#7 – Routinely doing four handed chairside assisting | Dental Practice Coaching

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#7 – Routinely doing four handed chairside assisting

Before we start with procedures, let’s begin at the beginning- your client. Here are some tips when you
Meet/talk with a client
1. Let your smile build slowly after you make good eye contact and confirm the client preferred name.
2. Keep good eye contact, but break occasionally
3. Review the remarks section of the treatment sheet, what do they like to talk about.
4. Ask if the client has any questions about the treatment

Dental procedures chairside support for dentists
The most important early task you will accomplish is working with the doctor at the chair. When you have mastered these skills, you will have accomplished most of the skills of the average chairside assistant. We will review all the procedures that you will usually assist with, but first, review the pictures and practice your technique of instrument transfer. Make 3×5 card “cheat sheets” outlining the major steps in each procedure. Keep them in your pocket for quick reference.

You will be the “quarterback” of your team. Even though the EFDA has more training and experience than you, she is focused on clients and her schedule. During the times that you are not needed by your doctor, check everyone’s schedule and help both your dentist and EFDA to stay on schedule.

Try to standardize as much equipment and procedures as possible. This will make it easier for other assistants to take your place. Your chair should be 3″-4″ higher than the doctor’s. This allows you to see clearly.

Learn to anticipate what your dentist wants before he asks for it. Use the following skills to help.
1. Learn this section
2. Review each procedure with your dentist
3. Ask the dentist what he/she likes you to do
a) Should you or he/she pick up instruments from the tray
b) Will he/she tell you each step in advance until you’ve learned it?
c) Does your dentist want you with him at all times, or will he release you to stay caught up/ahead?
d) How much should you talk with the client? Any topics to avoid? (including the obvious: religion, sex, politics)
4. Take your printed schedule home with you the night before to review your procedures.
5. Have everything ready in each of your 2 treatment rooms before your first client.
6. Watch for non-verbal cues from doctors and clients.
7. Never apologize or get flustered. Do your best. What looks like a stupid mistake to you won’t mean anything to the client.

Infection Control
Our clients trust us but they are concerned about our sterilization/cleanliness procedures. One of
your primary responsibilities will be to show our clients how safe they are. Here is what you must
do:
1. Always wear gloves
2. Don’t wear gloves, masks, or protective eyewear in the reception room
3. When possible, open sterile packs in front of the client
4. Offer clients clean eye protection
5. Anything that goes in a client’s mouth (including x-rays) should be on a tray or a paper napkin – never on the counter
6. Never put x-rays in your pocket
7. Remove your gloves when you leave the operatory. Put them on again when you return.
8. Tell the client about our universal precautions, “sterilization procedures, and barrier protection while waiting for your dentist.

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EFDA                                     Date

Index of procedures by pages

A. Instrument transfer
B. Anesthetic syringe transfer
C. New client exam
D. Amalgam fillings
E. Plastic Fillings
F. Crown and bridge-preparation
G. Crown and bridge-seating
H. Post and core
I. Endodontics
J. Pulp capping – direct/indirect
K. Partial dentures-preparation
L. Partial dentures-framework try in
M. Partial dentures-seating
N. Complete dentures-exam
O. Complete dentures-impression appointment
P.TMJ exam
Q. Seat splint
R. Porcelain Inlay/Onlay
S. Implants
T. Porcelain Veneers
U. Oral Surgery
V. Dry socket
W. Repair of fractured porcelain on crowns
X. Maryland Etch bridge
Y. lasers
Z. Snore/Sleep Apnea
AA. Ergonomics
BB. Tips on docs
CC. Prophy’s
DD. Invisalign

The following pages will review each procedure in detail. However, first, learn how to hand your doctor instruments and receive instruments from him. The next section needs to be mastered as quickly as possible. Have other staff members help you practice.

A. Instrument transfer

Chairside 2 Instruments Functions

1. Cord Packer (Double Ended)- pack cord around gum margins during crown prep
2. DyCal instrument- place dycal during restorative procedure
3. Acorn Burnisher- (Double Ended)- adds anatomy to both amalgam and composite fillings
4. Spatula- mix contents
5. Amalgam Carrier- carry amalgam from amalgam well to mouth
6. Cotton Pliers- to pick up material: cord, wedges, articulating paper, etc.
a. Patient cotton forceps – used in the patient’s mouth (dirty)
b. Doctor cotton forceps – used by dr to pick up burs and instruments without needing to remove gloves (clean)
c. Assistant cotton forceps – used by asst to pick up supplies without needing to remove gloves (clean)

7. Cotton Forceps/Millers- hold articulating paper to check bite
8. Perio Probe- marked every 3mm-mark probing depth of pockets
9. Anterior Sickle Scaler (Double Ended)- clean front teeth of tartar or cement and helps remove temporary crowns
10. Posterior Sickle Scaler (Double Ended)- clean back teeth of tartar or cement and helps remove temporary crowns
11. Condensor (Double Ended)- packs amalgam or composite fillings – small & large
12. Spoon Excavator (Double Ended)- to lift temporaries or spoon decay out during restorative procedure
13. Spoon Endo Spoon (Double Ended)- helps remove decay during endo procedure
14. Explorer- to probe areas of teeth for decay or fractures
15. Mirror- to see all areas of teeth
16. Toffelmier- holds matrix band on while doing filling
17. – (large cleoid/discoid) carves amalgam fillings
18. Cleoid/Discoid carves amalgam fillings
19. Hollenback- carves amalgam fillings
a. Tharp carver – used to carve amalgam
20. Plastic Instrument (small)- to smooth composite on for anterior or facial fillings
21. Plastic Instrument (gold, slightly larger- double ended)
22. Amalgam Well- (2 different looks)- amalgam is placed after mixed and put into amalgam carrier
23. Syringe- holds anesthetic and needle to administer anesthetic
24. Scissors (crown and bridge)- used to cut cord and other material during procedure
25. Woodson/Glick- applies temporary filling/melts off and helps seal gutta percha during endo procedures
26. Spreader- condenses gutta percha in canal during endo procedure
27. Endo Explorer (Double Ended)- helps in finding canals during endo procedure
28. Millimeter Ruler- measures length of files during endo procedure
29. Mixing Pad- use to place gutta percha on and mix cement during endo procedure

B. Anesthetic Syringe Transfer

1. Pull back slightly on syringe to make sure harpoon is embedded in rubber stopper
2. Hand syringe to doctor behind client’s head with needle cover on
3. Hold onto the needle by the cover
4. The Doctor will take the syringe from you leaving the needle cap in your hand
5. Set the needle cap on the doc cart with the open end pointing the doc
6. The doc will recap the syringe

B. Retraction of tissues for improved vision

1. Doctor will take care of his side of client
2. You take care of facial surface of anterior and other side of tongue.
3. Primarily you will retract with your high speed suction
a. Rotate the bevel so the open side is beside the tooth
b. Use the air/water syringe in your other hand to blow air on the doctor’s mirror to keep water from ruining the doctor’s vision
c. When the doctor finishes cutting, blow air/water onto the tooth, rinsing it clean, then suction your client and let him swallow is s/he wishes
d. For maximum client suction, place the suction at the corner of the client’s mouth on the lingual side of the lower ridge. If you place the suction down the center of the throat, you will gag the client.

