3STEP Academy - Dr. Francesca Vailati
The most comprehensive additive training consists of 3 modules of 2 days each with different hand-on parts and time in between the modules. The 3 modules give the participants the possibility to meet Dr. Francesca Vailati several times, while making progress with their own 3STEP cases. They are intense and 2 days are the perfect time frame to absorb all new information in tranquilizing surroundings near the Lake of Annecy.
The 3 Modules
Modulus 1 mainly focuses on the increase of the vertical dimension of occlusion and the posterior teeth.
Diagnosis and data collection to make the correct treatment plan will also be one of the main objectives of the course.
Modulus 2 focuses on the palatal veneers and the restoration of the anterior teeth.
The participants will also be invited to present their own cases of dental erosion, which will be jointly discussed in the treatment plan session.
Modulus 1, Day 1
Dental wear is a frequently underestimated pathology that nowadays affects an increasing number of individuals. Teeth in general are wearing down faster, not only for the excessive presence of the acid in the mouth, but also because of parafunctional habits. Generally, the affected patients are left untreated until more damage occurs and conventional treatments are more justified (subtractive dentistry based on crowns). Postponing the therapy is not the correct attitude. Non-invasive (ADDITIVE) adhesive restorations should be proposed instead, to protect the remaining dentition from further degradation.
- Learn the rational behind an ADDITIVE non-invasive approach versus traditional subtractive dentistry.
Before starting any dental treatments, a diagnosis of the origin of the tooth wear should be made. Even though loss of tooth structure is often multifactorial, clinicians should try to identify the cause, in order to also explain to patients how the restored dentition will be aging in the future.
The participants will learn how to recognize the signs of early tooth wear and be capable of predicting the type of evolution if the dentition is left untreated.
- Learn to identify the signs of dental erosion.
- Know the evolution of untreated mouths affected by dental erosion.
- Make the differential diagnosis between erosion and parafunctional habits.
CLASSIC 3STEP - The maxillary vestibular mock-up (I step)
Despite the tendency for adhesive techniques to rather simplify the involved clinical and laboratory procedures, treatment of patients affected by severe dental erosion still remains a challenge.
An innovative approach, called the CLASSIC 3STEP Technique has been developed by Dr. Vailati. The 3STEP Technique is a structured approach to achieve a full-mouth ADDITIVE adhesive rehabilitation with the most predictable result, the minimal tooth preparation, and the highest level of patient acceptance.
Fundamental before starting the rehabilitation, is the communication with the patient and the laboratory technician on the esthetic final outcome. Thanks to a simplified less expensive mock-up, the patient can make an informed decision if he/she is willing to start the more comprehensive rehabilitation.
In this session, the participants will learn how to start developing a full-mouth rehabilitation, starting from two fundamental parameters, the incisal edges and the esthetic occlusal plane.
- Avoid full-mouth waxup.
- Plan an INTELLIGENT esthetic outcome for the future rehabilitation.
- Learn how to communicate with the patient and the technician by means of the 3STEP mock-up.
ACE classification and facial veneers
In case of severe dental erosion, the facial aspect of the anterior teeth may also need to be restored. In this case another veneers, made in ceramic, could be used. The ACE classification is a clinical oriented classification, which considers the maxillary anterior teeth to evaluate the severity of the dental wear related to dental erosion. Instead of trying to precisely quantify the wear due to erosion, this classification proposes to correlate the damage at the level of the anterior maxillary teeth to the possible options of treatment. Patients are grouped in six categories, and for each of them a dental treatment plan is suggested.
The classification is based on several parameters, relevant for the selection of the treatment and the assessment of the prognosis, such us the dentin exposure, the preservation of the incisal edges, and the pulp vitality.
- Classify patients affected by erosion, looking at the damage of their anterior teeth.
- Propose a treatment based on the ACE classification.
- Learn how to decide if facial veneers are indicated in the treatment.
