Aesthetic Materials and Treatments James R. Dunn DDS-

Aesthetic Dental Treatments Patient requests for aesthetic treatments is driven by “Appearance Phenomenon”: the quest for

beauty. Dentistry is only following the Universal trend of “youth and beauty”. Programs like “Extreme Makeover” have fueled this demand. Dentistry offers many treatments to enhance natural beauty of a smile. Ethical concerns caution against over treatment. Conservation of natural tooth structure is a high concern while meeting patient’s wants and needs. Remember the golden rule and our Hippocratic oath—Do no harm!

Materials- Composites, Dentin Bonding Systems, Devices Use Diamonds rather than carbides for tooth preparation. Air abrasion, Laser preparation-(no biological or physical advantage), may allow more conservative preparations, diagnosing (Diagnodent) and treating disease earlier with less tooth destruction. Hybrids are used for most treatments-anterior/posterior; nanoofills for enamel like surface translucency and polish. New translucent hybrids-”Natural shaded composites” (4 Seasons™, Supreme™, Vit-l-esence™, Esthet-X Improved™, Renew™, Point 4™, Premise™, Miris™, Venus™ ,Simile™, Tetric EvoCeram™, TPH3™, Gradia Direct™,Palfique Estelite ∑ ™, Artiste, Ceram X, etc.) promising. No current validation for flexible, flowable composites. Current use as liners in posteriors promising as stress relief and adaptation. New NanoComposites (Supreme™) have high surface gloss. Apply with IPC, and brush. Finish with #12 blade, discs, rubber polishing cups. New micro-hybrids have higher gloss with final use of diamond/rubber cups/brushes. Place Composite Surface sealant on margins and surface after finishing. Multiple-bottle dentin bonding systems have more testing (IE. SB-MP™, AB-2™, OptiBond FL™, AmalgamBond™) but new simplified systems more convenient (IE. Single Bond™, Solo Plus™, One Step+™, P&B NT™, PermaQuik 1™, Bond 1™, Excite ™. Self etch--,SE Bond TM, Prompt L-Pop TM, I Bond TM, Touch N Bond TM, Solo Self etch TM, XENO IV TM, etc.). Question: is simplified better? Early tests raise questions of strength and seal.Self Etch a concern for durability. Posterior composites use hybrids. Flowables, GI’s, may reduce stress. “Heavy Body” in early clinical tests. Prep with Diamonds (Pedo and small pointed shapes), wedge with spring rings (Bitine™, Composi-Tight™, Danville Contact™ ) and thin matrix. At present, cure in layers, use VLC lights, cure after finishing. Pre-cured or quartz inserts, or plastic cure/wedging devices not validated. Curing composites is either “Low and Slow” or “High and Fast”. Best curing method not validated-from high output Quartz Tungsten Halogen lights (Optilux™, XL3000™, Spectrum™) or (LED and PAC, and other high output sources, ramp or low output curing). Amalgam bonding is benefit, but not magic. Dual cure DBS and metal primer (PANAVIA F™,,Bistite II™) have high numbers In-Vitro testing, ()UniCem™ MaxCem™) have low. Bonding Porcelain Veneers use DBS and clear, high viscosity Composites, Hurculite™ Incisal Light, Esthet-X™ CE, Vitalesence™ Clears, Point 4™ trans.etc. Or light cure resin cements (NEXUS™, Opal™, Calibra, Choice™, Variolink™. Unicem™, Permaflo hopeful.

Dentin/Enamel Bonding- Etch, Moist surface, Adequate surface coverage, Prepare surface with diamonds, etch with 35-40% Phosphoric acid for 15-30 Sec. Wash until etch color gone, leave surface moist without excess water layer or dessication. Use vacuum or blotting to remove excess water. Apply enough primer or (combined primer/adhesive single bottle) so that surface is glossy after solvent removal. Remove solvent with high volume vacuum or slow gentle stir. Cure. Key to more predictable bond is visible glossy surface. “Self etching” adhesives do not require phosphoric acid pre etching. May need to etch enamel. Apply composite. Use light cured DBS for direct composite or PV’s , Dual cure for indirect posterior composite , crowns or Amalgam. Bond to dentin/enamel is micro-mechanical, not chemical. Do not contaminate etched surface with saliva, blood or other chemicals. Re-etching is not adequate after contamination, must re-prepare surface. Desensitizers, ie. NaOCl, Gluma do not appear to effect bond.

Direct Composites- Class 5, 4, Diastema, Veneers Class 5: Careful diagnosis, adjust occlusion on teeth with “abfraction” lesions. Retention is never bad preparation design. Use pedo shape and pointed diamonds. Light cured GI for high caries risk patients. Use Microfilled composites in layers Durafil™, Renamel Micro™, Amelogen™). Hybrids may be too stiff. Polish carefully, do not abrade cementum. Soflex™ Discs, Optidiscs™ are flexible and thin. Place composite surface sealer.

