Jason Olitsky, DMD, AAACD, a 2001 graduate of Temple University School of Dentistry, is past president of the Florida Academy of Cosmetic Dentistry and an accredited member of the American Academy of Cosmetic Dentistry. He is the program director for Clinical Mastery Series and teaches portrait and clinical photography and over-the-shoulder anterior aesthetics courses with The Clinical Mastery Series. He is on the Editorial Review Board of Inside Dentistry. Dr. Olitsky is also a KOL and accredited Digital Smile Design Master as well as a clinical consultant with Dental Advisor. He publishes on various topics of cosmetic dentistry, has appeared in numerous national beauty and health magazines, and serves as product consultant for dental product companies. Dr. Olitsky maintains a private practice in Ponte Vedra Beach, Florida.

Jason Olitsky, DMD, AAACD

Presented by the faculty of Clinical Mastery Series, the New Generation of Dental Education.
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	“Presentation” is the key word in case presentation, and it begins with the patient’s first contact with the office. Presentation has the potential to shape patient perception about the dentist’s competency and to establish a bond with patients.

	When presentation is successful, trust is built with the patient, who makes an appointment and already respects your opinion. This results in increased case acceptance.

	Presentation is about paying attention to details that influence case acceptance. It can be tailor-made to the case types that you would prefer to present in your office, and it can promote confidence and experience in selected services.

	We have so many opportunities to capture media for case presentations. It is obvious that photography is a requirement for case presentation. We take pictures of our patients’ teeth, show them areas that are concerning, and recommend treatments.

This can be as simple as using an intraoral camera or, for higher quality presentation, a digital single-lens reflex (DSLR) camera with refined lighting 

. In case presentation, the higher the quality, the better. Make no mistake about it: Dentistry is a big-ticket item. Think about the presentation that expensive products use to target and attract customers.

	The next logical step after taking high-quality images for case presentation is to document the results of the case with high-quality images. This creates a presentation to use for a future patient.

	Now, I need to talk about stories, because images really do not tell the whole story. They just show the results. Every patient who has their teeth or smile improved has a story about a struggle with their teeth and what it took to overcome that struggle and get the treatment. Asking the right questions will reveal the struggle in the story and create a valuable connection between you and the patient 

Share another patient’s story during your case presentations to complement the high-quality images. You can also tell stories with visual media. You can play video testimonials during case presentations and post them to social media. Not all video requires words. Music has a way of creating emotional connections, too.

	Sharing “after” pictures to social media that reflect the patient’s confidence with their smile is obvious stuff 

. Even more important, this moment shows that a patient is connecting with you as the dentist-and has become a fan.

	Create as many raving fans as possible. More fans create more social proof 

. Continue to expand this circle of trust by creating more raving fans through the use of high-quality visual media and/or more targeted images and videos.

 Sharing after pictures to social media is an important way to develop trust and facilitates case acceptance. Pictured is Dr. Olitsky's patient, Lauren.

A niche is a target demographic. If you are able to specify the type of patient you want to see in your office, you can create a buyer persona of your ideal patient and then design presentations to catch their eye. By being this specific, you run the risk of turning off some potential patients, but these customized images and videos are for your ideal customer, to create trust and to create more fans. Fans respect your opinion.

	If you are convinced that photography and video are important for case presentation, then understand that being competent at visual media presentation has the potential to completely change your practice.

	Now, focus on building the relationship with your patient. Show that you authentically care about your patient by asking the right questions and listening to the answers. Remember what is important to the patient and customize the case presentation and language to reassure the patient that you are recommending the best options based on their concerns. This will help them see that your values align.

For example, if the patient wants conservative treatment, develop more trust to create more common ground by saying something like, “I understand wanting a conservative treatment plan for your teeth because that is what I would want for my own teeth. In this case, doing more teeth will enable me to give you the most conservative treatment because if we do this one tooth at a time, I will have to grind down each tooth excessively to fit into your current bite, which is failing you.”