Modulus 1, Day 2
CLASSIC 3STEP - The white bite (II step)
Since the main objective of the 3STEP Technique is to avoid the removal of healthy tooth structure, while restoring worn down dentitions, an increase of vertical dimension of occlusion (VDO) is always advocated. The role of the clinician to determine the new VDO is fundamental. Once the project in wax is clinically validated, the posterior teeth are reconstructed, using transparent silicon keys. These keys are loaded with composite and positioned in the mouth to fabricate the posterior restorations (the white bite). In this session, details on how to decide the increase of the VDO will be given. Special attention to the communication with the laboratory technician in the fabrication of the wax up of the posterior quadrants will be stressed.
- Learn to understand the clinical validity of a more comprehensive waxup.
- Determine the increase of VDO for each 3STEP rehabilitation.
HANDS-ON - Fabrication of the white bite
Often laboratory tecnician do not know how to correctly make the transparent keys, leading to clinical complications during the fabrication of the white bite. Errors, such as incorrect occlusion, or interproximal excesses can be reduced if clinicians are able to evaluate the quality of the posterior waxup first and the quality of the transparent keys later. Examples of laboratory and clinical mistakes will be shown during this practical part, where the partecipants will fabricate a correct transparent key by themselves.
Even with both a correct waxup and a transparent key, potential risks of mistakes may still be present during the II clinical step, when the key is used to fabricate the white bite directly in the patient’s mouth. A critical step could be how clinicians handle the transparent key, the quantity of composite loaded, the quality of composite used, the pressure applied on the key etc. These steps will be evaluated, using clinical examples, while partecipants will use their transparent key and fabricate the white bite themselves.
- Learn to analyse a posterior waxup.
- Learn to fabricate a transparent key.
- Avoid clinical errors while handling the transparent key.
HANDS-ON - Fabrication of the maxillary vestibular mock-up and the posterior provisional onlays
In the first step of the 3STEP Technique a vestibular mock-up is fabricated. Even for this step the evaluation of the waxup is crucial as well as the correct fabrication of the mock-up key.
In this session, in addition to analyzing the clinical potential mistakes of this step, the participants will fabricate a mock-up key themselves and load it with provisional composite to learn how to accomplish this step without bubbles. The participants will also fabricate another key, using the same material, for the provisional restorations of the posterior teeth. The key will be loaded and placed on the model. The exercise is concluded with the removal of the provisional restorations without breaking the model.
- Fabricate the maxillary vestibular mock-up key.
- Learning how to inject the composite to avoid bubbles in the mock-up.
- Fabricate the posterior provisional onlays and master their removal.
Modulus 2, Day 1
The control visit - Review of the 3STEP technique
During the period of time between modulus I and II, the participants will have the time to look at their patients differently, making diagnosis of dental erosion, and even treating some of these cases. After a brief review on the fundamental aspects of the previously explained I and II STEPs, this course will start with the control visit. After the increase of VDO with the white bite, patients present an anterior open bite, which will be restored by means of palatal veneers. After 1 week, before passing to the next step, it is crucial to evaluate the patient’s posterior support, the new VDO and the occlusal comfort in general with the white bite. Occlusal adjustments are one of the 8 steps necessary to prepare the patient for the III STEP, which will be explained in this session.
- Learn how to evaluate the occlusion after the white bite.
- Learn to prepare the patient for the palatal veneers.
Palatal veneers LAB: analysis of the cast
This part of the course deals with the difficulties that clinicians and laboratory technicians may find in planning palatal veneers. Few lab technicians know how to do these uncommon restorations and in Dr. Vailati’s experience more than 80% of what the participants bring to the course should be remake or at least modified before be delivered to the patient. To help clinicians to evaluate the laboratory work, 10 laboratory parameters should be considered. The palatal veneers brought by the participants will be photographed and evaluated together with the group to decide if they are clinically acceptable.
- Learn to evaluate if palatal veneers are clinical acceptable on the cast.
- Evaluate participants’ palatal veneers.
HANDS-ON - Palatal veneers modification before bonding
After the theoretical session on the ideal shape of a palatal veneer, each participant will modify his/her own palatal veneers, following the guidelines of Dr. Vailati. The reshaping of the restorations will facilitate their bonding and improve their aging in the patient’s mouth. New pictures of the restorations will be taken and showed to the group to really analyse if the modifications were correctly executed.