Class 4, Diastemas, Incisals: Prepare heavy chamfer margin around defect. Use micro-hybrid, nanofilled composite for shape and strength, may use microfill on facial for polish. Can lengthen anterior teeth with careful occlusion diagnosis. Rebuild Canine guidance. Warn patients of potential gingival “black triangle”, with diastema closure. Placement depends on artistic skill of dentist with color, translucency, New Natural Shade Composites. Veneers: Benefit of composite veneer, conserves tooth. With diamonds, remove only enough

enamel for thickness of composite. Etch, bond, place thin layer of micro-hybrid, cure, layer of microfill, nanofill, or new micro hygrids, using colors, natural anatomy. Brush surface for anatomical detail. New “natural shade” composites give lifelike translucency. Cure, finish should only require margin finishing, polishing, and sealing. Use diamond rubber finishing cups to retain surface anatomy, yet high surface polish. Composite surface sealants. “Bleached” white shades available in micro-hybrids, nanocomposites and microfills.

Posterior Composites- Preparation, Wedging/Matrix, DBS, Liners

Size comparable to Ag. Gingival margins in enamel. Use dentin, enamel shades. Use Diamonds or air abrasion, prevent unsupported enamel margins. Place clear, pre-formed Mylar or “soft” SS matrix segments. Use shortened wooden wedge. Use spring steel separating ring to separate teeth. Burnish matrix. DBS, may use Glumma or HEMA desensitizing agents. HEMA based DBS may have less post-Op sensitivity. May use flowable or GI as liner (not on occlusal margins) to reduced effect of polymerization shrinkage stresses. Use microhybrid or “Heavy Body” composite in layers, cure each from Facial, Lingual and Occlusal. Place final clear layer to correct anatomy. Place composite surface sealant.

Crown Margins- Repair, Opaqers Small class 5, roughen metal margin, etch dentin, DBS, PANAVIA OP™, on metal margins, thin layer composite, layer PANAVIA OP™, or 3M ESPE Masking agent, final layer, composite. GI may be opaque enough for many margin area.

Tooth whitening- Home, In Office, Light, Laser, Safety No long term whitening effect advantage between accelerated bleaching ( high concentration H2O2, light, PAC, laser, LED, Zoom AP™, BriteSmile™ Saphire™) from at-home, mouth guard bleaching, using 10-15% carbamide peroxide. Least traumatic method; oral exam, custom tray limiting CP to teeth, wearing tray 2-3 hours/day, recall by dentist. New “Tres White”, a self contained disposable tray system interesting. Whitening is oxidizing organic stains with O2 molecules. 10-15% CP shown to be safe and effective when used as directed. Can use high viscosity F+ for sensitivity. Potassium nitrate and F+ is desensitizing treatment. New amorphous Ca and Po promising. Patient may want touch-up bleaching every 4-6 months. No reported adverse effects with available H2O2 tested products. Transient tooth sensitivity greatest complaint. New OTC products (Crest Whitestrips, Colgate, Rembrandt Plus) Shown to be effective and safe. For patients wanting “whiter-than-white, “deep” bleaching may be helpful.

Porcelain Veneers- Preparation, Temporaries, Try-in, Cementation. Diagnosis: Composite veneers more tooth conservative, but porcelain can be more aesthetic and defect resistant. Use porcelain only where pt. understands more tooth must be removed! Bond to enamel best and most conservative. Younger pts. may need direct composite. Remove only enough tooth for porcelain thickness at correct morphology. Temporize with direct composite or use thermoplastic splint, Temp Tab™, or PVS impression to make thin Triad™ or Acryl-Composite temporary. Usually, do not cement. Only a cosmetic temporary. Ceramic artisan KEY to PV success! Try in PV’s with water. Do not contaminate etched PV surface with resins. Check color, use clear, high viscosity, cementing resin. Place resin on each PV, seat, remove excess, continue with each PV until all are in place, floss with thin floss, place 10 micron mylar strips, make sure all PV’s are seated completely, margins smooth, then cure for 20 secs. to hold, cure for 2 min. each area, remove excess resin cement (#12 Scalpel blade, brush), Seal with composite surface sealant. Adjust and polish occlusal interferences.

Indirect Posterior inlays/onlays- Diagnosis, Preparation, Temporization, Seating Heavy occlusal forces can destroy tooth colored materials. Prepare adequate (>2mm) thickness for porcelain/composite. >150-180 draw, rounded angles. Concern with margins fracture in occlusal contact .Porcelain more abrasive. Composite may be alternative. Onlays more durable. Use Temp Tab™ or PVS impression as matrix for temporary. Triad™ or acryl-composite temporary material. Try-in without testing occlusion. Cement with dual cure DBS and resin a concern. Light Cure best. Adjust occlusion, seal margins. Waiting for validation of reinforced composite crowns/bridges. Direct’s may be as good. CAD/CAM (CEREC) may be wave of future as tooth design software improves to mill accurate, detailed anatomy.

Light Curing- Light Sources and Timing LED lights dominating market, but high quality QTH lights (Demetron 501™) still excellent curing sources. PAC and Laser diminishing in use. LED lights still heat dental interface. Select light for ergonomics, intensity, wand tip size and ability to cure all light curing products used.

After thoughts Be Conservative! Conserve tooth structure-think long term, teach patients advantage of long term

Ca(OH)2 only for physiologic direct pulp exposure. Only cover exposure. Seal with DBS or GI. Dycal™ good temporary cement. Use new “Natural” shaded composites, possible to closely resemble natural tooth shade of enamel and dentin, a competitor for ceramics. New brands appearing. Very artistic, decreased chamaeleon effect. Follow manufactures instructions exactly, use commercial products (no home brew)

Find good DBS system and stick with it! Use a small sandblaster. Clean, roughen, esp. metals.