	Then present a similar case: “For example, another patient had a similar concern (give background story about this patient), so we ended up doing all the teeth at one time. This patient did minimal preparation on the teeth, and we improved the smile at the same time.”

You can organize case presentations in software such as Keynote, which keeps images and videos together and in sequential order 

. This makes it simple to present a case from start to finish. Consider images and videos, digital design, provisional images, try-in images, after images, and video testimonials. You can share these packages of creative content with everyone from laboratory technicians to specialists to patients.

The better you get at creatively producing high-quality content-by utilizing programs such as Keynote, Adobe Lightroom, Final Cut Pro X, and Adobe Photoshop-the easier it is to generate more presentations to share with patients, create more fans and increase case acceptance 

Articles

Using social media in case presentation can create patient confidence and practice ‘fans.’

How to: Deliver effective case presentations using visual and social media

	Posterior restoratives are required to meet many criteria to be clinically successful. As practitioners, we strive to meet these criteria in every case despite the unique and individual challenges presented by each tooth and patient. The question becomes one of “How do I predictably achieve the same degree of success in the multitude of situations presented?” I was looking for esthetic and void-free restorations that sealed the margins and left the patient with little or no postoperative sensitivity. I began using bulk fill restoratives to create a more efficient protocol to reduce chair time and patient discomfort but found that the materials offered an ease of use that could predictably be used to achieve my expectations. At the end of the day, I want my patients to be comfortable and happy with the esthetics, the fillings to seal the teeth, and I want to look at the radiographs and feel good about my dentistry. Tetric Evo Line enables me to predictably and efficiency provide my patients with top-notch dentistry.

	Case presentation                                                                                  

	A 14-year-old patient presented to our office for a new patient examination. He had just completed orthodontic treatment and he had several large posterior caries and areas of defective enamel on his anterior and posterior teeth (Figs. 1-5). After a thorough examination and consultation with the patient and father, it was determined that the large caries on teeth #14DO, 18OB and 31OB should be sealed with large fillings, the defective enamel be treated with CTx4 toothpaste and CTx3 oral rinse (CariFree), and monitored as he gets older. The patient was appointed for caries removal and direct restorations to be placed at his next visit.

	Fig. 1                                                                                                   Fig. 2

		Under rubber dam isolation (Hygenic Non-Latex Dental Dam, Coltene Whaledent), the caries were removed and the teeth restored one quadrant at a time. A carbide bur was used to remove caries, followed with a diamond to bevel the cavosurface margins and finally with a round bur to excavate the deepest portion of the decay (Figs. 6-7).

		Fig. 3                                                                                                     Fig. 4

Trending article: How to complete a Class II restoration without anesthesia

		The bevel on the cavosurface margin allows for increased esthetics for the materials to have a chameleon effect with the underlying enamel. The resultant cavity preparation revealed preparations that were in excess of 4 mm deep in all prepared teeth. Once the caries were completely removed, the dentin and enamel were particle abraded with a PrepStart™ (Danville) with 40 micron aluminum oxide to homogenize the dentin, creating a uniform smear layer of the dentin forming the ideal interface for dentin bonding. The decision was made to use Tetric EvoCeram Bulk Fill (Ivoclar Vivadent) composite restorative.

		Fig. 5                                                                                                    Fig. 6

		After disinfecting with 2% chlorhexadine gluconate, 35% phosphoric acid gel (Total Etch, Ivoclar Vivadent) was applied to the enamel for 15 seconds. Selective etching technique of enamel only takes advantage of the universal adhesive technology of Adhese

 Universal (Ivoclar Vivadent). Etching enamel creates maximum bond strength to enamel. Etching of dentin isn’t required, so sensitivity is reduced from no dentin etching and long -term bond strengths are not effected by the phosphoric acid etched dentin interface (Figs. 8-9).

