CDA-Anaheimd1ue90e5sp4tcv.cloudfront.net/2855/images/Asset296428_v1.pdf · CDA-Anaheim Daniel H Ward DDS Graduated 1979 OSU Private Practice‐Columbus, Ohio Assistant Clinical Professor

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Daniel H Ward DDS

May 14, 2016

Let’s Be Direct:Plain Talk about Perfecting

Esthetic Posterior Restorations

CDA-Anaheim

Daniel H Ward DDS

Graduated 1979 OSU

Private Practice‐Columbus, Ohio

Assistant Clinical Professor The Ohio State University‐13 years

Daniel H Ward DDS

Fellow Academy of General Dentistry

Fellow American College of Dentists

Fellow International College of Dentists

Fellow American Society for Dental Aesthetics

Associate Member American Academy of Esthetic Dentistry

Daniel H Ward DDS

Reviewer‐Journal of Prosthetic Dentistry

Reviewer‐Journal of Esthetic and Restorative Dentistry

Member and Evaluator for Catapult

Lecturer and Chief Examiner University of Minnesota Post‐Graduate Program in Esthetic Dentistry‐20 years

“I get by with a little help from my friends…”Dr Harry Albers

Dr Paul Belvedere

Dr John Burgess

Dr Mark Canon

Dr Gordon Christensen

Dr George Freedman

Dr Galip Gürel

Dr Geoff Knight

Dr Doug Lambert

Dr Karl Leinfelder

Dr Graeme Milicich

Dr Buddy Mopper

Dr Jeff Morley

Dr Brian Novy

Dr Jorge Perdagão

Dr Steve Rosenstiel

Dr Robert Seghi

Dr Irwin Smigel

Dr Byong Suh

Dr Ed Swift

“I get by with a little help from my friends…”AdDent

BISCO

Caulk/Dentsply

Centrix

Clinicians’ Choice

Coltene/Whaledent

GC America

Heraeus Kulzer

Ivoclar

Kerr

Pulpdent

Shofu

SDI

SSWhite

Tokuyama

Triodent

3‐M

VOCO

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Some Images May be:

Cropped

Rotated

Levels adjusted

No Images were: Site adjusted

Enhance to produce a better result

Composite

The most USED

and ABUSED

Material in Dentistry

Composite

Marginal Integrity

Composite Direct Placement Challenges

Expose ends of enamel rods

EnamelEnamel Enamel Bonding

96% inorganic carbonate hydroxyapatite 96% inorganic carbonate hydroxyapatite calcium phosphatecalcium phosphate

4% organic (tyrosine rich amelogenin 4% organic (tyrosine rich amelogenin protein) and waterprotein) and water

Enamel rods 4Enamel rods 4--8 microns in diameter8 microns in diameter Bonding occurs within enamel rodsBonding occurs within enamel rods HydrophobicHydrophobic

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Sheared enamel Sheared enamel rodsrods

White Lines

Unprepared MarginsExpose fresh ends of the enamel rods

with a very fine diamond

Koase K, Inoue S, Noda M, Tanaka T et al. Effect of burKoase K, Inoue S, Noda M, Tanaka T et al. Effect of bur--cut dentin on bond strength cut dentin on bond strength using two allusing two all--inin--one and one twoone and one two--step adhesive systems. step adhesive systems. J Adhes DentJ Adhes Dent. 2004;6:97. 2004;6:97--104.104.

Hosoya Y, Shinkawa H, Suefiji C, Nozaka Ket al. Effects of diamHosoya Y, Shinkawa H, Suefiji C, Nozaka Ket al. Effects of diamond bur particle ond bur particle size on dentin bond strength. size on dentin bond strength. Am J DentAm J Dent. 2004;17:359. 2004;17:359--364.364.

