But I love the lathe. All right. And then polish it up. And again it should be polished up to a high gloss. And you know, polishing is relatively simple. You can either use those big rubber points that I'm sure you familiar with. Okay. Or you could use a lathe with a disposable rag wheel and flour, flour, parmesan, lab pumice and water. Okay. And again, you can get a real nice detail. Now everything I said was about the block temp. The second technique that I'm going to describe, but it's actually I should have used this first because this is the most popular, the most popular technique for doing a single restoration is using a template, also known as a matrix. Okay. And I know that Dr. Brown is going to teach you and have lots of experience. You're going to have lots of experience like summative exams, doing both a block and a matrix. Although he uses a silicone matrix most of the time I'm going to show you two techniques. Okay. This is a vacuum forming. Whoops. Darn button. Everyone's seen this before. Everyone have experience with a vacuum forming machine? DMVs? No. Well you will. Okay. As I'm assuming you have. But this is a great little machine for making a variety of different appliances, including templates or matrices for for temporaries. But you could also make soft night guards with this. You could also make bleaching trays with this. Okay. The thing that this requires is a really nice study model that's been adapted a little bit and I'll show you that. But this is a really interesting machine. And there are several different companies that make this. But you'll notice that there are two buttons down here. One says vacuum and one says heater. Okay. What you do is you take a very thin piece of plastic, a very thin piece of clear plastic. And again, there are thicker things that could be used for night guards and other things. But this is going to be for, for temporaries. That's why it says clear temporary splint and it's relatively thin. Now. How are we? The key here is that the model has to be in pretty good shape. So let's just say you're doing a crown on this tooth right here. But the distal lingual cusp has broken off. In order to make a good template, you have to rebuild that distal lingual cusp. Okay. And the best thing to rebuild it with is flow composite. Don't waste your time with a good flow composite. Use a lab flow composite okay. That's generally in a different color. This one here is blue, but it's made for a variety of different reasons. But it's really good for replacing anything, any part of the tooth that you're you're treating with that acrylic. So that when you make a template it's going to be of an intact tooth, not a broken tooth. I want to make sure everybody understands that. So you need a pre-op study cast and you may need to rebuild the tooth. You may need it, but if it's already intact, let's say you're doing a crown on a tooth that has an old crown in it that has a little bit of secondary caries. If the shape of the old crown is fine, you don't need to do this. But if there's a piece missing of the tooth that you're working on, then you need to rebuild it. And again, this is a good, good material for rebuilding it. And it's a typical floor. It's like durable. So you simply build it up and either with a curing light or in a triad of it. Because what is a triad oven. You've used triad. Right? Okay. What is it? It's like a mother of all curing lights. That's what it is. It's three lights. They're coming from different directions. And between the the highly intense light coming from different directions and a little bit of heat, it does a really nice job of curing triad material. And what is triad material. And the answer is it's composite. Okay. It's not the same composite that you put in teeth, but essentially it's gamma and some filler particles. Right now I take the clear plastic square. Okay. And again, making certain that it's the one that's designed for making temporaries. And I put it up here. Okay. Okay. Now I haven't touched well, I actually did touch it. And I put the model right there. And there are some other things I'm not going to go into detail, but you you need to either make it a horseshoe, make the model a horseshoe or put a big hole in the palate if it's a maxillary molar, so you get maximum sucking. Now what am I talking about in terms of sucking? This is a vacuum right here. It says vacuum when I push that button. See the little holes in that platform? There's a vacuum cleaner or a vacuum that will suck down this as soon as you're ready to have it sucked down. So when you press that, there's a lot of vacuum pulling on those little holes. That's why you want just a horseshoe and or a model that has a hole where either the floor of the mouth or the palate would be. So you get maximum sucking now when you press. Now remember that thin piece of plastic is right here. It's secure in that that platform, when you press the heater, you wait patiently for that to start softening, okay? And it will get softer and softer and softer. And as it gets soft, it does something called it will droop. It'll simply start drooping down a little bit. And when it droops down, let me backtrack here. When it droops down about an inch or so, that's when you press the vacuum, okay. And immediately push this down that way. And it's sort of like shrink wrapping okay. It's very similar to that, that concept where the softened clear plastic, when it's sucked down over that will form this. Okay. And it does a really nice job. It takes a little bit of of experience and a little bit of practice at getting good with using this instrument. But once you've mastered the technique, although it doesn't require a lot of mastery, it actually works well. And almost immediately the plastic cools and as it cools, this