		Fig. 7                                                                                                 Fig. 8

		The Class II cavity preparation was prepared for composite filling with a matrix ring, sectional matrix band and a wedge (Garrison Dental Composi-Tight

 Soft-Face 3D XR Ring, Slick Band and Wedge Wand). The band, 5.5-mm small molar matrix, was placed carefully on the distal of the upper left first molar to have proper contour at time of placement to prevent less than ideal tooth form when the filling was completed. Due to the lack of interproximal contact prior to cavity preparation, additional shaping of the band was necessary to create a new contact. If not placed properly, it would necessitate additional contouring after composite curing with rotary instruments in an area of inadequate access.

		After thorough rinsing of the phosphoric acid gel, the preparations are dried with an A-dec air dryer and two coats of universal adhesive are placed (Adhese Universal VivaPen

, Ivoclar Vivadent). The dentin is thoroughly dried with this technique as this adhesive is flexible in its dentin moisture tolerance. The VivaPen delivery system is preferred, especially when treating multiple teeth to allow fresh, uninterrupted delivery of adhesive to the teeth. Adhese Universal is less technique sensitive in that it’s indicated for both dry or moist dentin (Fig. 10). Each tooth is then cured for five seconds per surface in turbo mode (Bluephase

		Fig. 10                                                                                                  Fig. 11

Related reading: Solve my problem: Capture, design and collaborate for cost effective restorations

	This first layer of direct restorative is Tetric EvoFlow Bulk Fill shade IVW (Ivoclar Vivadent). This is used as a dentin replacement layer. The lighter shade is perfect for younger teeth with a brighter final shade. The shade is one of three choices from Ivoclar Vivadent to reduce the amount of shades necessary to keep in stock and reduce time necessary to choose shades for ideal shade matching. The IVW shade matches bleached teeth. The material has a similar opacity as dentin and high radiopacity to be easily distinguishable on radiographs. Utilizing its strength in opacity and ability to place up to four millimeters enables the practitioner to place this material in a way that minimizes treatment time and idealizes esthetics. The material also utilizes Ivocerin technology to realize its four millimeters depth of cure with a dentin-like opacity. The material, when first placed, is highly translucent, and when cured for five seconds with the Bluephase 20i in turbo mode, it gets more opaque (Figs. 12-13). This makes Tetric EvoFlow Bulk Fill an excellent material as a dentin replacement and opaquer of discolored floors of preparations. The opacity prevents the finalized restorations from looking gray when placed at the correct thickness.

	Fig. 12                                                                                                   Fig. 13

	Once the flow layer is placed to idealize depth and opacity, the Tetric EvoCeram Bulk Fill layer shade IVW is placed in one increment, sculpted with OptraSculpt NG (Ivoclar Vivadent) and cured for 10 seconds per surface (Figs. 14-15).

	Fig. 14                                                                                               Fig. 15

	The manufacturer recommends five seconds, with the Bluephase 20i in turbo mode, but in the clinical environment it makes sense to increase the cure time depending on access, light proximity and intensity variations. For Class I restorations, the occlusal surface is cured for 10 seconds.

	Fig. 16                                                                                                  Fig. 17

	Class II restorations are cured for 10 seconds from the occlusal, then the ring and band are removed and the proximal surfaces are cured for an additional 10 seconds. Both the practitioner and the assistant have Bluephase Styles and this speeds up cure times by enabling multiple teeth curing at the same time as well as multiple surfaces.

	Fig. 18                                                                                              Fig. 19

	After occlusion is adjusted and restorations are finished and polished with OptraPol polishing cups and points (Ivoclar Vivadent), final radiographs and photos are taken to demonstrate the radiopacity of the material, the ideal interproximal contours and sealed margins, and its monolithic, void-free qualities (Figs. 16-20).

How one dentist uses Tetric EvoLine bulk fill materials to provide patients with excellent dentistry. 

How to perform a void-free restoration

	Placing direct restoratives on patients is a very common procedure in most general dental practices. While esthetics are important when utilizing composite restoratives, practitioners are also concerned about post-op sensitivity and longevity of the restorations. 

	Dentists can review the results of their techniques in radiographs taken at recare appointments and consult with patients about post-op sensitivity and esthetic results. Dentists can use techniques to improve the Class II posterior direct composite procedure. While many of us received minimal training in dental school on clinical placement of posterior composite restorations, it’s important to keep current on improved restorative materials and treatment modalities to ensure more consistent results.