Use a fine 25 micron diamond when using self-etching primers

Exposing ends of enamel rods resulting inGreater angle than direction of enamel rods

Better bonding and less shearing of enamel rods

Class II Interproximal Margin Preparation

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Expose the ends of the enamel rods to avoid tooth fracture at margins


Composite Composite PreparationPreparation

Amalgam Amalgam PreparationPreparation

Bevel Interproximal Enamel for better bonding and less shearing of enamel rods


Importance of flaring Class II Interproximals

Fractured tooth structure


Parallel preparation


Result

Post-Operative Sensitivity


Hydrodynamic Theory

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Hydrodynamic Theory

Fluid flow within dentinal tubules causes PAINBrannstrom M. The Cause of post restorative sensitivity and its prevention. J Endod 1986;12:475-481.

Hydrodynamic Theory

Opened, unsealed dentinal tubules causes PAIN

DentinDentinPlacement of Resin Primer

Apply multiple coats

Dentin Bonding

70% inorganic carbonate hydroxyapatite 70% inorganic carbonate hydroxyapatite calcium phosphatecalcium phosphate

30% organic (collagen) and water30% organic (collagen) and water

Dentinal tubules 0.06Dentinal tubules 0.06--3 microns in diameter3 microns in diameter

Most Bonding occurs between dentinal tubulesMost Bonding occurs between dentinal tubules

HydrophilicHydrophilic

Demineralize surfaceExpose collagen fibersRemove smear layer Increase porosity of intertubular dentinOpen up dentinal tubules Increase surface area

Etched Dentin

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•Total Etch Technique Fill and Occlude open dentinal tubules

Bonding agent should not leave the dentinal tubules open

Method #1-Reducing Post-Op Sensitivity

Placement of Etchant

Total Etch Technique

“Moist” Dentin”

Rinsing of Etchant

Moist Moist

Placement of Resin Primer

“Overwet” Phenomenon

Tay FR, Gwinnett AJ, Wei Sh. The overwet phenomenon: a scanning electron microscopic study of surface moisture in the acid-conditioned, resin-dentin interface. Am J Dent. 1996;9(3):109-114.

Overdrying

Gwinnett AJ. Dentin bond strength after air drying and rewetting. Am J Dent. 1994;7(3):144-148.

Collapsed collagen fibrils

Overdrying

SEM Perdigao

Un-collapsed collagen fibrils Collapsed collagen fibrils

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Proper Moisture Moisture Variability

Air only syringe Warm air dryer

Air/water syringe Air/water syringe

Evaporating the solvent with dry air

Bond StrengthSensitivity

Variability

Lopez CL, Perdigao J, Lopes M et al. Dentin Bond Strengths of Simplified Adhesives:Effect of Dentin Depth. Compendium. 2006;27(6):340-345.

17.6(+/-5.9)

18.4(+/-4.8)

14.2(+/-7.0)

Deep

Dentin

21.0(+/-7.4)

18.9(+/-4.1)

22.1(+/-2.8)

Superficial

Dentin

Clearfil

Liner

Bond

Optibond

Solo

Single Bond

Adhesive

System

Mean shear bond strength in MPa

Effect of Dentin Depth on Bond Strengths

•Occludes tubules

•Anti-bacterial

GLUMA

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•Occlusions


Summary

Most technique sensitiveRequires proper attention to detailUse in ideal sized preparations


Materials-4th

Generation

Acetone solvent Alcohol solvent


Materials-5th

Generation

Acetone solvent Alcohol solvent

•Self Etch Technique Never leave the dentinal tubules open

Bonding agent should not leave the dentinal tubules open

Method #2-Reducing Post-Op Sensitivity

Acid-groupsHydrophilic end

etches tooth structure (self

limiting)

Spacer-chainlink between

functional groups

Methacrylate-groupHydrophobic end

connects to polymer-network

COOH

COOH

CH 2

CH 2

O

OO

O

Self-Etching Primer

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“Self Etching” PrimerAcidifying Primer accompanies etch

Acid reaction is self-limiting Lohbauer U, Nikolaenko SA, Petschelt A, Frankenberger R.. Resin Tags do not contribute to dentin adhesion in self-etching adhesives. J Adhes Dent. 2008;10(2):97-103 .