Use metal bonding material (PANAVIA F, Rely-X Unicem™,MaxiCem™ , Meta Bond™, for post cementation, Use magnification, higher the better! Keep up! Read CRA Newsletter, Dental Advisor, Reality, etc. Do not be first with materials or techniques, carefully evaluate anecdotal or testimonial statements, find scientific validation, do not be last to give up old.

1. Why do patients want aesthetic Dentistry?

a. Through-out history people have always wanted to look younger. b. Television, movies, magazines emphasize beauty and youthfulness. c. Television programs (Extreme Makeover, the Swan, I want to look like …….,

Dr. 90210) show seemingly easy makeover. d. Dentistry is “in” in aesthetics. ( Veneers, bleaching, orthodontics, gum

surgery)

2. Do I have to provide extreme makeover to be an aesthetic dental practice? a. Many less extreme procedures can give a more youthful appearance. b. Bleaching, bonding, orthodontics and gum surgery can give very good dental

appearance without cutting down too much tooth.

3. What procedures are considered extreme makeover dentistry? a. Porcelain veneers:

i. Requires much tooth removal ii. Requires a high quality, aesthetic, laboratory procedure. iii. Requires cementation

b. Posterior porcelain inlays/onlays, or crowns i. Requires much tooth removal ii. Requires a high quality, aesthetic laboratory procedure. iii. Porcelain crown can break with heavy chewing iv. Some teeth are sensitive after cementation.

c. Gum Surgery i. Requires careful evaluation. Is plastic surgery of the gums. Can

make a difference in smile. d. Bleaching

i. In office: (Zoom, Britesmile, Rembrandt) 1. Gives instant (one or more hours) white smile with many

patients 2. Requires trays and gel for long lasting whiteness 3. Many patients have severe tooth pain for short time after

in office whitening ii. Tray whitening

1. Still considered the most reliable method to whiten teeth. 2. Requires patience by dental staff and patient for best

whitening result. May take longer time than patient wants. iii. Over the counter

1. Whitestrips are considered the best of the OTC. 2. Newer OTC products are being introduced and are under

development. e. Anterior Direct Composite

i. Most conservative way to repair diastemas, fractures, worn and decayed anterior teeth. Requires artistic placement of new composites

f. Posterior Direct composite fillings.

i. One of the most popular fillings to enhance the smile. ii. Most commonly used to replace amalgams. iii. Requires a liner (Glass Ionomer or Flowable composite) to reduce

post treatment sensitivity. iv. Requires spring rings and other devices to make a tight

interproximal contacts v. Needs careful placement to make good anatomical detail to look

like natural teeth.

g. Orthodontics i. Conventional or Invisalign can give a straight and beautiful smile ii. Dental office should work with Orthodontist in diagnosis and

treatment plan, especially if restorative work will be needed to give the best result.

iii. Many patients require closing of spaces or repair of worn teeth after orthodontic treatment is finished.

4. What are the problems with aesthetic dentistry? a. Some patients have high expectations, sometimes higher than any dentist

can meet. b. Most aesthetic treatments have a higher failure than metal restorations. c. No aesthetic materials will last forever. They all will fail with time. Many

patients do not realize that they are not permanent. d. The rule is: Never over promise!

i. Bonding to Enamel and Dentin Bonding systems

1 Etch, Prime and Bond (Generation 4) (3 Step procedure) e. Always 2 or more bottles plus Blue etching gel f. Requires etching of enamel for 30 seconds and dentine for 15 seconds then

washing to remove all gel, gentle drying, then application of primer, then adhesive then cure.

g. Why use? Long history, good bond, difficult to abuse technique. h. Why not use? Multiple steps, etch, wash, dry. Tedious.

2 Etch, and combined Prime/Adhesive. (Generation 5) (2 Step procedure) a. Usually 1 bottle plus blue etching gel. b. Requires etching of enamel for 30 seconds and dentin for 15 seconds, then

washing to remove all gel, gentle drying then application of primer/adhesive, and cure.

c. Why use? Clinical history, good bond, easy to use. d. Why not use? Requires etching, careful placement of resin/adhesive,

reports of post-treatment sensitivity, may hydrolyze with time.

3 Self etching (no separate etch), (Generation 6, 7) (2 or 1 Step procedure) a. Can be 2 Bottles or a single bottle b. With 2 Bottle systems, apply the primer, then apply the adhesive, then cure,

or if directed, mix the two bottle materials, then apply. If a single bottle, apply for two 15 seconds applications, then gentle dry and cure. (Must remove any residual water in adhesive before curing)

c. Why use? Very simple to use. No separate etch. Very little, if any post treatment sensitivity.

d. Why Not Use? Some self-etch systems have not shown high bond strength, and weaken rapidly in water (new evidence of rapid hydrolyzing in dentin fluids.

4 Which bonding system has shown longest clinical success?

5 What is the most popular reason for using a self etching bonding system?

Direct Composite Bonding

1. Which composites look the most natural? a. Composites which (1) have good color with enamel like shades. (2) Will

polish to a high surface gloss and keep the shine for a long time. (Look like real enamel)

b. Which composites meet the above criteria?

i. New Micro-hybrids 1. Tetric Evo Ceram (Vivadent) 2. Esthet-X (Caulk) 3. Venus (Kulzer) 4. TPH3 (Caulk) 5. Premise (Kerr) 6. Four Seasons (Vivadent) 7. Vit-l-esense (Ultradent) 8. Gradia Direct (GC) 9. Estelite ∑ (Tokuyama/J. Morita)

ii. “Nano” composites 1. Filtek Supreme (3M)

iii. “Microfilled composites 1. Durafil (Kulzer) 2. Renamel Micro (Cosmodent)

2. Is there a best composite? a. Each composite has different shade or handling characteristics. Each of the

listed composites can give very aesthetic results. All require artistic application.