- Learn how modify the participants’ palatal veneers before bonding.
Palatal veneer bonding (III step)
Palatal veneers are an outstanding treatment for eroded anterior teeth. However, since it is also an unusual one, clinicians may not be familiar with this type of restorations. In this session, each step on how to deliver them in the patient’s mouth will be explained, stressing the importance of a correct adhesive protocol.
- Learn the adhesive protocol to bond palatal veneers.
Modulus 2, Day 2
HANDS-ON - Palatal veneers bonding
Bonding palatal veneers could be a stressful clinical situation, not only for the fitting of the restoration, but also for their unusual location in the mouth. Dr. Vailati is perhaps the clinician who has delivered more palatal veneers in the world, and her clinical experience has brought her to simplify the technique. However, this is still an unusual procedure for the majority of the dentists. In this practical session, the participants will learn first how to isolate the operatory field with a rubber dam, and second how to follow the different steps to bond the palatal veneers, to become more confident in their clinical reality.
- Learn to isolate the teeth with a rubber dam to bond palatal veneers.
- Execute the different steps of the adhesive protocol for palatal veneers.
Photos and case documentation
A solid initial documentation is fundamental for a correct treatment plan. To avoid waste of time, clinicians should know what is really necessary when it comes to data collection during the first visit with the patient.
In this session it will also be explained how to register the patient’s occlusion, the type of impression to take, how to mount the casts etc. In addition a list of essential photos will be described. Very few clinicians understand the fundamental importance of documenting their work with photos. Some of them take pictures only to communicate shade to the technicians, other to show the patient aesthetics. Following the 3STEP Technique, instead, there are several crucial photos to document clinical parameters necessary for the treatment plan.
In this part of the course, the participants will be instructed to take only the necessary pictures and they will be capable to identify the critical parameters for the diagnosis and the treatment plan by looking at those .
- Learn how to collect the initial date for treatment planning of a 3STEP.
- Learn which are the essential pictures and which clinical parameters they show.
Pedro Planas, introduction to occlusion
Before starting the treatment plan session, Dr. Vailati will introduce some very pragmatic ideas about function and occlusion, which have been embraced during her clinical experience. In addition, these ideas are in total agreement with the clinical observation of Dr. Pedro Planas, a spanish dentist who based his opinions on an impressive number of treated patients.
In this session, participants will be exposed to the world of Dr. Planas before this subject is described in the details in the Modulus 3.
- Give some practice tools to the clinicians to test the function of their patients.
- Calibrate clinicians to understand which is their level of competence about occlusion in relation also to the population of the patients selected.
Treatment plan of the participants' erosive cases
In this session, cases of dental wear of the participants’ patients will be analysed. It is recommended to select cases of dental erosion. Each participant will be asked to select one patient and documented the initial status with maximum 15 clinical photos and one video. These pictures will be transmitted to dr. Vailati and analysed with the group during this session. The attention will be placed not only on the quality of the documentation, but also on the diagnosis. Advices on the treatment plan will be given. The session will be based on the interaction between dr. Vailati and the participants, especially on the type of dental material selected for the rehabilitations.
- Evaluate the documentation to analyse erosive patients.
- Treatment plan of the participants’ cases.
Modulus 3, Day 1
Increase of VDO complications
The increase of VDO represents often a challenge for many clinicians, not only because it is necessary to treat several teeth at the same time, but also because there is a generalized fear for the potential clinical complications. In this part of the course, the increase of VDO will be explained in details to comfort clinicians that it is possible and often very well accepted. However, attention will be paid to the different situations where this approach should be used more carefully.
- Dare to increase the VDO even in difficult cases.
- Evaluate the clinical conditions where this increase could be problematic.
Due to a raising awareness about dental erosion, several clinicians would like to propose treatments even at the initial stages of this disease. However, when the loss of tooth structure is visible only by an attentive eye and it has not affected the esthetic of the smile, proposing a full-mouth rehabilitation is not easy. Reduction of the cost of the therapy, simplification of the clinical steps, and NON-invasive ADDITIVE techniques may promote patient’s acceptance. With the MODIFIED approach of the 3STEP Technique, initial cases of dental erosion could be treated, skipping some clinical and laboratory steps, to make the therapy faster and less expensive for the patients. In addition a modified approach can be used to lower the price of the rehabilitation even in more severe cases of tooth wear.