Resin Tags do not Contribute to Dentin Adhesion in SE Adhesion

Self-Etch Technique

Challenges

Decreased bond strength to un-etched enamel

Marginal gap formation with un-etched enamel

Bond incompatibility to self-cure and dual-cure resins

More susceptible to hydrolytic degradation resulting in significantly diminished bond strengths over time

Self etching Primer

37% H3PO4 etched Unprepared enamel surface for 15s. Popular SE primer etched Unprepared enamel surface

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•Tests confirm that preparing the enamel margin improves bond strength especially with self-etch dentin bonding agents

Substrate All-Bond UniversalSelf-Etch

All-Bond UniversalTotal-Etch

Uncut Enamel 18.7±6.7 31.4±7.1

Cut Enamel 29.0±5.5 35.6±3.6

Bisco in-house data.. Lee IS, Son SA, Hur B, Kwon YH, Park JK. The effect of additional etching and curing mechanism of composite resin on the dentin bond strength. J Adv Prosthodont. 2013;5:467-484.

55% improvement

Effect of Enamel Etching-Bond Strength

•Tests show that etching uncut enamel with phosphoric acid increases bond strength to enamel with 1- bottle dentin bonding agents



Uncut Enamel 18.7±6.7 31.4±7.1

Cut Enamel 29.0±5.5 35.6±3.6


67% improvement




Uncut Enamel 18.7±6.7 31.4±7.1

Cut Enamel 29.0±5.5 35.6±3.6


22% improvement


•Tests show that etching cut enamel with phosphoric acid increases bond strength to enamel with 1- bottle dentin bonding agents

Solution: “Etching prepared enamel w phosphoric acid promoted better marginal integrity with self-etching bonding agents.”

Souza-Junior EJ, Prieto LT, Araújo CT, Paulillo LA. Selective enamel etching: effect on marginal adaptation of self-etch LED-cured bond systems in aged Class I composite restorations. Oper Dent. 2012;37:195-204.

Effect of Enamel Etching-Marginal Gaps

When the pH of a dentin bonding agent is too low (more acidic), tertiary amines (necessary for the polymerization reaction) are deactivated resulting in bond incompatibility with self and dual cured resins.

Bond Incompatibility with Self and Dual Cured Resins

Suh BI, Feng L, Pashley DH, Tay FR. Factors contributing to the incompatibility between simplified-step adhesives and chemically-cured or dual -cured composites. Part III. Effect of acidic resin monomers. J Adhes Dent 2003;5:267-282.

Solution: Use of a higher pH (>3.0)self-etching dentin bonding agent does not inactivate the tertiary amines and allows for polymerization.

Suh BI, Feng L, Pashley DH, Tay FR. Factors contributing to the incompatibility between simplified-step adhesives and chemically-cured or dual -cured composites. Part III. Effect of acidic resin monomers. J Adhes Dent 2003;5:267-282.


pH=3.2

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Solution: Use a dual-cure activator


“The cured layer of 1-step self-etching adhesives is hydrophilic and a permeable membrane.”

Tay F, Suh B, Pahsley D, Carvalho R. Single Layer Adhesives are Permeable membranes. J Dent 2002;30:371-382.

Hydrolytic Degradation

Solution: Use 2 layers-a hydrophilic layer covered with a hydrophobic layer

Yoshida Y, Yoshihara K, Nagaoka N, Hayakawa S, Tori Y, Ogawa T, Osaka A, Van Meerbeek B. Self-assembled nano-kayering at the adhesive interface. J Dent Res 2012;9:376-381.


Solution: Use MDP containing bonding agents which become hydrophobic upon polymerization due to high amount of cross-linkage.“MDP-containing adhesives form nano-layering at the adhesive interface. Stable MDP-Ca salt deposition along with nano-layering may explain the high stability of MDP-based bonding.”

Yoshida Y, Yoshihara K, Nagaoka N, Hayakawa S, Tori Y, Ogawa T, Osaka A, Van Meerbeek B. Self-assembled nano-kayering at the adhesive interface. J Dent Res 2012;9:376-381.