3. How do I choose a good composite?

a. Does the dentist want to be artistic or just fill a cavity or repair a broken tooth?

i. Artistic: Any of the listed composites can make beautiful restorations.

ii. Fill: Try Venus, TPH3, Premise, Gradia or Estelite.

4. Which Composite is best for my practice?

5. Does my practice want to produce the highest aesthetic restorations possible? If so what techniques will I use?

Porcelain Veneers, Porcelain inlays/Onlays

1. When are porcelain veneers indicated? a. When less aggressive treatment cannot be done or patient refuses b. When enamel is damaged or tooth arrangement is too sever for composite bonding c. When patients demand porcelain (dentist determines if they will treat)

2. When are porcelain veneers not indicated? a. When less aggressive treatment meets the aesthetic and physical dental needs. b. Cost. c. When bonding is questionable. Dentin margins may leak and stain, bonding to dentin may cause debonding of the veneer.

3. How much tooth should be removed?

a. Only as much as needed for the thickness of the porcelain veneer. Usually less than .5 mm. If too much is removed, dentin is exposed and bonding strength will be compromised. b. The lab quality determines the thickness of the veneer and the final appearance.

4. How do we temporize veneer preparations? a. No temporaries are best if the patient can tolerate the feel and appearance. Need to seat as soon as possible. b. The next best temporary is a removable stint. Use a vacuum stint with Bis-Acryl temporary material, remove just before it is completely set, then continue to try in and trim so that is will “snap on” without cement. The patient should treat it as a “smile only” temporary. c. Use the same type of temporary but with temporary cement. Patients should also know this is a “smile only” temporary.

6. How do we cement Veneers? a. Remove all temporary cement and clean prepared teeth with pumice and

either sodium hypochlorite or water. b. Try in veneers with only water. Test for fit and shade. c. If fit and shade are acceptable, dry veneers and place bonding agent on

inside of veneer. Thin but do not cure. d. Isolate teeth and prepare for bonding. Cure bonding agent. e. Place cement in a thin layer inside the veneer. f. Apply the veneer gently and with vibration onto the tooth. g. Continue vibrating pressure until the veneer is completely seated. h. Remove excess cement around margins with explorer and brush with

composite surface sealant. i. Hold veneer in place and cure for 40 to 60 seconds. j. Use #12 scalpel blade to remove excess cured resin. k. Try not to use high speed rotary finishing instruments.

7. When would we do porcelain inlays or onlays a. When the cavity or defect is too large for a direct filling b. When the patient wants porcelain looks.

8. When would we not do porcelain inlays or onlays. a. Where concern for bonding or sealing of margins on dentin. b. Where occlusal margins are in contact areas (margins are susceptible to

fracture in heavy bite. c. Where the bite is very heavy and can fracture the porcelain. d. Where cost is prohibitive. High lab cost.

9. What do the preparations look like? a. Like gold inlay, onlays except with slightly tapered walls, and rounded

internal angles. b. No sharp angles or parallel walls and no margin bevels c. At least 2 mm of occlusal clearance. Occlusal thickness of porcelain needs

to be at least 2mm thick. 10. How do we temporize the preparations?

a. Take pre-impressions for a mold, then use to fabricate a temporary inlay/onlay

11. How do we cement porcelain inlay/onlays a. Clean the teeth with pumice and sodium hypochlorite or water. b. Try the restorations in with water only (DO NOT CHECK BITE) Restorations

will break if occlusion is checked before cementing. c. Place bonding agent on inside of onlay, thin with air, cure. d. Place bonding agent on teeth, thin, cure. e. Place cement on inside of onlay. f. Seat onlay onto tooth with gentle, vibrating pressure. g. Continue seating with gentle pressure until seated completely. h. Clean margins with explorer and brush with composite surface sealant.. i. Cure, then clean excess cement with #12 scalpel blade.

Materials List Preparation 220 or 330 diamonds(Pedo) Brasseler, Axis, Premier, SS White,etc. 201.3 F, needle shaped-Premier Two Striper Fissurotomy –SS White Burs SmartPrep burs-SS White Burs Bonding agents 4th Generation ScotchBond MP—3M-ESPE Optibond FL—Kerr All Bond 2—Bisco AmalgamBond Plus—Parkell ProBond--Caulk 5th Generation Bond-It-Pentron PQ 1-Ultradent Single Bond-3M/ESPE One Step Plus-Bisco Excite-Ivoclar/Vivadent Prime and Bond NT-Dentsply/Caulk One Coat Bond—Coletene Whaledent Tenure-DenMat Gluma Comfort Bond-Heraeus Kulzer OptiBond SoloPlus-Kerr Bond 1—Pentron 6th, 7th Generation (Self Etch) Clearfill S E Bond—Kuraray Clearfil S3 ----Kuraray Prompt-L-Pop---3M ESPE Xeno IV---Dentsply Caulk i Bond—Heraeus Kulzer Touch&Bond- Parkell Optibond Solo Plus Self Etch—Kerr One Up Bond F-J Morita Tyrian Spe One Step—Bisco Nano Bond-Pentron Uni Bond—Den Mat