becomes rigid. Now remember this particular material is not flexible okay, so it doesn't create a flexible matrix. It creates a rigid clear plastic matrix okay. The challenge now is getting this plastic off the model. And you may destroy the model. And again anyone who's done this before knows that this is the challenging part to tease this off. Now, if it was flexible like a bleaching tray, it's easy because it's flexible. But when it's rigid like this, it's not so easy. So you need to tear it off. What I typically do is take this off the platform, take some sharp scissors and trim away all of this. Because remember this is plastic and you can see that it's been sucked down into those little holes about a millimeter or so. Okay. And then once I've removed that I can take either sharp scissors, a lab scalpel blade, or even a handpiece and cut it back until it turns into something like this. So if this is the tooth that I'm preparing, I don't want this template to just go on that tooth. It has to go on adjacent teeth so that it can be reposition able. You want to make certain that this template can be nicely positioned over. Not that I don't want to touching this. Remember this tooth is going to be prepped when I when I'm all done making this thing and I fill it with with temporary Crown Bridge material, I need to seat it in exactly the right place. Okay, so I want to go on this tooth. Maybe I actually cut this a little bit short. I'd like to go a little bit further back, a little bit further back. That's why this technique doesn't work all that well on the last two. When you're prepping the last tooth in the mouth, okay. It works best when you have nice rigid teeth on either side of the tooth that you're crowning or the tooth that you're restoring. Everybody got that. So reposition ability is the key to making this accurate and easy. If if it's hard to reposition, you're probably going to have a lot of adjusting to do. It's probably not going to be as accurate and not as easy to do if you have good stable stops on adjacent teeth. Okay, so it must be repositioned. But this is just another example. And let's just say I'm working on this tooth or this tooth. I need to make certain that this is nicely repositioned. And again trimming this back looks easy, but it's not okay. So this is the challenging part. And you need nice, sharp, good high quality scissors scalpel blades and or hand pieces. Now I don't know whether you saw this, but I actually punched a little hole on the non working cusps. There, there and there. Why is a vent hole. Because again if you don't cut little vent holes, you're running a high possibility of getting air bubbles trapped in this. When you see this in the mouth okay. Now there's a technique to doing this. Let's go back to second. See how there's a hole right there. There's a hole right there. There should be holes right there. But just take a number 23. Explore and poke from the inside out. Trust me, if you poke from the outside in, you're going to get a weird looking temporary. So always poke from the inside out so I don't poke it this way. Take that off the model and poke it from the inside out, okay? Because I want a recognizable hole over all of the teeth. Okay, now here's the good news. You can use either methyl methacrylate or bicycle with this technique. And this is actually a little bit nicer than using the next technique I'm going to show you which is using silicone putty. It's nice because it's small and it's easy to position because it's clear. It's it's just much smaller to reposition. Right. But you could use bicycle materials. You could use methyl methacrylate. It's up to you. And if you use the bicycle material, remember the whole idea is that there's a cylinder here and there's a cylinder there. And when you squeeze it properly after you've bled to mix it, then there's nothing dry there. As it goes through this baffle tip, it comes out the other end properly mixed. So it's really simple to use. And as I've said multiple times already, aren't we making life really easy for our dental assistants? You could hire a six year old to be a dental assistant nowadays. Okay. But this is the consistency. Remember this consistency is like the first consistency of the bicycle. This is the wet, sticky consistency. But for a template technique you can go directly. You have to wait for it to to go into the next stage. You simply load where the tooth that you're prepping or you have prepped. Remember, the prep is fully done at this. At this point, you simply put that into the vacuum formed template and almost immediately seated. And then once it's properly seated, the technique is very similar to the block temp. You simply wait for it to get into the rubbery stage, because this will go through the rubbery stage, it just doesn't go through a doughy stage. If it's if it's bicycle material, and then you trim it up and with a little bit of luck, unless it's there's a big air bubble, because this is more dimensionally accurate, it doesn't distort as much. Because of that. You probably don't have to realign. If you do have to realign, don't use methyl methacrylate doesn't work because now you're mixing materials. You have to use a composite like material, like a floorball. And flow balls work really well to touch up or realign a bicycle. Bicycle temporary. All right. Now let's talk about a very common technique. And I think a technique that Dr. Brown loves. That's why you guys are always playing around with the tubs of this stuff. Right. All right. So remember this is silicone putty is designed primarily as a temporary as an impression material. That's the primary purpose of this. It's sort of like the tray mix which is very viscous. And if you're using it as a temporary material, you'd have a lower viscosity