Anytime you are assisting, be sure to follow these rules.

1. Wash and glove before you sit down.
2. Keep the instruments covered with the bib until the client is seated. The sight of syringes, etc. can frighten some people.
3. Don’t hold syringes and other instruments up so the client can see them.
4. Always include the client in the conversation. It’s rude to talk to your doctor as though the client isn’t even there.
5. Never apologize for a mistake or, worse yet, excuse a mistake because you are “new”. Clients usually won’t notice a mistake unless you draw their attention to it. I like the joke: if you make a mistake, like sticking an instrument in a client’s ear, don’t say “whoops”, say “there.” It makes it seem like that’s exactly where you intended to put the instrument.
6. If you drop an instrument, leave it on the floor. You can always get another sterile one. Make sure your doc knows you dropped the instrument. Rather than announcing the dropped instrument to our client, your doc will usually communicate to you if he needs another replacement instrument.
7. As much as possible, stay with the client when s/he is in the operatory.

C. New Client Exam

*Be sure new client form has been filled out
1. Set up
a. New patient instrument pack
b. 1 Gauze (wet)
c. High and low speed suction tips
d. Patient bib
e. 1 air water syringe tip (doctor’s side)
f. Mirror, explorer
g. Perio probe

2. The assistant will take the folder and go out and greet the client in the reception room. The client will be escorted to the doctor’s private office or conference room where the doctor will get to know the client and review the medical/dental history. Be sure the medical/dental history form has been filled out. This portion of the exam will take about 15 minutes.

3. When the client is ready your doctor will escort the client to the treatment room you have selected. Once the client is seated and bibbed, the doctor will begin the oral exam. Read down the exam sheet with the doctor. If an item is ok, just put a dash beside it. If there is a problem, write it in detail. If your doctor forgets to say an item, remind him/her.

4. When the doctor gets to the point in the oral exam that he is going to ask you to chart oral conditions turn on your tape recorder. Continue recording until s/he has finished discussing treatment with your client. Later you can make sure you have charted correctly and written down all the doctor’s and client’s observations by reviewing the tape. If you are just learning, have an EFDA or one of the doctors review your charting with you by listening to the tape with you.

5. When this sheet is complete, the doctor will bring the client into an upright seating position and discuss the results in five broad categories:
a. Gums
b. Decay
c. TMJ
d. Bite
e. Oral Cancer Screening
Your job is to write down everything the doctor says and everything the client says on the yellow sheet. This is written in the Dentist report card.

6. When this is completed, the doctor may ask you to take a blood pressure, photograph, and/or a complete set of x rays – often this is done before the appointment.

7. When finished, client can be dismissed.
Dull explorers can be sharpened by punching them through fine sandpaper.

D. Amalgam Fillings

1. Set Up
a. Nitrous oxide and nose piece (optional) r. Client eye protection
b. High and low speed suction tips
c. 2 air water syringe tips
d. Patient bib
e. High and low speed handpieces
f. Syringe or wand (only use the wand for the lower arch with Dr. Smith)
g. Instruments
h. SE-bond drawer
i. Wiggle bug or amalgam mixer
j. Amalgam
k. Gauze
l. Topical
m. Paper towel on Doctor’s side with bur block open and laying on paper towel
n. Matrix band/holder
o. Wood wedges
p. Vasoline
q. Bite block (adult & small)

2. Small fillings can sometimes be done without an anesthetic (shot) particularly I fusing nitrous oxide.
Your doctor will make this decision.

3. Give the client a pair of safety glasses.

4. Doctor will place topical, adjust the nitrous oxide and anesthetize. (either lidocaine or articaine)

5. When the client is comfortable, the doctor will begin to cut the tooth using the high-speed handpiece.
You will use the high-speed suction in one hand and the air/water syringe in the other. Blow air on
the doctor’s mirror to keep water from obstructing his/her vision if he is working on an upper tooth. To
protect you and your doctor, keep splashes and spatter to a minimum by:
a. Proper positioning of the high speed suction
b. Proper positioning of the client

6. When the doctor stops, move your high-speed suction to the rear of the mouth at one side and suction out the excess water. Don’t push the suction straight back at the center of the throat. This will gag the client. By going to the corners, you can clear the water and avoid the gag.

7. Beginners often have trouble getting the water out of the client’s mouth. You can use the low speed suction rather than the airwater syringe. When your doc pauses in the preparation, use the low speed suction to remove the remaining water; you won’t suck up the tongue and cheek, but you wont’ be able to remove debris from the mouth like you could with the high speed suction.

8. Repeat this procedure until the doctor completes using the high speed and switches to the low speed
handpiece. Occasionally, the doctor may want you to continue suctioning to keep the soft tissue from getting caught in the low speed bur or to control saliva. Usually when the doctor is carefully removing the last of the decay this is your signal to start getting your materials ready to fill the tooth.

Your doctor will tell you which materials will be used. The sequence is always the same. Some materials will be skipped if the cavity is small. First, hand the doctor 1 2 cotton rolls to isolate the tooth from saliva.

1. If exposed nerve, the doctor will place sodium hypochlorite (an antibacterial) on cotton pellet on exposure for 3-4 minutes, then dycal – (Theracal) used to heal the exposure and reduce inflammation that can cause pain in the tooth. The doctor will place it in the tooth and light cure for 30 seconds. Then place a glass ionomer to seal in the dycal.
Mix the A and B primer bottles of SE Bond in a dappen dish. Hold each bottle about 1″ above the dappen dish and squeeze out 1 drop. If you let the bottle touch the dish, more than one drop will be pulled out. Once mixed, place for 15 seconds, dry lightly..

Matrix band Tofflemire If the decay involves a proximal as well as the top of the tooth, a -0015″matrix band will be needed. This is a metal band with holder that is adjustable to fit all sizes of teeth.
When putting the toffelmeyer together you bend the matrix in half, put the larger half of the matrix into slot vise and tighten outer nut. The guide channel opening slot will always go toward the gumline. The matrix band, when bent and inserted, will have a wide side and narrow side. The narrow side goes toward the neck or base of the crown of the tooth. Think of the shape of a back tooth. The band must fit the narrow part of the tooth next to the gums and then flare out near the biting surface. (See pictures in master manual). Once you have assembled the matrix band in the Tofflemire retainer, note the inside is coated to prevent the amalgam from sticking to the matrix band. , the doctor will slip it onto the tooth. If the matrix won’t fit between the teeth, give your dentist a metal lightning strip to open the contact. Next hand one or two wooden wedges held by a locking cotton forcep. The wedge will push the matrix tight against the side of the tooth to prevent silver filling from pushing out and filling the space between the teeth. If the wedge is too high it will crimp the matrix and ruin the proximal contour. Loosen the matrix band ¼ trun and burnish the matrix band with a spoon or burnisher to develop the correct proximal contour. Retighten the wedge if necessary. If the proximal space is too wide, place a second wedge beside the first. Use your mirror and look at the tooth next to the band – If you can see the gum tissue between the tooth and matrix band – you need to wedge better.
Now mix one drop of the SE Bond silver and black bottles. Don’t mix these in advance. It must be used within 5 minutes of mixing. They begin to chemically change as soon as they are mixed. An early mix allows them to partially set and the bond between the tooth and filling will be weakened.