UniFil Bond---GC AdheSE---Ivoclar Vivadent G Bond---GC America All in One---Kerr

Matrices/Rings/Wedges Bitine Ring and segmental matrices Dentsply/Caulk Composi-tight Gold, Silver Plus Garrison Dental Solutions Wedge Wand-Garrison Dental Solutions Contact Matricies/Bands-Danville Materials Microbands-Dental Innovations/Vivadent Hawe Adapt sectional matrices--Kerr/Hawe Luciwedges—Kerr Hawe Sycamore wedges—Premier Dental Elastic margin seal----Danville Liners Vitrebond---3M ESPE Fuji Liner LC—GC Esthet-X Flow—Caulk Point 4 Flow—Kerr Star Flow-Danville Materials Filtek Flowable—3M ESPE Tetric Flow—Ivoclar Vivadent

Perma Flow—Ultradent Flow It—Pentron Instruments Heliomolar P1—Vivadent IPC, polished—Hu Friedy Amalgam condenser—Hu Friedy Contact Pro 1, 2—CDJ Products CompoRoller—Kerr Optra Sculpt Ivoclar Vivadent Composites Premise—Kerr Surefil—Caulk Alert-Pentron Heliomolar HB—Ivoclar Vivadent Esthet-X improved—Caulk Vit-l-esence—Ultradent Venus—Kulzer Simile—Pentron Supreme—3M ESPE Four Seasons---Ivoclar Vivadent Gradia Direct---GC Estelite E---J Morita Inc TPH3---Dentsply/Caulk Tetric EvoCeram---Ivoclar Vivadent Arteste-Pentron Ceram-X-Dentsply Caulk Finishing H274 016 Carbide finishing bur--Brasseler # 12 Scapel –Bard Parker, Hu Friedy, Miltex Soflex XT discs—3M ESPE Astropol—Ivoclar Vivadent Identoflex Diamond—Kerr PoGo-Caulk Jiffy Cups, Brushes—Ultradent Occlubrushes---Kerr

OptiDiscs---Kerr PDQ Comp Polishers—Axis Composite Polishers—Brasseler Composite Polishers and brushes—Clinicians Choice EpiTex polishing strips GC America Soflex polishing strips 3M ESPE Composite Surface Sealants Fortify—Bisco BisCover—Bisco PermaSeal—ultradent Optiguard—Kerr Gloss-N-Seal—Den Mat Protect-It—Pentron Bisco www.bisco.com

GC www.gcamerica.com

Axis www.axixdental.net

Brasseler www.brasselerusa.com Pentron Technologies www.pentron.com

3M ESPE www.3m.com/espe/ Kerr www.kerrdental.com

Garrison Dental Solutions www.garrisondental.com

Caulk www.caulk.com

SS White burs www.sswhiteburs.com

Microbands-Dental Innovations www.thinmatrix.com

Ivoclar Vivadent www.ivoclarvivadent.us.com

Ultradent www.ultradent.com

Contact Pro 1, 2 www.cejproducts.com

Heraeus Kulzer www.kulzer.com

Danville materials www.danvillematerials.com

Hu-Friedy www.hu-friedy.com Premier Dental Products www.premusa.com

Den Mat www.denmat.com

Parkell www.parkell.com James R. Dunn DDS 3180 Bell Rd. Ste. 100 Auburn, CA 95603 Ph 530 888 9764 Fx 530 889 9946 E-mail jrdunndds@.gmail.com Aesthetic Materials Handout 10 07

An Introduction to Digital Dental Photography

James R. Dunn DDS

Dental Digital Photography is still Photography! 1. Principles of Photography apply to dental photography Lighting-Most Important-quality, amount and direction

Use light to make subject appear most attractive Composition-frame and isolate subject you want to photograph Exclude unwanted or distracting items from the image.

Clarity-focus, depth of focus. Subject (all of subject) should be clear and sharp. Use large “f stop” for “long depth of field” -- Front to back focus.

Color-Accurate, natural tooth, gingiva, and skin color

Depends on Camera, computer, monitor, printer, software settings and capability. White balance, sensor quality, exposure.

(Resolution)-Number of pixels per image. Higher is better. Maximum need in dentistry? Minimum approx. 8 Mp, Above 12 Mp difficult to manage or use in dentistry. Sensor and pixel quality, wide tonal range, high dynamic range. (visit glossary at www.dpreview.com for explanations of terms)

Three Levels of Dental Digital Photography for dentistry 1. BASIC “Snapshots”, in-office, patient, Lab use Simplified camera equipment Simple image storage and organization Simple printing and presentations primarily with prints Snapshot portraits for patient identification

Auxiliaries take most photos

2. HIGH QUALITY-INTERMEDIATE marketing, web, portraits, diagnosis Modified point-and-shoot cameras and introductory SLR’s More sophisticated organization and manipulation image software Presentation and manipulation software (Power Point and Thumbs plus type software)

More sophisticated image quality, marketing quality On camera lighting, mirrors, contractors

Higher quality portraits using small size lighting equipment and backgrounds

Printing, higher quality, dye sublimation, copies to patients Dentist and/or highly trained auxiliaries take photos 3. ADVANCED artistic professional quality, marketing, presentations