in the syringe and a high viscosity like this in the tray. But this isn't mixed with a spatula. This isn't mixed on on a pad. This is mixed with what. And the answer is your non latex fingers do not use do not need this together. Do not mix this together with your latex gloves. Use either non latex gloves or in the SSC. Go with no gloves. I don't know whether I'm allowed to say that, but again in the SSC you can do it. But in the old days that's what we were taught to do to take off your gloves and needed to properly mixing. And of course, anything that's mixed like this, you need the right proportions, but you also need contrasting colors. So the base and the accelerator are always in contrasting colors, which means what? When you mix it properly, it has no no streaks and hopefully no bubbles. But in a high viscosity like this, it's almost impossible to get bubbles and it's mixed with your fingers. This is the old days, and if the two materials are yellow and blue, when it's all done, it's going to be green. Okay, like a nice pea green, I guess. All right. So it's mixed properly although this looks blue but that must be the camera okay. And you can actually see my fingerprints in that. All right. And then you simply put that over an intact tooth. But again remember this is done before the tooth is prepped. Now the good news here is this can be done either on a pre-op study model that's been rebuilt or not rebuilt, depending upon what kind of shape the tooth is in, or it can be used directly in the mouth. So if you're not someone who has study models on hand and you don't like to do stuff before the appointment, the beauty of this technique is that you can actually make the template directly in the mouth. It's a little bit challenging when there's a cusp missing, because then you're going to have to kind of cut it out of your of your template. Now I mold this into a like a rectangle, okay. Almost like a, almost like a cube. So it's molded properly and simply adapted over the intact tooth. Remember, we're not dealing with prep tooth prepped teeth at all. The tooth is intact either on a study model and or a natural natural sextant or quadrant, and you simply wait for it to totally set. This doesn't go through doughy and runny and rubbery stages. It either is mixed and then it's it gets firmer and firmer until it's totally set. Don't remove it until it's totally set. Now this is. Not a rigid material. It's impression material. So it's designed to be what the key word, the e word is what it has to be elastic. You have to be able to remove it without distorting it. And again that's a quality of any impression material is it has to come out of the mouth without any permanent distortion. That's elasticity. It will deform but then bounce right back to its original shape. All right. So this now is allowed to fully set over the intact tooth. And then it will look like this. So if this is the tooth that's going to be treated okay. You have plenty over here. Now with a big large lab scalpel blade. You can trim it back because you don't need this. You don't need this, but you do need 1 to 2 teeth on either side of the tooth that you're you're restoring. And again, that's really important. So I trim it back like this. So this is not the tooth I'm restoring. This is not the tooth I'm restoring. This is the one that's going to be restored with either a crown prep or non prep whatever. Okay. Now one step. And I don't think Dr. Brown teaches this, but I think it's a good idea is to cut some vents. But you're not going to cut a hole there. The best place for a vent hole is there and there. So watch what I do. Well actually I can't. I thought I had pictures of it. There you go. I probably should have moved these slides a little bit. I'm taking a big scalpel blade and cutting a v shaped vents on the buckle and lingual of the tooth that I'm restoring. Okay. Because I want the excess to ooze out the buckle and lingual. Because if you don't do that, it may not seed properly, and you may incorporate air bubbles. So again, I think event is a good idea for a vacuum form template. And I think event is a good idea for a silicone template. Now let me backtrack a little bit here. Before I cut the vents, the reason why I'm doing this is that that's what it's going to look like pre-op or the very beginning of the appointment. Then I'll go to the tooth and do my prep, and I'll finalize the preparation. Take my final impression, take the counter model, take bite registration if I need it. And then I picked this up again. I'll try it in before I cut the vents. And what I mean by trying it in. Remember, the tooth is now prepared so there's my tooth. Prepared for a crown. Okay, I remove it. I'm sorry. I seat it so that it nicely seats to place and I need to check it both the anterior and the posterior to make certain that it fully seats. Because reposition ability. I said it sounds like an exam question. Reposition ability is really everybody writes it down. So really it's like your lemming seal. All right. So I need to make certain that it's reposition able. So I look on the medial tooth I look on the distal tooth. And I need intimate contact so that I can I know when I see the back of the mouth after it's filled in with, with the either methyl methacrylate and or bicycle that it's going to see properly, and I have minimal adjusting. That's when I after I make certain that sits properly, then I'll make the vents and the vent on the buckle will look like this. The vent on the lingual will look like this. Okay, now I can use either bicycle or methyl methacrylate. And this is methyl methacrylate. And remember this can't be light curable because some bicycle materials are like curable. And again if you're using silicone putty if it's light curable is it going to