2. Mix the amalgam as soon as the doctor applies the SE bond. Place an amalgam capsule in the amalgamator and push the white center button. The Wig l bug DS 80 will run for 7 seconds. Separate the capsule and place the amalgam in the amalgam well. Check the consistency of the amalgam. If it looks grainy and rough, throw it away. If it is too shiny, it is overmixed, but useable if you work quickly. We use Tytin a silver-copper-tin spherical allow. This blend requires less mercury (41-45%) and less trituration. If amalgam sticks to the capsule, it is overtrituated. Reduce time by two seconds. Crumbly amalgam is either undertriturated or didn’t have enough mercury. A well mixed amalgam looks glossy and then gets a matte finish within a few seconds. An amalgam that crumbles when placed in a carrier should be discarded. It has poor properties. Remember, mercury is a very toxic material. You can absorb it through your skin. 80% of the mercury you touch is retained in your body. To protect us, you will need to be very careful in handling mercury. Use these guidelines:
a. Use only amalgam capsules
b. Don’t heat the mercury
c. Close amalgam capsule after use
d. Store amalgam scraps
e. Clean accidental mercury spills immediately
f. Don’t dump amalgam scraps down the drain it pollutes our environment

3. Fill the amalgam carrier with amalgam by pushing the open end several times quickly into the mass of amalgam. Hand your doctor the amalgam with the open end pointed up so the amalgam won’t fall out. While the doctor places the amalgam, pick up the double-ended amalgam condenser. Now rotate back and forth: doctor hands you empty carrier, you hand doctor condenser, doctor condenses while you fill the carrier, then hand doctor the carrier while you hold condenser and continue this pattern until 1) The cavity is filled or 2) we run out of amalgam. Your dentist will start in the proximal box (least accessible area (distal) and move toward the Occlusal. Tytin is a spherical alloy. It doesn’t require heavy pressure to condense. Condense into the line angles using overlapping strokes.
a. Fill the proximal box up to the gingival floor first.
b. Loosen the matrix band and push the amalgam against the side of the band to ensure a tight contact.
When you hand the doctor the last carrier tell him there is no more. If doctor wants more, you will be told now. Start another capsule immediately. If too much time elapses between mixes, the first mix will begin to harden, causing a layering that may not allow the new amalgam to unite with the old. If this happens, the second mix will come off with the matrix band when it is removed and this means starting all over again. Occasionally, in large fillings, your dentist will ask for the whole pellet at once. He will carry it with cotton forceps. While he is condensing, be ready to mix another pellet. He will tell you if this is necessary.

4. Once the amalgam is condensed, take the condenser from the doctor and give your dentist the burnisher to finish condensing the amalgam. Your doctor will burnish 15-20 sec. over the occlusial. Make sure you keep about 1 mm of excess amalgam as you burnish. This brings the excess mercury to the surface where it is carved away. Turn the condenser sideways and form the initial anatomy on Occlusal surface as you burnish the amalgam. Your dentist will use different instruments to carve and finish the filling. One usual sequence begins with the carver next hand an exploring point to finish the marginal ridge. Keep the same height as the adjacent tooth. Now remove the wedge. Remove the band using fingers or cotton forceps by pulling laterally to break any seal with the Bond It. Use the exploring point to make sure there is no proximal overhang or flash on the sides or at the cervical. Avoid removing the contact area. When finished take the explorer and hand the floss to check contact and remove any overhang. Clear the matrix band with an explorer; keep the tip of the explorer on the band. Loosen and remove the Toffelmire, but leave the band. Begin carving with a Cleiod/Discoid.
a. Cut into the fossa and grooves with the cleiod and rest the side on tooth and carve toward and into the groove.
b. Cut the fossa with the discoid
If the floss goes through the contact well, rub up and down a few times and pull it through the proximal. If you pull it back up through the contact, you may lighten the contact too much. If the contact is open or you can’t get a smooth contact, have your doctor remove the filling and start over. When finished your doc may want the burnisher again, then take the floss and hand a cotton pellet on a cotton forcep to smooth out the filling. When finished place a piece of articulating paper on the forceps to check the bite. Place articulating paper on a cotton forcep. Your doctor never asks the client to “close”. S/he will fracture the amalgam. Say “relax your jaw and let me lightly tap your teeth together.” Hold the chin with your finger and thumb. If you feel the client using muscles to close, push down on the chin and warn about biting. Jiggle the chin up and down until it’s loose. Slowly guide the teeth together for a first contact. Make sure the end of the cotton forcep is at the end of the articulating paper. This prevents the paper from curling up when inserted into the client’s mouth. If the bite is “high” give your dentist a carving instrument, then the articulating paper again. If the amalgam gets too hard, your dentist will use the low speed to finish carving.

5. When this step is complete rinse/suction your client. Offer a hot towel. Then dismiss the client. Don’t throw the scrap amalgam away. It could contaminate our environment. Store the used amalgam in a sealed plastic container. This absorbs mercury vapor.
When you are doing primary teeth back to back, put one matrix band on the tooth with the widest proximal box. Place the wedge, and then condense the first amalgam. Next, switch the wedge to the other side and condense the second amalgam.
Due to recent press/TV coverage, many of our clients are worried about the mercury in silver fillings.

Here are some answers to frequent questions.
1. What are silver fillings made of?
Answer silver, tin, copper, and mercury. Mercury is 50% or less of the mixture.
2. Why use silver fillings?
Answer they are strong, quick to replace, relatively long lasting, and not too expensive.
3. Silver fillings have been used for 150 years.
4. Silver/Mercury works like plaster. The silver, copper, tin metal powders mix with the mercury liquid to form a hard mass.
5. When you chew, some mercury vapor is released. The amount is so small, that it is well within health limits established for mercury exposure by the federal government.
6. The problem isn’t the toxicity of the mercury. When it combines with the other metals, it is relatively inert. The problem is mercury allergy. A person can be allergic to anything. Only about one dozen cases of true mercury allergy have been recorded in the last 60 years. An allergist or dermatologist can run these sensitivity tests.
7. If your client has had fillings for many years, it would be virtually impossible for an allergy to be a problem.
8. Blood and urine tests can show if there is a mercury toxicity. These tests cost about $100.
9. Protect the office when using amalgam
a. Keep cover on amalgamator when mixing
b. Never let mercury touch your skin or gloves
c. Change masks after placing amalgams
d. Store amalgam scrap under fixer solution
e. Use clean up kit for mercury spills
f. Check out the information in the manual.

Polishing Amalgams

If the filling has been in the client’s mouth longer than 24 hours, the NuPro won’t work. Use this technique:
1. Dry the tooth, have client bite down on articulating paper and chew all around. The markings ideally should match the picture below. Don’t polish away these contacts!
2. Use a #7803 bullet shaped Midwest finishing bur in the low speed to work down on the edges (use an explorer to check these edges). Be careful not to ditch the margins between the tooth and filling.
3. If an overhang is present in the proximal, use the Profin system (or have a hygienist remove with a cavitron)
4. Use brown cups first
5. Use green cups to smooth
6. Have your client chew around on the articulating paper and show your doctor

In EFDA class you will be working on Typodonts and plastic teeth, which can be different than working on real teeth. Your instructors will help you. Be aware of how the teeth are chewed into the typodonts.