High resolution SLR for majority of images, modified P & S for basic images Equipment and software to meet higher image quality expectations Image manipulation, enhancement, cropping, and corrections Artistic quality images-lighting control, multiple flash, mirrors, contrastors Patient photos organized in folders Diagnosis, Treatment planning-full mouth photo series Marketing with images-web sites, printed brochures Digital radiographs-photos of radiographs or direct digital Laboratory communications-prints, email, CD Experience of imaging and photographic dental art Specialty referrals-email or CD of photos to Doctors Presentations to patients, service, educational and professional

groups Glamour portraits-external lighting and backgrounds Accreditation, memberships, and presentations to high end dental organizations. Dentist usually takes majority of photos

Digital Photos in Dentistry

1. Photos for Dentist use. Used to visually record, document, share and communicate dental information to dentists, patients, laboratories, specialists, insurance, peers and the public. Diagnosis and treatment planning, lectures, publications, accreditations, competition. Use slide shows or Power Point..

3. Photos for Patients. Any view patients see in normal environment. Smiles-anterior, lateral, oblique, non-medical glamour, or attractive portraits, Can print or burn photos to CD. Best marketing dental photos.

Imaging Equipment

Cameras Modified consumer with PhotoMed flash/macro attachment. Adequate quality for dentistry. 7-8 Mega-Pixel cameras. Will not take one or two teeth, but adequate for portraits, smile, occlusal, quadrants. Canon, Fuji, Olympus and Nikon. $1,200-2,000. Lens and flash attached to camera, not changeable. Must use supplied close-up lens and flash diffuser for dental close-up photos. Can be used with one hand and by one person.

Imaging Equipment, cont’d…

Cameras-SLR-Professional or semi Professional camera bodies with 100mm macro lens and flash attached to the end of the lens. Similar to 35mm in use. Canon 30D, 40D, Canon Digital Rebel XTi, Nikon D40, Nikon D300 systems $2,500 to 4,000.US Very high quality. Heavy-bulky camera/lens. Canon, 5D, 1D Mark III, Nikon D300, Canon 1Ds Mark III-very high quality, very expensive. Bodies from $4,000-8,000 have a questionable need in dental use for highest end cameras. A macro lens and macro flash must be attached to the camera body to take dental images. Requires two hands and assistance. High image quality.

Image quality is determined by chip size, lack of chip artifacts and noise, pixel size, number of pixels, quality and power of the Analog to digital processor. The larger the chip, more pixels, larger pixels, and more powerful A-D processor will give higher quality images. SLR’s inherently give better images. JPEG files of high resolution adequate for dentistry (1-3 Mega bytes)-Will need to decrease size to email. RAW files need processing to a working file type (TIFF or JPEG). Discussion and differing opinions on need for RAW image files in dental imaging. High quality JPEG files are adequate and save processing time. RAW files required in AACD accreditation process.

Input\Output Devices

To transfer the image to a computer, the camera can be connected directly to a computer with a USB (or firewire) cable, or the camera’s memory card is placed in a card reader connected to the USB port of the computer. Other

input devices are Scanners, CD’s or DVD’s and the internet. Images can be transferred from the computer to viewing monitors, printers (ink jet, lasers or dye sublimation), the internet, or to external storage, CD’s and DVD’s.

Computers

A Computer with adequate RAM memory (1 gigabyte minimum), operating speed, hard drive capacity, CD and DVD writers, Ethernet or wireless connection is a necessity for managing digital images. It is recommended that dental images not be stored in the office management systems. An external hard drive is useful to store the large files digital images can create.

Software - Image Management software organizes and helps file the images into named folders. $50-$130 range. Thumbs Plus7 Pro Cerious software, ACDSee Pro 2, ACD software, Windows Explorer, Piscasa (Google).

Software - Image Manipulation allows alteration of the image (crop, rotate, color correction, etc.). Most dental images can be managed by inexpensive software.

Photoshop Elements 5 (inexpensive yet has many features needed by dentist) Photoshiop CS3 (powerful and expensive with many features not needed by dentist, used by professional photographers and graphic designers)

Software - Designed for Dentistry includes the ability to create predictive dentistry, commonly called “computer dentistry”. These programs also can integrate with associated dental management systems. Dental terminology is used in all image management. Most dental image management programs degrade or permanently compress the image quality. If you want to retain the original image quality, store the original images in separate organizing software. (windows explorer, Thumbs Plus, ACDSee Pro 2).

Software - Power Point--Microsoft Office presentation software is used to create patient diagnostic and treatment planning presentations, and presentations to other groups. Accessories

Sterilizable cheek retractors (metal, or plastic), front surface mirrors, contrastors (black tooth backgrounds) are needed for high quality intraoral images. External strobes, diffusers essential for high quality portraits.

Sources: In Southern California-www.photomed.net

External flash

Flash diffusers and a background are needed for portraits. (Canon has a flash system (430 EX and 580 EX series) for use with EX flash compatible digital cameras—G series and D SLRs.

Techniques: Workshops or individual mentoring best No detailed, technique books currently available. Diagnostic Series-number and view depends on dentist Smile-open lips Anterior View-retracted lips. Cheek retractors Occlusal-Maxillary and Mandibular. Cheek retractors, Occlusal contrastor and mirror, Quadrants-anterior or posterior-facial, lingual, Incisal\occlusal. Retractors, Contrastors, mirrors Portrait-(optional), X-Rays (optional).