work. No. Because the silicone is going to block the light. If it's a clear plastic vacuum matrix, you can use any kind of of curing technique for your temporary. So some of the bicycle materials are dual cure. Some of them are like cure, some of them are totally chemically cure. But again remember if you're using an opaque matrix like that you can't rely on light curing okay. So I seat it back and the excess will ooze out the vent on the buckle and lingual. Another reason I like this is I can test this to see how well it's set. Okay. And again, if it's if it's nice and firm or I'm sorry if it's doughy. Remember this has to come out when the patient when the temporary is in the doughy stage. If you wait until it fully sets what's going to happen? It's going to get locked into place because it's going to flow into the gingival and braces of the adjacent teeth. All right. So I need to watch this carefully. The key of making good temps with with whatever material you use is understanding at what stage in the setting the material is. All right. So at that point, I'm sorry, at this point, let me get back to this. Once it's in the doughy stage, I remove it and I plop it into the hot water again and wait for it to fully set, and then I trim it back, try it in exactly like I did before. Now, you may not need to to realign this. Depending upon the size of the restoration inlays, you almost never need to rely on it. Crowns, bridges. You almost always need to realign it, even if it's a material, but you're less likely to need it if it's a bespoke material, but definitely needed if it's a methyl methacrylate material. All right. So at this point it's just like the other techniques. So I've described three good techniques for making single tooth temporaries. One is block temp which has pros and cons, two is using a vacuum form template has pros and cons, and three is using a silicone putty template which has pros and cons. This technique here is the most popular. Now there are some variations here. There are actually some little mini impression trays that can be made to to minimize the the amount, so you don't have to form it into a little cube. You can actually put it into this little mini impression tray and seat that. So there are some variations in this technique okay. All right. Now once you have a temporary you need to cement it okay. What are the best temporary cements. And that's what we'll talk about next. All right. By far historically meaning going back to the black Times. Literally going back to the black times, the most common temporary cement is zinc oxide in all. Okay. And the most common brand in the last 50 years is temp bond made by the company. Ker. So put up your hand if you've ever heard of temp bond. Okay, so for those of you who put up your. You probably haven't used it because tempo has pretty much been replaced by something called tempo and knee. Okay, so knee is a non huge null containing temporary cement. And unfortunately the company cur named their non usual temporary cement temp on an E. So it's very common for students and for practitioners to confuse the two. So if you're writing up a chart you should write in your in terms of your documentation what you used as the temporary cement. So if you use temporary, if you've used if you used temp on E, don't write in your notes notes that you use temp on and vice versa. Now. Why? Non usual. First of all, why you. General, what was the. The beauty of Eugenia back in the black days when he used lots of huge and all. First of all, what is your channel and what does it smell like? Okay. It's a little oil of cloves is what it is. Okay. And in the first ten years of my practice, when I used a lot of huge, all containing practices, I would go home and my wife said, you smell like a dentist, okay. And again, when you walked into a dental office, let's say in the 1970s, it had a typical smell and it was huge enough because it has a very distinctive smell to it. I can remember stopping at a store on the way home from work, and the cashier said, are you a dentist? Right. So sort of embarrassing. I said. I smell really all right. So, so usually has the advantage of calming down a hypothermic pulp. It's a, it's an a pain of thunder, which means that it lessens discomfort and lessens sensitivity or lessens pain. So it's nice to use, especially on a freshly cut when you when you cut a crown. Preparation. How many dental tubules do you cut? Millions. Okay. So you run the high possibility, especially with a big crown preparation of having post-operative sensitivity. So it was nice to use a calming sedative type temporary cement. So that's the good news about all the bad news is that huge null interferes with the polymerization of resin. Okay, now, when is that important? And the answer is when you're using a resin final cement okay. Because it won't set as well. Okay. So the solution was coming up with temporary cements that don't have huge null in them. The best brand name or the best name I ever heard something called no general. I thought that was kind of a cool, cool name. Much better than 10.0. All right, so the trend today is now no longer using zinc oxide. Usual like tampon, but using the non zinc oxide cements like tampon and a or no journal. All right now. If you have a highly retentive prep, first of all, shame on you. But if you have a prep that's not very retentive and you have a very short crown, for example, on a second molar, okay, which are notoriously short, by the way, and or your patient says this, oh, I just realized that I'm going on vacation starting tomorrow, and this is your prep temp and impression appointment. So your first appointment doing this restoration. And I'm a worry that my temporary might fall out. So what you could do is actually use some poly