Self Etch Technique

OptiBond XTR

6th generation DBA that effectively etches enamel

Unprepared enamel surface

Etched with 37% Phosphoric Acid OptiBond XTR 6th Generation DBA

Popular 6th Generation DBA Popular 7th Generation DBA

Swift E, et al. J Esthet Restor Dent. 2011;23(6):390-398.

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Self Etch Technique

OptiBond XTR

Self Etch Technique

OptiBond XTR

2 component self-etch 15% filled by volumeHydrophilic acidic self-etching primer with

enhanced etching capabilitiesHydrophobic adhesive to maximize

material compatibility, increase strength and promote bond durability

Self Etch Technique

OptiBond XTR

Primer contain acetone, alcohol and water solvents

Low film thickness (5 micron)Bonds to gold, non-precious metal,

zirconia, porcelain Direct and indirect restorative procedures

Seventh Generation DBA

BeautibondDual acidic monomersLow film thickness (5 micron)RadiopaqueEasy to use-single application 10 sec

Self Etch Technique

Materials 6th & 7th

Generation

Sixth Generation Seventh Generation

All-Bond SE Clearfil SE Protect

BeautiBond G-BondOptibondXTR

Selective Etch TechniqueApply etch to enamel only for 15 secondsWash thoroughlyPlace self-etching primer

Frankerger R, Lohbauer U, Roggendorf MJ, Naumann M, Taschner M. Selective enamel etching reconsidered:better than etch-and-rinse and self etch? J. Adhes Dent. 2008;10:339-344.

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Selective Etch TechniqueHigh Viscosity allows precise placementContains BAC

Selective Etch TechniqueAllows total etch or self etch of enamel

and/or dentin

G-aenial Bond

Selective Etch TechniquePrecursor to “Universal” Bonding agentsBond strength same to total vs self etch

Dentin Bond Strength

Self-Etch Total Etch Moist

Total Etch Wet

Total, Self or Selective Etch Universal Bonding

Materials

Self‐etch Selective‐etch Total‐etch

Total-etch, self-etch or selective-etch technique

Can be used for direct and indirect restorations

Bond to all indirect substrates-metal, ceramics, zirconia, porcelain and lithium disilicate.

Compatible with light-cured, self-cured and dual-cured composite and luting cements.

Universal Bonding Materials

Total, Self or Selective Etch MDP Universal

Bonding Materials

Total, Self or Selective Etch

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Universal Bonding Materials

Total, Self or Selective Etch

Decay Removal


Thoroughly remove decay only

Amalgam Preparation

Composite Preparation

“Convenience”Form MID Lifetime of tooth often determined by first dentist

intervention

Minimally Invasive Dentistry

Fissurotomy bur

201.3VF

Conservative Tooth Preparation

169L330

Low Viscosity Flowable Composite

How do you restore?

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G-aenial Universal Flo

Homogeneous spherical particles

High Viscosity (Low Flow) Flowable Composite

Mean particle size 200 nm Particle size range 40-5000 nm

G-aenial U Flo Conventional Nano-hybrid

G-aenial Universal Flo

Homogeneous spherical particles

Good wear resistance

High flexural strength (167 MPa)

Filled 50% by volume

Good polishability

Blends in well



Beautifil Flow 00

Unique glass ionomer filler particles

Releases fluoride and other ions

Neutralizes pH-Antibacterial

Good polishability

Visibly blends in well

S-PRG (Surface pre-treated Glass Ionomer)

Intra-oral plaque formation（24 hours W/O Brushing）

Less plaque Full-grown plaque

BEAUTIFIL Ⅱ（Containing S-PRG filler）

Conventional Restorative Material

（Not containing S-PRG filler）

plaque

S PRG Fillers

Reduced Plaque Accumulation

Dispenser Gun

Tray

Compule Tray

Warmer

CALSETThermal Assisted Light Polymerization

WARMER

Improved flowability of composites

Improved marginal adaptation

Improved rate of polymer conversion

Improved surface hardness/durability/polishing.