AACD dental series required for accreditation (see www.aacd.com for guidelines and digital protocol))

Simplified Dental Portrait-New dental style portraits are more artistic than “medical” portraits. Requires external flash! 1. Lighting and background most important

2. External Flash with diffuser to soften light, reduce shadows, light bounced to ceiling to highlight hair. 3. Black, non-reflecting background fabric attached to a foam board or hanging from a wall or door. 4. Lap reflector. Brightens face by reducing shadows under nose and chin. White board or Collapsible spring fabric. Reflects light bounced from ceiling.

Modified Consumer (point and Shoot) Systems Canon G7, G9 with PhotoMed flash attachment.* (TTL Flash) with 7-10 MP 430 EX and 580 EX Canon Flash with Fong diffusers ST E2 Canon speedlite Transmitter *Ideal modified P&S for dentistry at the moment. (Earlier Canon “G” Series—Only a few available)

1. Light weight, Easy to use, 7 megapixal 2. Magnification: Portrait (without attachment) macro .to approximately 5 teeth. Uses zoom control for magnification selection. 3. Macro attachment gives soft, even light. 4. Video viewfinder-wide swivel-easy to see image from multiple positions. 5. Compact Flash Type I and II memory cards (to 1 qigabyte) 6 Allows off-camera TTL flash for portraits or small object photography.

Olympus C-5060 with PhotoMed flash attachment (TTL Flash)

1. Light weight, Easy to use, 5 megapixal 2. Magnification: Portrait (without attachment) to approximately 4 teeth macro. 3. Macro attachment gives soft, even light. 5. C F, Smart Media, and xD memory card compatibility 6. No accessory flash systems available 7. Must use in-camera TTL flash for portrait

Canon A620-640 with PhotoMed flash attachment

1. Light weight, Easy to use, 7 Megapixal2. Magnification: Portrait (without attachment) to approximately 4 teeth macro. 3. Macro flash attachment gives soft, even light. 4. Video viewfinder-wide swivel-easy to see image from multiple positions 5. S D and Multimedia memory card compatibility 6. No accessory flash systems available 7. Must use in-camera TTL flash for portrait

Fuji S9000 with PhotoMed Lighting attachment and Macro Lens

1. Between Point and Shoot and SLR 2. 10x Optical zoom lens-can preset lens for repeated same-size photos. 3. Uses standard batteries (can use rechargeable batteries) 4. No TTL flash hot shoe-must use on-camera flash for portraits

Kodak DX7590 kit Dentalfoto 80

1. Light weight, accessory flash system 2. Kit includes close-up lens, and easy share docking station for printing and transfer to computer. 3. Uses “digital zoom” for close-up macro 4. Uses “distance guides” for positioning camera to patient 1. Simplified lightweight camera 2. Kit uses add-on close-up lens. 3. Uses only in-camera flash

Canon SLR Semi-Pro Systems

EOS 30D* 40D (8.3 MP, 12 MP with new Digic II (III) A-D processor) with 100 mm macro lens and (1) MR 14EX Macro Ring Lite or (2) MT 24EX Macro Twin Lite with flash “diffusers” (Sigma “ring” flash for Canon now available) *at this time an ideal digital camera body for high quality, size and ease of use. Rebel XTi 10 MP good introduction SLR dental camera.

1. Moderate cost SLR digital body with high resolution and image sharpness. Can use all EOS lens and flash. 2. MR 14EX has 2-curved flash lamps, use both as a ring light and one (either right or left) as a near point system. Lighting effect similar to a ring light. 3. MT 24EX has 2-point lights controlled as separate or dual lights. Lighting effect similar to point source. Must be used with diffusers on flash head to light molars in occlusal views. 4. MR 14 EX and MT 24EX can be used with 430EXand 580 EX for multiple flash lighting.

430 EX and 580 EX Canon Speedlite Flash with Fong diffusers ST E2 Canon speedlite Transmitter

3. Allows off-camera TTL flash for portraits or small object photography. Can use multiple speedlites for studio lighting effect. Controls external Canon Speedlites in TTL mode without a speedlite attached to the EOS camera body.

Nikon Based SLR Semi-Pro Systems

Fuji S3 Pro with 105 Micro lens and Sigma 140DG macro “ring” flash TTL.

1. Built on Nikon N 80 film body 2. Fuji film electronics 3. 6.1 MP Super CCD sensor, 12.1 MB file 4. TTL flash with Sigma 140DG Macro Flash 5. Heavy, Uses multiple batteries 6. High resolution

Nikon D 40x with 105 Micro lens and Nikon R1 C1 flash (New Sigma EM 140DG macro “ring” flash only TTL flash with D50, D70) NEW! D80-10 MP Not yet tested

1. Built on Nikon N 80 film body 2. Manual flash exposure with Nikon SB 29s 3. 6.0 MP

SB 29s Nikon “ring” flash (Discontinued by Nikon)

1. TTL only with Fuji S2 Pro 2. 2-point lights-use both or one (L or R) 3. Flash can be removed from front of lens for portraits. 4. No Nikon external flash units for TTL multiple flash portrait or small object lighting.