See Master Manual

E. Plastic Fillings / Direct Composite Veneers

1. Set up
a. Nitrous oxide and nose piece – Paper towel under bur block with bur
b. High and low speed suction tips block lid off
c. 2 air water syringe tips – 5 cotton rolls bent
d. patient bib – Dappen dish
e. High and low speed handpieces – Dycal
f. Syringe or wand (wand is used for lower arch with Dr. Smith) -Flowable – posterior
g. Instruments – Gradia
h. Curing light – Mylar strip with wood wedge (anterior)
i. SE Bond drawer – Articulating paper
j. Composite Material – Plastic cup for trash

2. Small fillings can sometimes be done without an anesthetic (shot) particularly if using Nitrous. Your doctor will make this decision. Pick the shade of composite while waiting for the dentist.

3. When the client is comfortable, put on your safety glasses, the doctor will begin to cut the tooth using the high-speed handpiece. You will use the high-speed suction in one hand and the air/water syringe in the other. Blow air on the doctor’s mirror to improve his vision if working in the upper arch.

4. When the doctor stops, move your high-speed suction to the rear of the mouth at one side and suction out the excess water. Don’t push the suction straight back at the center of the throat. This will gag the client. By going to the corners you can clear the water and avoid the gag.

5. Repeat this procedure until your doctor completes using the high speed and switches to the low speed handpiece. Occasionally, the doctor may want you to continue suctioning to keep the soft tissues from getting caught in the low speed burr or to control the saliva. Usually, you will be expected to use this time to get your materials ready to restore the tooth. The doctor will now tell you what is needed. Remember that speed is important.

6. Once all the decay is removed, your doctor will probably use the diamond burs to create a bevel to improve the composite’s retention.

7. Exposure: put sodium hypochlorite on a pellet of cotton. Cotton roll to isolate the tooth. Your dentist will place the pellet over the exposure to kill the bacteria at the exposure site for 1 minute. Next he will apply Theracal to cover the exposed nerve. Give your dentist a dycal instrument. Once the calcium hydroxide is placed use a curing light to harden it for 15 seconds. Next, express one drop of SE Bond A and B in a dappen dish and hold the dish in front of the client while handing your dentist a disposable brush. After several coats and 30 seconds, the dentist will lightly air dry the tooth for 2-3 seconds. Your dentist will place the plastic matrix (anterior) or Toffelmire (posterior).

8. Put 1 drop resin (black bottle) in the dappen dish and hand the brush to your dentist. Hold out the dappen dish. Once applied, cure the resin for 10 seconds.

9. Place the amount of composite you believe is enough for the fillings on the dappen dish and cover it when not in use. Give your dentist a composite instrument and he will apply the composite with a double-ended plastic instrument with you hardening each layer for 20 seconds. For direct veneers Dr. will roughen the surface and smooth composite over the front of tooth, light cure and add more composite as needed.

10. When the doctor has completely filled the cavity, you can begin some cleanup. You won’t be needed unless more plastic needs to be placed and hardened. The Doctor will use ET burrs, and/or rubber polishers/polishing paste to finish the restoration.

11. Once the final shape is finished, your dentist will dry the tooth and apply one last coat of unfilled resin from the dappen dish you already have, and then cure for 10 seconds.

12. Finally your dentist will place a final polish with Pogos and polish paste.

13. Give client a final rinse and a hot towel.

14. Dismiss the client.

F. Crown and Bridge Preparation

Impression single crowns, three unit bridges, or 2 single crown preps.

1. Seat the client, place the topical anesthetic, and paint adhesive on 2 impression trays for final impression. Get impression trays ready. One extra impression tray for preliminary impression.
2. Doctor injects anesthesia, mixes the alginate impression material, and seats the impression tray in the clients mouth for 2 minutes.
3. If the tooth has an old crown your dentist will section it into two pieces using the used carbide and diamond burs. Then he will use the crown remover to wedge the two halves apart and finally use a spoon to lift the two halves out.
4. The tooth is prepared with diamond burs while you suction. Occasionally an existing crown will need to be removed. When the crown is cut off, place it in a smaller envelope and give it to our client. The client will mail it in and receive some money for the gold.
5. The doctor will place temporary crown resin in the prepared tooth portion of the impression and place the tray in the client’s mouth. You will time for two minutes and then remove. If the temporary crown remains on the tooth rather than coming out with the impression, carefully remove it from the tooth with an exploring point. If the impression tray is left in the mouth longer than 3 minutes, the acrylic may harden and lock on the tooth. If this happens, your dentist will have to cut the acrylic temporary out of your client’s mouth – wasting time and making a big mess. Your dentist will be very unhappy. If you need to remove the acrylic temporary from your client’s mouth (stayed on the tooth when you removed the impression at 3 minutes), be very careful. Slightly lift one side, then go to the other side and slightly lift that side. Work very slowly back and forth. If you just pull it off, it will warp and won’t fit onto the tooth.
6. Your doctor will pack the retraction cord (usually 1 layer of small cord, followed by a larger cord) if needed, fill out the treatment record and lab sheet and make shade selections. Allow the cord to stop the bleeding and push the gums away from the prepared margins of the tooth for 4 minutes.
7. After 4 minutes, the doctor will remove the cord useing the air/water syringe to rinse the tooth while you suction. You will mix and load the triple tray. Don’t overload the tray. One coat over the mesh is enough on each side), your dentist will inject a small amount of light material to make sure its well mixed and then inject light impression material around the tooth twice without stopping or lifting the tip away from the tooth. After he covers the tooth, he will place the tray. Have the client bite and hold for 4 ½ minutes with a fist under the chin and elbow resting on the chair arm. Give a paper towel in case of slobbers.
8. Remove the impression after 5 minutes. Don’t use the handle to remove the impression. Pull away with fingers on the facial and lingual. Evaluate the impression:
A. enough impression material
B. no voids or ripples on margins
C. no try shows through
Show the result to your dentist. If not good, he will make another impression. If the impression is good,
spray it with Biocide and place it in a plastic bag.
9. Make a second impression yourself to use as a lab control. Follow the same impression steps as above.
10. Now take the shade (see master manual for how to use the Vitashade guide and also use the x-rite shade system) and make the temporary crown.
11. Finally, the temporary crown will be seated with temporary cement. You can cleanup, rinse, and dismiss your client. You can also give the client a sample of fixodent in case the temp comes off before they return in to have it seated.