carboxylate cement okay. And add a little bit of Vaseline. And that is like a stronger version of a temporary cement. Okay. Now the bad news with that is it sticks to the tooth and you really have to anesthetize the tooth and scrape it off when when you're ready for the next appointment, which is I'm about to talk about in just a few minutes. Okay. And the post-op instructions are always what when a patient has that nicely cemented temporary what are the instructions you give the patient? Okay. You got to and I started off with this. This temporary is made for me to be able to remove it at the next appointment. Therefore it can loosen up. Okay. Now in order to prevent it. Seems like it's dying out. Maybe it's time for a battery. All right. Maybe it's time for a break. All right. So. So I always say to the patient, be careful when you floss this, okay? So floss it, but then threaded out. Don't don't try to pull it up because that's almost always got to loosen it up okay. And stay away from very sticky foods like taffy and gummy bears and things like that. I told you my gummy bear story, right? I tell you that. All right, so I always use gummy bears as an example of something very sticky. So a patient 3 or 4 days after I prepped, tempted, and pressed for a single crown, he called up my office and said, I need my temporary re cemented, which is not uncommon. All right. So he comes in and he has this temporary in a little Ziploc bag, and the temporary is attached to a gummy bear. Okay. So he said I just wanted to leave this like this because I went to the movies with my kids the other day, okay? And they were eating gummy bears, and I gave in to the temptation of picking up a gummy bear and putting it in my mouth. And as soon as I started chewing on it, it loosened up the temporary. And you told me specifically don't eat gummy bears. So I just wanted to show you that you're absolutely right. You make something that every patient knows not eating. Of course, at that point it was disgusting because I then had to go in my lab and remove the gummy bear from the temporary and then re cement it. But patients should be told very clearly that this is a removable thing and it can loosen up. The other thing to remind a patient of is that if it does loosen, even if it doesn't hurt, okay, if it does loosen up, call me okay. Because it can't go for multiple days with it being outside the mouth. Why? Because teeth move, okay? And they only move where you don't want them to move. All right. So the longer the patient goes without a temporary, the more likely they are to have gingival damage. Because again you can injure the soft tissue, especially in approximately with food being impacted because there's nothing there to protect them. If you don't reestablish a proximal contact, the proximal tissue that call that under characterized area just below the contact is going to be traumatized and inflamed. All right. So so this is what I was talking about before. This is not tamponade. It's temp on any and any does not stand for a New England okay. All right. Now the last thing I'll show you before I go into the next or before I give you a break. Is this what in the world is this? I can't do dentistry without this thing. It's one of the cheapest things I buy. It's one of the most valuable things I buy. Okay. What is it? It's a. If you read down here, it's a handle for small objects. This particular brand from pulp is called a pick and stick. Okay. And again, I finally convinced the school to put these in the clinic. So they should be in the clinic right now. But imagine if you had a little mo inlay and your job was to mix temporary cement, put it in that and carefully seat it onto the tooth. Can you do this with your gloved fingertips? It's almost impossible to do so. You simply take one of these, which is soft wax on a plastic stick. You break that off and you dry off the temporary, and you simply that soft wax will stick to the occlusal surface and allow you to hold on to that. Okay? Whether it's an inlay and on lay a crown, even a bridge. Okay. And I use this for permanent restorations as well as temporary restorations. But don't forget to do this. I also take a little bit of Vaseline and coat very carefully, a little bit around the margin, not on the inside of the crown or in lay on lay, but on the outside. Why? And the answer is it makes cleanup much easier. So then as you can see here, this is attached to this not permanently attached to obviously. Okay. And Vaseline goes around here on the outside. Okay. And then it's seated. And this this is actually the temporary cement. And once that temporary cement fully sets then it's relatively easy to remove because the Vaseline is kind of created a lubricant. If you don't do this it's going to be more difficult and messy to remove. Right. And then again, make certain that you go around the entire circumference of the restoration. Make sure that all of the temporary cement has been removed. Again, this is a challenge. Okay, let's do the QR code. I'll give you a break and then we'll start with a brand new slide show when you get back from the break. I don't I don't get why. You don't you don't. Seriously. Have to. You add the thing. Because. You can. Always. Find an hour of. Is there anybody who knows how to get into space from here? Yes. I know, I know it's not. Like. This is something new for me. On my way. There you go. Thank you. So I actually have to log in first. Log out. Hi. If I was in charge, I'll be so. I. Absolutely. Awesome. Where we. When? I'm. We have to come. Oh. Oh, oh. Okay, now let's assume that everything went well with this appointment. So this appointment would either in the clinic, there would probably be two appointments. The first that you would prep and the second one is that you