DISCOVER THE MULTI-PURPOSE CASE SOLUTION.
For more than twenty years, Kent Garrick has been advising dentists on comprehensive case design. As Arrowhead’s Director of Technical Services, he recently talked with Aesthetic Dentistry about Snowcaps—what they are, when they are used, and how they can benefit patients and dentists alike. Here’s a part of that conversation:
AD: What are Snowcaps?
KG: Snowcaps are provisional temporaries made from a material called Radica® that can be used in a number of applications, including placement over an unprepped tooth structure to compensate for an occlusal discrepancy, or a vertical change.
AD: When do you advise a doctor to use Snowcaps?
KG: There are a few different options. The first option is when you’re dealing with a complex, full mouth restoration case and you want to verify occlusion and AP (anterior/posterior) position. Typically, when [a dentist] opens a vertical, the patient’s mandible advances forward. Snowcaps ensure that your patient is compliant with wearing an appliance. Most appliances are removable—they’re uncomfortable, they affect the speech, and aesthetically there’s not much benefit. Many doctors find that their patients are just not compliant and that creates numerous and complicated issues later on. Snowcaps resolve many of those issues.
AD: Is it correct to say that the Snowcaps become a built-in appliance, like a living splint?
KG: Exactly. A living splint is bonded in place and you take patient compliance out of the equation. The great thing with Snowcaps is that in addition to removing the compliance issue, you also get a more aesthetic look. It helps the patient to visualize how things will look with the final result.
AD: How closely do the Snowcaps compare to the final restoration?
KG: It’s not identical. It’s a different material, so you don’t get the translucency that you do with porcelain. A lot of doctors say that a patient is so happy with the temps, they’re worried that the patient is not going to come back! But the intent of the material is short term (up to two years).
A benefit of Snowcaps is being able to segment out a large case and make it more comfortable for the doctor, for the lab, and for the patient. It decreases the amount of chair time required in one sitting. The patient doesn’t have to be in the chair for up to six hours continuously to have a full mouth completed. Another main benefit for the patient is financial. If a patient can’t afford to do a full mouth restoration all at once, or they want to do quadrant dentistry, Snowcaps are a perfect option.
AD: Are there special considerations when caring for the material?
KG: Often, Snowcaps are connected in quadrants. It’s important that patients floss or use a Waterpik®, because hygiene is compromised slightly. After Snowcaps are cemented, the doctor can take a disc and cut through the contact and make it single units. The reason they are connected is because they’re floating on top of tooth structure and it’s easier to cement a quadrant at a time.
AD: Are they cemented, bonded, or adhered with some other material?
KG: It depends on the situation. Dentists can use temporary cement if it’s going to be a quick transition. If it is going to be prolonged, most doctors do a permanent bond.
AD: Can dentists bond them without damaging the tooth substructure?
KG: Dentists are going to prep the tooth down eventually anyway, so it is required to go through that etching technique when they do a permanent bond. However, they don’t need to do that procedure with a temporary. We typically do not recommend conventional cement as it tends to be thicker and we don’t build in a die spacer like we would for a crown. Snowcaps are placed over existing tooth structure, so you want something as thin as possible.
AD: What are some advantages of Snowcaps?
KG: They’re advantageous for more advanced techniques. Often, dentists find that when they need to do an upper arch or lower arch, it usually turns into a full mouth restoration because of the vertical decrease. When they use Snowcaps, they can finish the upper arch, put Snowcaps on the lower, and let the patient test it out for a period of time. The dentist can make simple adjustments to the lower Snowcaps and not damage the upper crowns. The dentist can fine-tune the occlusion before he or she finalizes the case and restores the lower arch. This approach removes a lot of the unpredictability of a complex case and it allows for fine adjustments without a lot of extra lab costs.
AD: Should new dentists use Snowcaps when they start practicing full arch dentistry?
KG: Even veteran dentists see the value in Snowcaps. If a doctor preps a full mouth and the occlusion is off, it could be an expensive remake. With Snowcaps, instead of having everything perfectly dialed-in at the moment of bonding (which can be time-consuming and stressful), you can make alterations over time to ensure the perfect fit and function. It’s basically an insurance policy.
AD: Is Radica® always the material used in Snowcaps?
KG: Yes—approximately 99 percent of the time. There is a resin material that the removable department can make, too. It’s more durable but the aesthetics are compromised. When I design cases, I only go with the Radica®. You can add on to it, you can polish it, and the durability of it is predictable.
AD: Are there special techniques for handling Snowcaps?
KG: Just like any restoration, before you do the bonding technique, make sure that everything is cleaned out. You will get some contamination if you do a try-in and then go directly to bonding without ensuring that the bonding surface is properly prepared.
AD: What is the intended lifespan of Snowcaps?