Seating Implant Crowns
1.Setup
a. Lab case with final abutment screwed into working cast with the retaining screw (permanent crown in separate lab box) and the impression coping (place in a sterilization bag and sterilize for reuse). You should have already checked the crowns for shade, contours, anatomy and occlusion.
b. C&B setup to seat crown
c. x-ray
d. digital, intraoral camera
e. articulating paper

2.Procedure
a) dentist will remove the temporary crown, verify abutment screw at 35 Ncm
b) try on the final crown
c) check occlusion-adjust as needed and polish
preliminary steps if needed:
1. remove healing cap
2. remove abutment from lab model
3. attach abutment to implant-tighten to 35 Ncm
d) take x-ray (if space present, redo these stops and take a new x-ray
e) seat crown with Rely-X
f) remove excess
g) take final pictures
h) recheck occlusion

When finished, unscrew the laboratory analog, which is an exact replica of the final abutment, from the working model and place the analog in the sterilization bag with the impression coping for reuse, tentatively setup one month recall

G. Seating crowns

1. Relay-X is our dual cured resin cement used for E-Max, metal and porcelain crowns.
2. For Zirconia crowns, apply Primer to interior of crown to increase bond strength: 1 layer, wait 30 seconds, air dry, apply a second coat, wait 30 seconds and air dry.
3. Isolate and dry the tooth.
4. For Zirconia crowns
5. Coat inside of crown with Rely-X
6. Seat crown and while holding in place, remove excess with 2×2 on facial and floss
7. Support crown and light cure for 1-2 seconds on facial and lingual.
8. Support crown and dentist will remove all excess
9. final cure 20 seconds facial and lingual

Seating zirconia crowns

1. If crown has little retention, sand blast interior. If crown is retentive skip this step. These crowns are hard to remove.
2. Rinse with air/water spray and dry interior and use Ivoclean
a. Shake bottle
b. Coat interior of crown with Ivoclean on brush
c. Wait 20 seconds
3. Rinse dry inside of crown
4. Isolate tooth and dry
5. Place Z-Prime for 30 seconds, air dry, 2nd coat Z-Prime, wait 30 seconds, air dry
6. Apply coating of Rely-X inside crown and give to doctor to seat
7. Support crown while doctor removes most of excess
8. 3 second light cure facial and lingual
9. Doctor will carefully remove excess while you support crown
10. Light cure 25 seconds facial and lingual
11. Doctor will remove any remaining excess

H. Post and Core

Teeth that have had root canals are often so badly broken down that there’s not enough tooth to keep the crown on. Your doctor will reinforce the tooth and add enough structure to support the crown by using a post and core. Doctor will use the Gates Glidden (2,3, & 4 stripe) on the straight sleeve with a latch type contra angle to remove some of the root canal seal and make room for the post. Next, the Dentatus or para post kit (in gray drawer) will be used. S/he will use the drill to complete the shape of the chamber. While the doctor is shaping the stainless steel post, you can get the Rely-X and composite ready. Dry the tooth. Sand blast post. Etch for 15 seconds then Doctor will rinse the tooth. Next, the doctor will dry the chamber with endodontic absorbent points. Put Rely-X on the special mixing pad. Also, get out composite and a curing light. Mix the Rely-X (for 30 seconds) and hold the spatula out to your doctor. Doctor will coat the post from your spatula and seat the post.

Doctor will place the band around the tooth and it will be filled with composite. While this hardens, all this set up can be cleared away and the crown and bridge materials set up.

I. Endodontic Appointment

1. Lay out all dentist and assistant’s equipment and materials following the picture on the next page.

2. Seat the client, start a movie, place topical anesthetic, and offer N2O.

3. Doctor will enter; inject Septocaine for maxillary teeth and anterior mandibular teeth; or Lidocaine for mandibular blocks. This will be followed by Maracaine, which adds 1-2 hours to the numbness. The first couple hours after the anesthetic wears off are the most uncomfortable, so extending this anesthetic significantly reduces the client’s post appointment discomfort.

4. Doctor will shorten the tooth (if a posterior tooth) with a high speed handpiece and diamond bur. Next, the tooth will be opened to expose the diseased pulp chamber with a round bur. You suction during this procedure. Finally, Dr. Pierson will use a diamond orifice opener to flare the opening of the canal to make it easier to use the automated files.

5. Now the doctor will place the rubber dam. You will often be asked to help by supporting the rubber dam while the doctor places the rubber dam clamp onto the tooth.

6. Remove the blue tray from assistant cart. Open the sterile preparation instrument set up and place the instruments on sterile autoclaved towel used to wrap the instruments. Your dentist will choose a file box to open based on the length of the tooth. Dip the end of a cotton roll into the cup ¼ full of sodium hypochlorite (diluted 10:1 with water) and rub a 2″ circle of rubber dam around the tooth and clamp to sterilize the work area.

7. The doctor will now locate the canals and fill the chamber with EDTA to dissolve any tissue remnants and soften the canal walls. He will place a file in each of the canals using the sonar to determine length. (See master manual for maintenance and trouble shooting) Dr. Pierson prefers to use the automated endo system now and then take the x-ray. Dr. Smith will take the x-ray with the files in place. Never place any sterile instrument anywhere except on the sterile towel and never place a non-sterile instrument on the towel. Now be ready for a periapical x ray with lead apron and thyroid protector. Process the x-ray.

8. The doctor will confirm the length of the canal(s) using the x-ray and will begin using the automated files to open the canal(s). Dr. Pierson will have you set the working length of files. All files have the same working length for one canal but, other canals may have a different working length. Dr.Smith and Dr. Scharnhorst will set his own files. Place syringe 1/3 filled with bleach next to your sterile towel. Your dentist will rinse out the EDTA and then fill the chamber with sodium hypochlorite to kill any bacteria in the canal. As doctor (Pierson) begins filing you can set the length of each set of files at working distance. Be sure not to touch the working end of the file. This possible contamination could lead to a contaminated tooth, which can be very painful to our client. Place 3 medium fine gutta percha points in the sodium hypochlorite for each canal that will be sealed. For Dr. Smith you can leave while he files the canals and fits the sealing gutta percha points. You can catch up on your other duties, but stay within hearing distance if Dr.Smith needs you.

9. When the doctor has finished filing, rinse the canals with anesthetic to remove NaHCl which would interfere with the sealer.

10. Now open the sealing pack and lay this sterile towel on top of the preparation instruments. Spread out the instruments on top of the preparation pack. Remove the cotton forceps and mirror from the open preparation pack and add them to the sealing set up.

11. Doctor will fit an initial sized gutta percha point in each canal to within one millimeter of the tip of the root end. Occasionally, your dentist may take an x-ray to confirm the gutta percha is positioned correctly.

12. Paper points, (small rolled blotting paper points shaped like gutta percha points), are used to dry the canals.
a. Open a sealed pack half way.
b. Fold back the cardboard side half way.
c. Be careful not to bend the paper points that will now be standing out of the pack.
d. Give your doctor a cotton forcep and hold the packet of points out so the doctor can remove one with the forcep.
e. Hold a 2 x 2 gauze pad in your other hand to receive the paper point when it is removed from the canal. If there is any bleeding, the doctor will dip the paper point in Viscostat and repeat until the bleeding is stopped.

13. Remove medium – fine gutta percha points from the sodium hypochorite and lay them out in a row on your sterile drape next to the sized gutta percha point that will seal the canal.