would take care of the tissue and take a final impression. That's what typically happens in a dental school environment in the real world, or when you get close to graduating, you'll do all three of those steps in one appointment. So in one appointment, you prepare the tooth. You made a beautiful temporary. You cemented it well. Don't cement it yet because you need to take a final impression. So all of those things are done at the first appointment. And then if it goes to a lab, you package everything up, make a beautiful prescription and get it to the laboratory. All right. When it comes back, I strongly suggest the very first thing is that you inspect it before the patient comes in, because again, if it's not exactly what you want, you don't want the patient to come in. And then as you open up the package, realizing it's not what you ask, ask for. So always inspect it before the patient shows up. All right. So and again this is an important statement here. The try in cementation is actually not as simple as you think especially when you're doing this for the first 20 times. Right. So again with experience it usually goes pretty smoothly. But this is not every so often a patient will say so at the next appointment you're just going to take off the temporary and put the permanent one in. Right? I say, well, it's not quite that simple because again, you may have some adjusting to. Do you have the contact that has to be checked and maybe adjusted. You have the occlusion that's that may need to be adjusted. If it's an esthetic area, you may need to send it back to the lab for better staining and glazing. Or if you have that capability in your office, you might have to do it. So again, there are things that in the trying that may make that next appointment a little bit more complicated and a little bit longer. Okay. The good news is that with milling technology, whether it's done by you or done by the lab, the train is actually a little bit easier. For some reason, the occlusion doesn't typically doesn't require as much adjusting, and it almost always fits beautifully, but not quite as simple as you might think. So evaluate before the patient shows up to make certain that it's what you asked for. Okay, then when the patient does show up, you almost always have to anesthetize the patient. Now, if it's a super gingival and a donkey treated tooth, you may not need to to anesthetize this patient. If you have an older patient who doesn't have a lot of sensitivity in their teeth and say, can we skip the anesthetic, you know, if the patient does not want the anesthetic, you might be able to get away with without anesthetize it. But most of the time you want the tooth nice and numb, because you may need to retract the tissue a little bit to eliminate any bleeding you may need to, or you will need to scrub the tooth okay to make it nice and clean. And you want to make certain that the patient is going to be comfortable during the entire procedure. So usually not always, but usually you want the pulp and the soft tissue around the tooth to be adequately anesthetized. Not critical, but a good idea. Remember, patients don't go to you because they like your line angles and point angles and margins. Patients don't go to you because you don't hurt them, right. So again, that's an important part of building a practice in internal marketing to make certain that your patients want to come back to you, okay. And then assess the provisional, not only when it's off, but also when it's still on the tooth. And you want to look at the provisional, make certain it's not worn through, makes it and it hasn't broken because that might be the sign that something's wrong. If you have a wear through on your provisional after wearing it for a couple of weeks, it may be that you didn't give the tooth enough occlusal reduction. All right. So again, it may be a sign that something's wrong. Remember one of the the purposes of well done provisional or well done temporary is to use it as a diagnostic tool. And you can learn about your prep by studying your provisional. Okay. Now so I assess the provisional both. When it's on the tooth I want to mix it into the tissue is nice and firm looking. And then when I remove it, what I'd like to see and I'll show you a picture of this in a second, is I'd like to turn that temporary over and see very clean, uncontaminated, temporary cement. That's what I'd like to see. Now, if it's Dorion or Poly Carboxylate, it's probably still going to be on the tooth, the cement. But if you've used temp on any, then it will be in the temporary and you want it nice and clean. And again that's the, that's a sign that the temporary hasn't leaked at all. The temporary hasn't moved a little bit because of temporary moves. It'll open up some of the margins and allow food stain etcetera to get underneath that. Okay. And then the final restoration is going to be seated not by firm biting on it, because again, you might break the tooth or you might not be able to see it properly with finger pressure. So it's seated on the tooth with finger pressure. And then I need to to determine whether or not it's properly seated or not. So those are the first several steps when I'm trying in either a crown, a bridge, an implant supported crown, or an implant supported restoration. And in. Lay it on. Lay et-cetera. All right. So again I assess it on the day ahead of time to make certain that's what I want. And again don't waste the patient's time. Don't waste my time. I inspect it in the on the tooth and I expect it off the tooth. And again this is what I want to see. I want to see nice, clean, unstained, temporary cement inside. And I want it to be nice and thin. And the tissue should be nice and healthy as well. All right. Now at this point, I clean the tooth