- Illustrate the MODIFIED 3STEP.
- Show how to reduce rehabilitation’s fee, but not its quality.
The posterior teeth are always the last teeth to be considered by patients due to their minor esthetic value. Instead these teeth are the most important in a full-mouth rehabilitation, since the longevity of the anterior restorations relays always on a solid posterior support. In this optic, treatment planning of the posterior restorations is very complex. In this session, different aspect of how to restore the posterior teeth will be evaluated, looking at the type of existing restorations, patient’s occlusion, money availability etc. New materials like CAD/CAM composite and ceramic restorations will also be described to try to improve the quality of the posterior support and may be to lower the price of the rehabilitation.
- Decide how to restore the posterior teeth to increase the VDO.
- Decide which material use for the final posterior restorations.
Pedro Planas, deep bite and ageing
In modern time, esthetic has gained more space in the treatment plan than function. However, planning a full-mouth rehabilitation only based on esthetic requests could be very risky. The risk of worsening deep bite, while rejuvenating the patient’s smile is very common. Three different phases of treatment planning can be identified, based on the different parameters considered important by each clinician during the therapy. Dentists are in phase 1 of their professional life when they consider that the mouth’s principal function is smiling. This attitude is very dangerous, since it increases the risk of restorations failure.
A simplified approach to achieve a rehabilitation, which doesn’t only look esthetic, but also functions well is derived from the clinical observations of Dr. Pedro Planas. His ideas have been fully integrated into the work of Dr. Vailati to improve the comfort of the patient and the longevity of the restorations. Thanks to his work, dentists can learn how to analyse the movements of the mouth and determine if they are physiologic or pathological. The development of the condyles, mandible and maxilla will be considered and information on how a dentition should age, will be given.
- Learn about the movements of the jaw.
- Learn Planas laws on the development of the mouth.
- Learn the potential risks of a deep bite.
- Decide to design the smile using an intelligent esthetic.
Modulus 3, Day 2
Bruxism and wear
Clinicians are generally not very keen to start treating patients affected by parafunctional habits (e.g bruxism), since they are afraid of the mechanical failure of the restorations delivered. A common attitude is to wait for more damage to occur, for then to be obliged to intervene. However, this late intervention is responsible for a further degradation of the original dentition, and a more complicated and expensive therapy. Generally subtractive techniques are then selected and healthy tooth structure removed, leading to further weakening of the dentition. Nowadays, however, these conventional rehabilitations (based on crowns) are very rarely accepted by patients, not only for their biological loss, but also for their important cost.
If dentists are not prepared to treat parafunctional patients, and patients are reluctant to restore their teeth with subtractive techniques, questions on the time of intervention should be raised.
ADDITIVE dentistry can be the alternative to propose to this population of patients, based on an early intervention with the maximum preservation of their tooth structure.
- Discuss the clinical complications of treating or not bruxism.
- Discuss pro and cons of choosing different dental materials for these rehabilitations.
Crazy treatments and future development
An ADDITIVE treatment can be proposed to a very large group of patients, not only the ones affected by dental erosion. In this session, clinical examples of patients treated with the 3 STEP approach for different reasons, such as to improve occlusion before and/or after orthodontics therapy, to avoid maxillofacial surgery, or to control periodontal problems. All of these are some of the potential indications for an ADDITIVE therapy.
- Learn how a 3STEP can be implemented in large spectrum of clinical situations.
Treatment plan of participants' parafunctional case
In this treatment plan session, the participants will select one of their cases affected by parafunctional wear to be discussed with the group, by looking at 15 clinical photos and a video of the initial status. The attention will be placed not only on the quality of the documentation but also on the diagnosis. Advices on treatment plan will be also given. These cases are more complex then the erosive ones selected in the previous modulus, and Dr. Vailati would like to see how the participants have developed their skills to start treating more difficult patients.
- Evaluate the documentation to analyse parafunctional patients.
- Treatment plan of the participants’ cases.