14. The sealing sequence is very much like placing an amalgam.
a. Your dentist has chosen the correct size gutta percha point. The doctor will tell you this length. Pick up the gutta percha point from the large end with the sterile cotton forceps. Put the gutta percha point at the “0” end of the metal millimeter ruler and hold it in place with your thumb. Move the tip to the correct length and grab it next to the end of the ruler with the forceps with the measured end to the outside of the forcep tip. Dip the gutta percha point in sodium hypochlorite to sterilize for 5-10 seconds.
b. Cover with the AH26 cement paste
c. Dr. will coat a hand file with cement to the coat the canal
d. Hand the doctor the sealing gutta percha point. He places it in the canal.
e. Take the cotton forceps from the doctor
f. Hand him the endo spreader. Next pick up a medium fine gutta percha point about 4 5 mm from the large end
g. Dr. prefers that you soften the medium fine GP points in eucalyptol for 3 seconds before handing them to him.
h. Receive the spreader from the doctor
i. Hand the next prepared gutta percha.
j. Receive the spreader and wipe the cement off the spreader
k. Repeat these steps with a third gutta percha point if needed.
l. Normally, 2-3 auxillary medium-fine gutta percha points will be used in each canal.

15. After the last gutta percha is placed in a canal (The doctor will tell you if more than 3 will be
needed.) Take an x-ray to check the seal. If the seal is good, heat the plugger by placing the tip of the condenser end into the tip of the flame for 5 seconds. Hand this to your doctor who will sear off the excess gutta percha.

16. If the x-ray shows the seal is not correct, your dentist will pull out the GP and re-prepare the canal to the new length and repeat the sealing sequence.

17. Then you dampen a cotton pellet with water to remove excess cement from inside of the tooth

18. Next, pass a small dry cotton pellet that is packed into the canal followed by a small piece of cavit on the end of the glick to fill the space temporarily.

19. Every root canal is different and the doctor may change the procedure several times throughout the root canal. Make sure your instruments are organized and ready to be used at any time.

Dismiss client
a. Make sure you have entered the treatment in the computer and on the yellow sheet. Don’t wait until now to enter the treatment. While the doctor is filling the canals is the best time to confirm the number of canals and that your doctor is planning to complete the treatment – in very difficult cases, the dentist will not be able to complete treatment and the client will be referred to a specialist (no fee is charged when this happens).
b. Dismiss your client. Tell the front desk if any medications are needed and what future appointment is needed.

J. Pulp Capping

If the filling to be placed is close to the nerve, a direct or indirect pulp cap will be necessary. Only pulpal exposures are considered a direct pulp cap. The goal of this is to seal promote pulpal healing, seal dentin surrounding the pulp and prevent sensitivity.

Theracal is considered a resin modified calcium silicate. It is a light-cured, resin-based, radiopaque liner that can activate the pulp to lay down hard tissue to create a distance from the new filling.

If there is a direct exposure of the nerve, the doctor will place sodium hypochlorite (antibacterial) on a cotton pellet on the exposure for 3-4 minutes. All bleeding must be stopped prior to placement. Once the bleeding has stopped, theracal is placed in no thicker than 1 mm increments and light cured for 20 seconds. Occasionally, your doctor may request for chlorhexidine to disinfect the area prior to placing the theracal. The procedure is the same for direct pulp capping minus sodium hypochlorite placement.

K. Partial Denture – preparation

1. Seat the client. Usually an anesthetic won’t be necessary.

2. Your doctor will study the clients’ diagnostic models and prepare the teeth using the diamond and carbide
burs. You will suction. Your dentist will choose the appropriate burs.

3. Once the teeth are prepared, the doctor will pick his alginate impression trays and make the impression.
You can pour this impression and place it in the plastic humidor. We will use the opposing model used
to diagnose.

4. You or the doctor will take a facebow, shade selection, and a white wax bite.

5. The client can be dismissed.

L. Partial Denture framework try in

1. Seat the client. Have high speed handpiece and 3 prong pliers in unopened pouches if needed.

2. When the doctor arrives, you won’t be needed for this appointment. The doctor will fit the metal
framework and check to make sure the client’s bite is correct.

3. If the framework doesn’t fit, then a new alginate impression must be made and everything starts over.

4. If the bite on the models is not the same as in the clients mouth, new bite records, will be taken.

5. The bite, the shade and the shape of the teeth are again checked. Adjustments are made as necessary.
When the doctor and client are satisfied, the client is dismissed.

M. Partial Denture Seating

1. Client is seated, when doctor arrives you won’t be needed.
2. Doctor will adjust the fit and bite.

3. When client and doctor are satisfied, client can be dismissed.

N. Complete Denture Exam Appointment

1. The assistant will greet the client in the reception room and bring him/her to the private office to get a
complete medical and dental history for clients without teeth.

2. The assistant will bring the client to the operatory and seat him/her. Next you will read down the check
list for a client denture exam and record your doctor’s comments.

3. Now the doctor will discuss the treatment and quote a fee. Dr. Pierson may want preliminary alginate
impressions.

4. Dismiss the Client

O. Complete Dentures impression appointment

1. Seat the client. When the doctor arrives you can work on other tasks. Check back every 10-15 minutes to see if you are needed to rinse client or clean up impression materials.

2. The doctor will make the final impressions with Viscogel in the client’s existing dentures and discuss the
esthetics of the dentures.
a. Your doctor will now take the face bow and Occlusal records
b. Pour impressions in slurry water. This speeds the set of the stone.
c. Place in humidor. Place a wet paper towel next to the impression to add moisture during hardening
for increased accuracy.

3. After the stone hardens, the doctor will mount the casts.

4. When Dr. and patient have decided on appearance and bite of teeth you can dismiss client, and send case to lab. Reschedule patient for 7 days out.

WAX DENTURE ESTHETIC TRY IN APPOINTMENT
1. To confirm esthetics and mounting, pink wax, and torch will be needed.
2. You will not be needed.
3. If allok, send back to the lab
SEAT
1. Have bite paper, PIP (Pressure Indicating Paste), Straight sleeve and denture bur ready.
2. You will not be needed. (1/2 hour).

P. TMJ Exam

*LOCATED IN RED FOLDERS IN FILE CABINET*

1. Set up the conference room with the client’s folder, an orthopedic pillow, and a full set of client TMJ handouts.
b. clicking
c. sleep
d. clench/grind (stress)
e. tension
f. upper splint
g. pillows
h. 2 “observation on the TMJ” with carbon on clipboard. TMJ report
i. Limited opening
j. TMJ tx presentation
k. TMJ exercises
l. Snoring questionnaire
m. Sleep Apena brochure
2. Greet the client in the reception room and escort him/her to the conference room

3. Set up a treatment room with mirror, explorer, stethoscope, and plastic mm ruler.

4. When the consultation is finished, the doctor will complete an oral exam by him/herself.
When the exam is finished, the doctor will return the client to the consultation room.

5. To keep your doctor on schedule interrupt their discussion with 5 minutes to go in the appointment to let him know his next client is waiting.

Q. Seat Splint

1. Seat the client.
2. The EFDA will adjust the splint so it is retentive, comfortable, and the bite is ok.
3. Go into the lab and fill the pressure cooker 2 inches full of hot water.
4. Let Dr. know you are ready for him.
5. The doctor will add acrylic to the splint and have the patient close in centric bite. Dr. Smith will remove the splint, take it to the lab and place it in the pressure pot.
6. Have 2 half full glasses of water and napkins ready for the patient to rinse.
7. The EFDA will remove the splint in 5 minutes, finish the bite, and then polish the splint.
8. The EFDA will then alert the dentist that she is ready to have the splint checked.
9. Box up the patients models and put them and a blue retainer case in a to go bag for the patient to take home with their “upper orthopedic appliance” and “post splint instructions” Hand outs.
10. Dismiss client and tell secretary to give chart to Dr. Smith in 1 week to call.