off to eliminate any small remnants of temporary cement that might be there. I clean the tooth off. And this is important? Not with Prof. Paste. Do not use Prof. Paste because it has oils in it. It has fluoride in it. You want to make certain that it's just flour of pumice and water. And again flour, pumice and water. You can either make your own mix with a little bit of water and a little bit of flour pumice. Now what is flour of pumice. It's the finest of all the dental promises. Do not use laboratory pumice. It's way too abrasive. So don't use the same pumice that you'd use on a on a lathe. Use the pumice that is designed for intraoral use. And that's flour of pumice. Okay. And either with a rubber cup or a bristle brush. And I clean it off really well and make certain that there's no temporary cement still on that. All right. Now the next step is trying it in to assess how well it seats. Now remember the definition of seating. Definition of seating means that the entire internal surface of your restoration is intimately, almost in contact with the preparation. So the space that will eventually be occupied by cement should be very close to zero. Now it can't be zero now and again 20 microns, 25 microns, 50 microns maybe according to some people. But you try to get that to be nice, that cement space to be nice and small. So how well it seats really relates to or relates to how thick the cement is going to be. All right. So the first goal is to maximize seating now. What is the best way to determine whether or not it seats properly? And many of you will say, well, take a radiograph, but that radiograph is flawed because it only shows you some of the margins. Okay. The best way is to use a material with a very sophisticated professional name called Fit Checker. Okay. So you'll see. So again what does it really mean. I've already described that. Now I throw this in to let you know that the dentists are all over the place in terms of their standards. Some dentists are a little bit sloppy. Some dentists are really maybe overly picky. Okay, so you want to be realistic, but you also want to be as precise as possible. So if I'm a really well established high end prosthetist who has high standards, I want that seating to be really, really well seated and or very small amount of space for the cement. But there are some dentists who have weaker standards. I'm hoping that everybody in this room will have very high standards. Okay. And if not, shame on you. All right. So again, is it clinically acceptable standards. ET cetera. And again, there are different textbooks even for milling machines. You can be asked what how well it should be seated. And again if you're a volume oriented practice you probably say well 100 microns is okay. It really isn't. But you could set the machine with a like a die spacer. That would be 100 microns, but a higher standard would be 50 microns or 25 microns. All right. So again you want to be high standards. And remember the consequence is is that if there's a thick layer of cement it's more susceptible to wash out and it's more susceptible to restoration dislodging. So those are the consequences of not having high standards. Okay. Now what is the best way to determine it. And the answer is, first of all understanding why it might not seat okay. What is the most common thing that would prevent something from seeding when you first try it in? By far it's the proximal contacts being too bulky because as you can imagine, if you have working on tooth number 30 and tooth number 31 and two, number 29 are still there. Okay. If the context is still bulky, can you seat it all the way? No. The adjacent teeth that bulky contact of your restoration is, is preventing it from seeding all the way. And I guarantee that if you didn't anesthetize, the patient will say that the patient will literally say to you, it's too tight, okay, because it's putting pressure on adjacent teeth as you're trying to seat it. That's why I say finger pressure is what should be used first. Okay. And then with you applying finger pressure or your dental assistant applying a pressure either with our finger and or a ball burnish on the occlusal surface. Then you try to snap floss, snap waxed floss through both the medial and distal contact. Okay. And you'll know whether or not you have a normal contact. But this is a classic exam question. The most common reason for it not seeding when you first try it in is the contacts are too bulky. Okay. Our tight proximal contacts. All right. Now that could also be especially with a metal restoration that's been made the old fashioned way with investing and casting is little internal blurbs on your on the internal surface of your restoration. So as you can imagine, if you have a little bleb, which is a positive, it's like a little pimple on the inside of your restoration. Will it it all the way? It can't, because that little plus that little bleb will prevent it from seeding. Okay, so that's the second most common reason why it doesn't see properly. Now a third. Now this doesn't really apply to CAD cam generated restorations. But in a conventionally made restorations may be the lab technician broke the Di. Or maybe your impression caused some kind of distortion in the Di that's going to be made. So if you have a little bit of Di damage, it's not going to see properly either. Okay. So there are multiple reasons. And of course the last reason is that you've made some mistake. The impression material distorted. The either was a bad impression. There was a bad undercut in your preparation. So there are times where nothing is going to be able to fix it. The good news is that this is almost always fixable. This is almost always fixable without having to redo the whole thing. This may or may not be fixable, and this