	A 50-year-old female patient presented for replacement of a fracture and decay in an existing composite restoration (Figs. 1-2). While crowns or onlays would be the typical treatment of choice in our office, the patient will need to put off receiving indirect restorations for a couple years. It was decided that due to the depth of the existing restorations and the recurrent caries present, it would be wisest to perform caries control for the teeth.

	Click through to see how this practitioner created great-looking restorations

	The direct composite restorative of choice in my office is Tetric EvoFlow

 Bulk Fill. When treating cavities of this size, the composite material makes placement much more efficient and predictable while still offering a high level of esthetics.

	The patient was anesthetized and a latex-free dental dam was placed with an NW clamp on the second molar (Fig. 3). Utilizing a Brasseler 6845KR.31.018 diamond, the old composite restoration was removed in its entirety. The deeper portions of the box were beveled with a 6856.018 diamond and the cavosurface margins were beveled to increase enamel bonding area and for esthetics.

	Once the preparation was complete, the preparation was micro-abraded with an air abrasion unit (PrepStart

, Danville) with a 90-degree .015 tip and 27-micron aluminum oxide powder. This step results in micro-retentive surface increases, surface area that potentially further increases dentin bonding and reduces post-op sensitivity (Fig. 4).

 (Garrison) were used to replace the missing tooth surface and form the adaptive layer of composite restoration. It is very important in this step to have a tight interface between the band and tooth to allow for ultimate adaptation of the direct restoration to the margins (Fig. 5).

The next step was the selective etching technique, utilizing 35% phosphoric acid (Ultra-Etch

, Ultradent) on enamel only. The etch was applied on the enamel for 15 seconds and rinsed thoroughly (Fig. 6).

	A universal adhesive was scrubbed on the selectively etched tooth per manufacturer’s instructions using 

	The adhesive was air-thinned with an A-dec air dryer to deliver oil- and moisture-free air and was light-cured for 10 seconds with a 

	Tetric EvoFlow Bulk Fill Shade IVA was placed as a first increment. While traditional flowable materials need to be placed as a thin increment to minimize shrinkage stresses and allow for complete curing, Tetric EvoFlow Bulk Fill can be placed in increments of up to 4 mm without worrying about shrinkage stresses or incomplete curing. Taking advantage of Ivocerin

 and its self-adapting and opacifying technologies means that practitioners get void-free restorations in the deepest of boxes, and the dark underlying tooth structure is blocked out with a similar dentin-like opacity. Figures 8 and 9 show before and after curing.

	The final layer is a single increment of Tetric EvoCeram Bulk Fill Shade IVA (IVA is a universal “A-range” shade). The material was placed from a Cavifil, injecting directly into the preparation. The material was condensed gently with an 

 composite instrument (Ivoclar Vivadent) and shaped with primary and secondary anatomy (Figs. 10-11).

	The composite was light-cured with the Bluephase Style for 10 seconds from the occlusal surface, then the band was removed and the restoration was light-cured again from the proximal surfaces for an additional 10 seconds to ensure complete curing (Fig. 12).

	The composite was contoured with a Brasseler flame 8274.31.016 and the margins were contoured and defined with discs (Cosmedent 

	The restorations were adjusted for occlusion and polished with Astropol polishing points and finished with 

	A post-operative picture and radiograph were taken to confirm ideal restoration placement with sealed proximal margins and a void-free restoration (Figs. 14-15). 

	Direct restorations can be challenging to complete with ideal results. The procedure begins with ideal isolation and is completed with regard to proper band placements and utilization of materials that facilitate ideal outcomes. Even larger restorations are completed with efficiency utilizing bulk fill restoratives that can provide not just shorter chair times for patients but also esthetics that exceed patient expectations.

When it comes to restorations, practice, a little know-how and the right materials make perfect. 

How to Create More Esthetic Restorations

When it comes to restorations, practice, a little know-how and the right materials make perfect.