R. Porcelain Inlay/Onlay Indications

Indications
1. Destroys less tooth than full crowns
2. Client wants no metal
3. EMax is most beautiful restoration
4. Less chance of gum disease since margins are above gums in most areas
5. EMax can be shaded for close match to adjacent teeth
6. Strengthen weak tooth
7. Low wear compared to composite

Contraindications
1. Subgingival margins can lead to micro leakage
2. Insurance may not cover.
3. Much more expensive than composite

Tooth Preparation
1. Triple tray alginate for temp.
2. Cavo surface butt joints all surfaces supragingival margins
3. Rounded internal line angles
4. Wedge prox. before prep
5. Occlusal reduction 2 mm, then 1 mm on 4 sides
6. Remove decay and weakened enamel
7. Buccal and lingual butt joint
8. Proximal butt or deep chamfer sides
9. Occlusal margins shouldn’t end on contact

Select shade look mainly at center 1/3

Temporary
1. Acrylic
2. Non eugenol cement (Nogenol)

Try in and Adjustment
1. Be careful! Weak until bonded
2. Fit onto die to check fit
3. Make sure all temp off before try in EMax (could fracture)
4. Client not to bite on it until finished
5. Use floss to check contacts
6. Seat with Rely-X – standard technique (see crowns)

S. Implants

I. Implant Exam
At this appointment, the dentist will evaluate the potential implant site and discuss the treatment potential for success, fees, etc.
1. Setup
a) Alginate, metal impression trays, 2 spatulas, 2 rubber bowls
b) Forms- “implant dentistry”, “implant evaluation”, “implant clinical exam”
c) Mirror, exploring point, perioprobe
d) mm ruler

2. Procedure
a) ¾ hour with assistant
1. diagnostic models, facebow
2. necessary x-rays (usually Pano and Periapical of area)
3. pictures (full arch, smile, area to restore)
b) 15 min- dentist initial conference
1. review medical, dental history
2. client expectations
c) 15 min-dentist will fill out “Implant Clinical Exam” form
d) at the finish of this appointment, the dentist will either:
1. present the case using the “Implant Denistry” brochure
2. have the client return for a formal case presentation
e) when the consult is complete, refer the client for a surgical consult
f) consult with surgeon
1. “type of implant”-length, width, angulation, platform, covering, custom or stock

II. Surgical Placement

Implants are titanium tapered posts placed in the bone to act as root support for replacement crowns. Once the implant is placed, the client has 2 choices:
1. Immediately place the implant
2. Wait about 3 months for the implant to integrate into the bone. Unless the client is adamant, it is better to wait the 3 months (survival rate is higher and esthetic result is better).
At HP Dr. Hamal surgically places implants, while all our general dentists restore the implants.
C. Surgical Implant Placement – In house.

1. Setup

a) Anesthetic / rinse with Listerine
b) Mouth prop
c) Have stent to use if available
d) Incision (flap or window) #12 / #15 blades
e) Implant kit (maestro) sequence of drills and implant motor
f) PA x-ray to confirm angulation
g) Final placement of implant fixture (body) is the portion placed in the bone. These titanium implants vary in length, width, coating, thread design, and taper. Other parts of the implant are:
1. hex-top part of implant visible in the client’s mouth when the healing cap is removed
2. canal- space in the center of the implant
– seat flipper if requested from our general dentists to be worn until healing complete

2. Procedure

a) client anesthetized
b) incision made in gums and tissue retracted to expose surgical site
c) hole is drilled in the bone- have 3 people at different angles evaluate placement: surgeon, assistant opposite side, third person front
d) implant screwed into this hole
e) suture tissue over implant
f) tell client to expect mild/moderate discomfort for only few days

III Implant Integration Evaluation Appointment (maxilla 4-6 months, mandible 2-3 months)

After the implant is successfully osseointegrated into the bone, Dr. Hamal will bring the client back and check this integration, usually and with an x-ray
If the implant looks good, the doctor will screw a healing cap onto the implant and allow the gums to heal for another 3 weeks.

1. Setup
a. mirror, explore
b. short needle, septocaine
c. healing abutment
2. Procedure
a. take an x-ray, anesthetize
b. screw on a healing abutment cap to allow the tissue to heal in an ideal shape or later restoration. This also prevents bone or gums healing over the area to be restored

IV Impression Appointment (4-6 weeks after healing cap placed)
1. Setup
a. implant drawer (screw drivers)
b. transfer coping- must be the exact size to fit the implant- may need to be ordered in advance (info from surgeon), dentist will tell you whether pick up or transfer coping needed
c. stock trays (2)
d. C&B impression material
e. C&B temporary materials, shade guide
f. Temporary abutment

2. Procedure
a) no anesthesia is necessary
b) unscrew the retaining screw and remove the healing cap (tissue should be pink and healthy, if not healthy, will need to reappoint)
c) seat the transfer coping quickly so tissue won’t collapse over implant. With multiple implants, remove most difficult healing cap and seat that coping, then go to each of the others. (2 types)
1. closed tray (coping locked on fitted into impression and comes out in the impression wear the impression is removed
2. open tray (retaining screw removed and pick up coping comes out in the impression and is then inserted back into the impress out of the mouth) This requires cutting a hole in the impression tray to be able to unscrews and release the transfer coping. This opening will be checked for accuracy before taking the impression. If there is an interference, move tray until the tray fits exactly with no interference with the coping
d) tighten retaining screw with hand held screw drivers. Don’t lose the healing caps (they are very small!) Place in a box on a piece of autoclave tape, buccal margin should be ½ mm subgingival. Next, take an x-ray to make sure coping is in the correct place. Space between the implant and the transfer coping means an incorrect seat..If any question, take a second x-ray. If all OK, place some wax over screw hole in coping. If this occurs, your doctor will unscrew the coping, reposition it, and then screw it into position and take another x-ray.
e) take the final full arch impression using standard C&B technique. Your dentist will syringe the light material as you fill the tray with heavy body. Put your finger over the opening (open tray technique) to keep material from leaking out.
f) remove the impression, seat the transfer coping(s) if using an open technique
g) place the laboratory analogs into the transfer copings
h) replace the healing cap or
i) make a temporary cap (ideal to wear 4-6 weeks)
1. seat temporary coping on abutment
2. fill impression tray with composite
3. seatl impression tray
4. remove tray, remove temporary, finish (form promotes gingival growth)
5. seat with temporary cement
impression
bite registration (if used)
retaining screw
laboratory prescription

T. Seating Implant Crowns

1.Setup
f. Lab case with final abutment screwed into working cast with the retaining screw (permanent crown in separate lab box) and the impression coping (place in a sterilization bag and sterilize for reuse). You should have already checked the crowns for shade, contours, anatomy and occlusion.
g. C&B setup to seat crown
h. x-ray
i. digital, intraoral camera
j. articulating paper
2.Procedure
a) dentist will remove the temporary crown, verify abutment screw at 35 Ncm
b) try on the final crown
c) check occlusion-adjust as needed and polish
preliminary steps if needed:
4. remove healing cap
5. remove abutment from lab model
6. attach abutment to implant-tighten to 35 Ncm
d) take x-ray (if space present, redo these stops and take a new x-ray
e) seat crown with Rely-X
f) remove excess
g) take final pictures
h) recheck occlusion