KG: The lifespan really depends on the application and the patient. Ideally, six months is a good time frame, but I’ve personally seen it used quite regularly for periods of up to two years. Some of the biggest factors are the patient’s eating and chewing habits. If a patient chews on ice or is a bruxer, the longevity of the Snowcap will be diminished.
AD: Are there any implications to keeping the Snowcaps in place for a longer duration?
KG: Yes, Radica® material is not as durable as porcelain, so it’s going to wear quicker. In prolonged-use cases, such wear can result in losing the vertical, and the jaw position could change based on the patient’s chewing habits. Further, if patients are comfortable with a 17 mm Shimbashi and they start wearing down the Snowcaps to a 16 mm Shimbashi, headaches or joint pain may return, because they’re putting pressure on their joints and muscles again. You should carefully consider the length of time you intend to use them, relative to what you are trying to accomplish.
AD: Are Snowcaps used in small cases? If so, when?
KG: A small case can turn into a segmented case, which will eventually be a full arch. The patient may have four, five or six units at a time, and the dentist can start building it out in segments, as opposed to waiting a year until the patient has the resources to do it. The dentist can actually alleviate the immediate problem and get the patient on the road to better health.
AD: Is Radica® ever used long term for single-unit cases?
KG: We’ve done that in unusual circumstances. For example, if a patient is going on a cruise in a couple of weeks and they don’t have time to get back to the dentist for a new impression. Radica® can help a doctor out of a bad spot. Or if a patient is tight on funds and the doctor knows that the patient can afford to replace it once a year, they can do that, too.
AD: What types of restorations can you make from the Snowcap material?
KG: Really there are no limitations. We can make everything from a crown to a bridge. For larger-span restorations, we add metal or Ribbond® reinforcement to it. We also frequently do inlays and onlays. Snowcaps can also be done as veneers, either on preps or over existing tooth structure. Snowcaps are a great multi-purpose tool that dentists can use to solve a number of problems.
AD: What cases are Snowcaps particularly effective for?
KG: For a patient who needs a full mouth case, focus on the uppers first, Snowcaps on the lowers, and then transition. That’s your insurance policy, doing the Snowcaps, letting the Shimbashi (or vertical dimension) get dialed in, adjusting the occlusion with the T-Scan®, and then progressing into the final restorations at the very end.
AD: Beyond full arch reconstruction and implants, could dentists use Snowcaps instead of a removable appliance?
KG: Yes. While it is slightly cheaper to do a removable appliance, it comes with a number of drawbacks: speech patterns may be compromised, it’s often bulky and uncomfortable, it’s difficult to eat, and requires nightly maintenance. With Snowcaps, a living splint allows the patient to see the aesthetic benefits. Plus, you don’t have to remove it every night or when you eat. It’s anatomical, so the patient can comfortably chew and speak. It’s a bit more expensive, but most patients report that the benefits exceed the additional cost.
AD: How compliant are patients with wearing removable appliances?
KG: We find the majority of the time they’re not. Maybe 20 percent of the time they are, [but] 80 percent of the time, they’re just not wearing the appliance like they should. With Snowcaps it’s essentially 100 percent compliant, because they have no option. A lot of patients can’t even tell that Snowcaps are in their mouth after a while. With a bulky appliance, patients always know it’s in the mouth. For the doctor, this is a huge benefit because noncompliance has a direct correlation to the time required to complete a treatment on a patient. Additionally, noncompliance also increases the complexity of some cases and dramatically increases the likelihood of a compromised outcome.
AD: Snowcaps put the dentist in the position of being a no-holds-barred solution provider. Is that correct?
KG: Absolutely. Snowcaps are tools that create options for both the dentist and the patient. They offer options for large-case dentistry, small-case dentistry, and effective and economical ways of providing solutions to patients.
AD: Dentists who do full arch reconstructions often comment, “I have to spend so much time and effort trying to get everything perfect, otherwise I’ve got a problem.” Are Snowcaps a good solution to this problem?
KG: Yes. Snowcaps are a way for dentists to create predictability. When a dentist bonds the upper arch, he or she can then put Snowcaps on the lowers. With the Snowcaps, the dentist can make alterations on the lowers and account for anything that wasn’t done perfectly on the uppers. Instead of worrying about being perfect the first time out, dentists can start building in control points where they can improve their skills and elevate their practice, without all the risks associated with that.
AD: Are there any other aspects of Snowcaps that might be helpful for doctors who aren’t familiar with this option?
KG: Snowcaps are good for confirming aesthetics and speech. A patient may ask for something that he or she saw in a magazine or on TV, but it doesn’t always work well. It is similar to the concept of test-driving. Before patients spend $40,000 on a case, with Snowcaps, you can verify that they’re going to look good with [a particular] shade. It is a really good tool that ensures that when the case is done in permanent materials like Empress® or e.max®, everything is perfect.