SLR Professional Systems Canon EOS 1Ds Mk III (21 MP) (Full frame sensor) with 100 macro and MR 14EX Macro Ring Lite or MT 24EX Macro Twin Lite with diffusers (Canon EOS 1D Mark III—10 MP, 1.3 Mag. Ratio) Fong diffuser with 580 EX for portraits

1.Very expensive, heavy, high resolution (higher than film) (21MP), Professional color management 2. Full frame CMOS chip (No mag. Ratio) 2. Used very little in Dentistry because of cost

3. TTL Flash with Canon flash system

Canon EOS 5D (12 MP) (Full frame sensor) with 100 macro lens and MR 14 EX Macro Ring Lite or MT 24 EX Macro Twin Lite with diffusers Fong diffuser with 580 EX for portraits

1. Expensive, high resolution full 35mm size sensor, no magnification ratio. 2. Higher resolution than 30D, and slightly larger, lighter weight than 1Ds Mk II. 3. Very high quality image, and color accuracy.

Nikon D300 (12 M P) with 105 Micro lens and Nikon R1 flash, or Sigma macro 140DG “ring” flash

1. Heavy Magnesium body, 12 MP CCD Sensor 2. TTL flash exposure with R 1 flash 3. New 105 VR micro lens and R1 TTL twin flash just introduced.

(Pt. and shoot) vs. SLR in Dental Use. Modified Consumer (pt. and shoot) SLR (Semi-Pro)

1. Light weight, easy to use, high resolution, shallow dept of focus (f 8), lowest cost

2. Technique easily learned (few settings and details)

3. Use Video screen for viewing 4. Magnification controlled by

zoom 5. Limited image repeatability 6. Limited flash variability (except

Canon) 7. Non-interchangeable lens

1. Heavy, large, requires two hands to operate, highest resolution, good depth of focus (f 32), expensive

2. Technique more difficult (multiple settings and detail)

3. Uses view finder for viewing 4. Magnification set on lens 5. Easy image repeatability 6. Multiple flash options 7. Interchangeable lens

SLR Dental Cameras Lens and Accessory options. Lens: Portraits, groups, buildings, rooms, equipment, materials, articulators, casts, nature.

Wide Angle Zoom: 24-105mm for wide to moderate telephoto view. “high quality” Cameras with above 8 MP need the manufacturers higher quality lens. Designated as “L”, “ED”, or other symbols. Normal lens may not record

camera’s high resolution image Telephoto Zoom: 28-300mm, or 70-200mm. High quality, used for distance objects or magnification from a distance. Lens: Ultrawide zoom: 10-30mm, 16-35mm. Used to record rooms in office or any area where space is small or difficult to record. May distort perspective of image.

Lighting: portraits, groups, rooms, nature, table top, still life, nature.

External flash systems: Canon 580 EX, 430 EX. Can be wireless TTL controlled by external transmitter, or by a 580 EX on the camera set to master and the other flashes set to slave. Can use multiple flashes for artistic lighting. Used with diffusers for softer lighting. Nikon has near equivalent systems SB 800 AF and Su-4 Wireless remote. Nature close-up use dental configuration. Twin light gives more attractive lighting.

Lighting: Reflectors, Diffusers, Backgrounds:

Reflectors: reflect or absorb light. White or black foam board, collapsible white, silver or black cloth. Used in portraits to add light or fill shadows. Absorb excess light or give black background. Diffusers: Translucent material on flash or near subject to soften light and reduce shadows. Stofen Omi Bounce, Fong Diffuser. Translucent Collapsible cloth, Plastic. Backgrounds: Portraits (Google search on materials, colors patterns and lighting) Dental: Non reflective Black or White. Can use mirror with black background as 3-D effect for crowns or dental materials.

Point and Shoot Consumer Dental Cameras

Cameras: Use Dental point and Shoot cameras without the close-up attachment as multi use camera.

Sources: www.photomed.net Source for dental cameras, equipment, ancillary items, and indefinite support with purchase. ADA Technical report #1029 “Guide to Digital Dental Photography and Imaging” available at www. ada.org Wolfgang Bengel, Mastering Digital Dental Photography, Quintessence Books, 2006 Irfan Ahmd, Dental Photography, Quintessence Books, 2004 Robert Maher, Simple High Tech Case Presentation and Imaging elpaseodoc@msn.com Photographic Documentation and Evaluation in Cosmetic Dentistry a guide to Accreditation Photography, American Academy of Cosmetic Dentistry www.aacd.com Thomas K. Hedge, Digital Dentisry, www.dentalhealthcenter.com www.normankoren.com/Tutorials/. In depth source for mathematics of digital imaging. www.dpreview.com Very good single source for camera reviews and information on Digital Imaging www.kodak.com/US/en/digital/dlc/index.jhtml General information on Digital Imaging www.photomed.net Best source in Southern California for imaging systems and support www.dinecorp.com Dental camera systems www.clinpix-on-line.com Dental Camera Systems www.normancamera.com Dental Camera Systems www.xrite.com source for information on digital dental shade taking and color information www.luminous-landscape.com/ Broad source of Information about digital

photography (Various Dental/Medical Photographic supply companies sell high end digital camera equipment)

James R. Dunn DDS 3180 Bell Rd Ste 100 Auburn, CA 95603 Ph 530 888 9764 FAX 530 889 9946 E-mail jrdunndds@.gmail.com Dental Digital Photography 10 07