When finished, unscrew the laboratory analog, which is an exact replica of the final abutment, from the working model and place the analog in the sterilization bag with the impression coping for reuse, tentatively setup one month recall

U. Veneers

A. Indications
1. Destroys less tooth than regular crowns
2. EMax is most beautiful restoration
3. Less chance of gum disease since margins are above gums in most areas
4. EMax can be shaded for close match to adjacent teeth
5. Strengthen weak tooth
6. Low wear compared to plastic

B. Contraindications
1. Subgingival margins can lead to micro leakage
2. Insurance may not cover remake

C. Tooth Preparation – Depth Cut Burs
1. Triple tray with alginate for temp. * Is this for Veneers??
2. Bevels all surfaces – no subgingival margins if possible
3. Rounded internal line angles
4. Wedge prox. before prep
5. Incisal reduction 2 mm
6. Remove decay and weakened enamel
7. Lingual = champfer 1 mm deep
8. Proximal butt or deep champfer sides – finish at contact
9. Run polish strip through contact

Select shade cores
1. High translucency choices
a. High translucency
b. 16 A-D
c. BL
2. Low Translucency
a. Low translucency
b. Medium opacity
c. High opacity
3. Brightness (increasing brightness)
a. V1
b. V2
c. V3
4. Opalscent (increasing opalescence)
a. O1 (opal)
b. O2 (opal)
5. Shade of stump is taken separatley

D. Temporary
1. Acrylic
2. Place a 1mm dot of SEB on center of tooth
Coat temporary with flowable and light cure

E. Client returns
1. Confirm shade and tooth shape
2. When shape of tooth is okay with client take impression to send to lab

F. Try in and Adjustment
1. Light anesthesia
2. Remove temporary – remove any flowable on prep
3. Clean preparations
4. Be careful! EMax – Weak until bonded
5. check fit, adjust each individually and then all together
6. Use floss to check contacts
7. verify shade match

G. Seating
1. Apply SE Bond AB to tooth, and after 30 seconds blow to evaporate excess.
2. Coat veneer with composite.
3. Place SE Bond resin layer and lightly blow off the excess.
4. Carefully seat veneer
5. Remove excess composite with a fine brush, floss
If shade not correct
b. Remove uncured acrylic with alcohol, dry
c. Try new shade
d. If ok, clean with alcohol, dry
7. Tack with 10 sec light exposure on mid facial
8. Remove rest of excess by flossing through contact and exploring point
9. Polymerize all surfaces 40 sec. each (facial, lingual, mesial, distal
10. Finish all margins with # 12 blade if necessary
11. Apply bonding agent to all margins
12. Polish with DiaGloss

U. Oral Surgery

B. Procedure
1. Client is seated topical anesthetic, N2O, headphones? Blood pressure and consent form!!!!
2. Doctor will anesthetize. Assistant will hand dentist periosteal elevator and mirror, then the 303, then the forcep. Doctor will remove the tooth (teeth) and place the tooth on 2×2 gauze so he can make sure the root tips are present. Next he will curette the socket. Irrigate with sterile water. Then he will place two 2×2 gauze over the extraction site for the client to bite on until the bleeding stops.
3. After 5-10 minutes check extraction site for less bleeding, replace new gauze.
4. Go over post surgery instructions. Make sure your client understands them.

Brush Biopsy – There are kits that have the brush and all the associated information for the client and their medical insurance inside. We need to fill out the paperwork in the kit and send it to the lab (address in the kit also) with the brush biopsy. We need to include both medical and dental insurance on the form. We have a charge for this and there will be a charge from the lab to run the tests that will be billed to the patient. In 7 days, we will receive faxed results. If the results are positive, we also will receive a letter from the pathologist describing what was found with color photos of the tests. The next step when we receive positive results would be to recommend a scalpel or punch biopsy performed by an oral surgeon.

V. Dry Socket

Occasionally the blood clot will break down. The exposed bone becomes infected. This is called an “osteitis” (inflammation of the bone) or, more commonly, a “dry socket.” It is very painful. If the client is very uncomfortable, your dentist will numb the area.
Your doctor will carefully clean/rinse out the socket to establish bleeding. and then apply dry socket paste. Often the paste is sutured in place.

In some cases it is changed daily. In other cases it is left in place and the client is examined in two day.

Materials:
o Dry socket powder/liquid or paste
o Unopened gel foam (don’t open until Dr. says he/she wants to use it because it’s very expensive)
o Monojet with saline
o Curette
o Mirror
o Cotton forceps
o Spatula
o Suture material
o Anesthetic

W. Repairing fractured porcelain crowns

This procedure is similar to doing a plastic filling.
1. The broken piece is pumiced. Rinse
2. Etch is applied carefully. This is a 9.5% hydrofluoric acid gel. It’s very dangerous to soft tissue. If
Ceram Etch gets on your skin, eyes, rinse with water. Never use this product on enamel or dentin. Allow
Etch to work for 5 minutes.
3. Rinse for 15 seconds.
4. Place the Silane coupler and blow dry.
5. Add S.E. Bond
6. Place a thin coat of Rely-X and seat crown
7. Remove excess
8. Tack for 1-2 seconds – facial and lingual
9. Remove any remaining excess
10. Cure 20 seconds on each surface
11. Polish as necessary

Alternative Technique
1. Once fracture area of porcelain etched
2. Use SE Bond
3. Add composite and finish as a composite filling

X. Maryland Etch Bridge

-Set up is the same for C&B

DOCTOR TIPS

Dr. _____
o Uses wand for lower teeth when anesthetizing
o Does not like anesthetic time scheduled for uppers
o Suction during treatment with both high and low speed (soft tissue retraction)
o Prefers to use small plastic instrument to pack cord.
o Remember crown and bridge carbides when removing crowns.

Dr. _____________

• Does not like anesthetic time for uppers
• Prefers Hollenback for all amalgam carvings

Y. LASERS

We use a diode laser which will cut soft tissue, but not hard (teeth, bone). The laser is very precise and less traumatic to the client’s tissue than a blade. Another important benefit is immediate control of bleeding.
LASER stands for Light Amplification by Stimulate Emission of Radiation. This device generates, amplifies and controls a beam of light. The wave length of light determines the type of tissue it cuts.
When you are at chairside, have the laser ready when doing the crown preparations and in reserve for possible use for fillings or other procedures. When you bring the gray drawer with the laser to the chair, the set up instructions for you are in the bottom of the drawer under the laser.
Here are ideas to help you avoid physical problems and enjoy a longer, more pain free career.
1. Assistant stool – seating your hip next to client’s shoulder, stool support at your secondd rib used as an upper body support, not an armrest, stool foot ring high enough that your knees are slightly above your hips
2. Sit with your back erect
3. Keep your arms as close to your body as possible.

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Chairside Team Leader              Date