obviously is not fixable. If this is the problem, take a deep breath and say well, darn, okay and then start all over again with a new impression, or maybe even a new prep. Okay, so let's pretend that it doesn't seat all the way. You can't get floss through. Your dental system is pushing it down, okay. And you're trying to get floss through the medial distal and it doesn't work. Okay. What should you do? And the answer is you adjust the proximal contacts with a usually a rubber wheel, but something that is not going to cause scratches because if you use something like a diamond or a very coarse disc, once you've got a good contact, then you're going to have to remove the scratches and you're running the risk of opening up your contact. Okay. So you want to use an instrument like a rubber wheel. So if it's gold I'll use a wheel like this. If it's ceramic, I'll use a wheel like this which is designed for ceramic, that's designed for for gold. And I remove a little bit at a time. Okay. And then I try it back in and if it's still tight, I remove a little bit more and try it back in. If it's still tight or remove a little bit more and try it back in. Okay. So gentle finger pressure. And again you need a dental assistant to do this properly okay. You assess whether or not you get a normal snap of floss and if not relieve, relieve it with a rubber instrument or an instrument that's not going to create scratches as you remove a little bit of that excess, okay. And then just recheck it and repeat it as necessary until you're really happy. Now what happens if you take away too much? What happens if you if you seat it and it's obvious that the medial contact is open? Do you have to start all over again? The answer is no. You don't sometimes because you can actually add gold. If it's a gold crown, you can add ceramic, or you could add porcelain if it's a ceramic crown, okay. If you have the ability in your office or you send it to the lab and ask them to to add a little bit more medial contact. So it is possible to fix an open contact. And you need to if it's an open contact. So if you remove a little bit too much and always open in the first place, you're not condemned into starting all over again. You may be able to fix it not all the time, but you may be able to fix it. All right. The other thing I stress is that when I check a contact, I check it for not only that, the two teeth are touching, but they're touching the right way. Okay, so I want to make certain that the contact is is. Not just a spot or a point of contact. I want to make something that's in the right place. It's the right contact area. So I'll take floss and and hold the floss this way, and then hold the floss that way to make certain that it's a nice normal contact. Remember, like any restoration, like an amalgam or composite or an indirect restoration, I don't want just a contact. I want a contact that is supposed to be there. And typically it's not a spot and I don't want it to gingival I don't want it to occlusal, I want it right where it's supposed to be. Okay. All right. So as I mentioned if there to light now have you ever heard of contact cider. This is to be used if you're doing a gold crown or a gold only or an inlay in your contact is open. Very interesting technique. If not, if you ever have to do this while you're a student, don't do it all by yourself. Go to John. I'm sorry John's retired. If you go to Jerry up in the lab and ask Jerry to add some contact solder to the medial surface of your crown. Now what is contact solder? And the answer is it's gold alloy that has a melting point lower than the crowns. Gold. Now think about that for a second. This is the technique. And it's a very, very scary technique, especially if you don't know what you're doing okay. So you clean off. Let's say you want to add a little bit more in the medial surface. You clean the surface of the tooth nice and clean and dry okay. You put something called flux, which is a gel like material that will just on where you want to add. And then you take a little piece of this gold contact solder. Okay. If you've ever done any soldering like an electrician would use soldering or a mechanic would use soldering, and then you take this little piece of contact solder and you put it on top of the flux, and then you take a blow torch, a very high heat, and you heat it up nice. Now don't hold it with your fingers. You're holding it with with tongs. Okay. And you heat it up. So what do you think is going to happen. It's getting hotter and hotter and hotter and hotter until it reaches the melting point of the solder, not the gold crown, by the way, don't wait that long because then you got a ball of gold. All right. So as soon as it's the contact solder starts to melt, it will start to flow. You immediately remove the flame from the blowtorch and it will harden as it cools right away. So you've added some gold to the proximal surface and then bring it back to the patient and try it. Now it's probably going to be too tight now. So you're going to have to remove a little bit. Remove a little bit until you get a nice normal contact. Now you may never have to do this because we're doing less and less gold nowadays. So it's much more of a problem having proximal contact to bulky than having the proximal contacts open. But if the proximal contacts are open, don't cement it. By definition it's a it's a critical deficiency. That alone makes it a bad restoration. All right. So that's what contact solder is okay. Now if it's a ceramic restoration if you know anything about ceramics, if you have a porcelain oven in your office, you can actually add a little bit of porcelain regardless of the type of ceramic. Right. Again, typically because a lot of people don't have porcelain ovens in their office, you'll s