Decreased curing time and increased depth of cure

Increased sculptability and ease in shaping anatomy

ADVANTAGESADVANTAGESThermal Assisted Light PolymerizationThermal Assisted Light Polymerization

Stansbury JW. Use of near-IR to monitor the influence of external heating on dental composite photopolymerization. Dent Mat 2004; 20(8).

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Dispenser Gun TrayComax Dispenser

CALSETCALSETThermal Assisted Light PolymerizationThermal Assisted Light Polymerization

Low Viscosity Flowable Composite & Warmed Composite

Completed Tooth Restorations

Recurrent Decay


Composite Alternatives

Oral Environment Challenges-Xerostomia

“40% of all prescription drugs have dry mouth listed in the PDR as a possible side effect”

Chalmers J. Personal Communication. 2006.Chalmers J. Personal Communication. 2006.

Oral Environment Challenges-Xerostomia

• Incidence increases with # of drugs taken

• 50% of patients taking 4 or more medications had Dry Mouth

Oral Environment Challenges-Carbohydrates

Nutrition Facts: Serving Size: 8.3 fl. oz Calories: 140 Total Fat: 0g Sodium: 200mg Protein: 0g Total Carbohydrates: 28g Sugars: 28g

Nutrition Facts:16 fl oz; calories 140; total fat 0g; sodium 220mg; potassium 60mg; total carbs 28g; sugars 28g

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Oral Environment Challenges-Bottled Water

Fluoride-less water Fluoridated water

Oral Environment Challenges-Illegal Drugs

“Meth mouth” or chronic marijuana use

Xerostomia patients

High carbohydrate users

Non-fluoridated water users

Drug abusers

Need TherapeuticRestorations

Composite Challenges

•Post-operative sensitivity

•Recurrent decay

•Achieving proper moisture

•Polymerization shrinkage

•Increased time-layering

•Technique sensitivity

Low post-op sensitivity

Fluoride Release

Moisture variability

No shrinkage

Bulk placement

Simple-more forgiving

Glass Ionomer

Glass Ionomers (Self-Cured)

Glass Ionomer Family

Resin-Modified Glass Ionomers

(Dual Cured)

•More highly filled-reduced wear

•Self-curing in 2.5-5 minutes

•No polymerization (setting) shrinkage stress

•Expansion/contraction similar to tooth

•High fluoride release

•Bioactive

Glass IonomerCharacteristics

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•Multiple cervical carious lesions

•Pediatric Patients

•Sealants

•Class V restorations

•Sandwich Technique

•Crown buildups

•Long term interim restorations

•Cements

Glass Ionomer Uses

Fuji IX

Glass Ionomer Bases

RIVA SC FX-II

Gain access to decay using a high speed

Closed Sandwich Technique

Use slow speed and then spoon excavator

Stop if you feel you will expose pulp

SEM of dentin treated with PCA

Condition dentin with poly-acrylic acid for 10 seconds and wash


CARD

OS

O et al. J D

ent 2010

Condition enamel only with phosphoric

acid

Rinse thoroughly

Re-prep if necessary after set

Place Glass Ionomer base


Wait 2:30

Apply Seventh Generation Bonding

Agent

Zhang Y, Burrow MF, Palamara JEA, Thomas CDL. Bonding to Glass Ionomer Cements using Resin-based Adhesives. Op Dent 2011;36:618-625.


Finish and polish

Place Composite & Cure

(Sonic Fill)

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Long term interim restoration

Glass Ionomer RestorationsGlass Ionomer Restorations







But… How long do they last?

Zanata RL, Fagundes TC, Freitas MC, Lauris JR, Navarro MF. Ten-year survival of ART restorations in permanent posterior teeth. Clin Oral Investig. 2011;15(2):265-71

Placement 2 years 10 years

92.7% success

65.2% success

Survival Rate

Single Surface Restorations*(*based on placement of older GI formulations)


Zanata RL, Fagundes TC, Freitas MC, Lauris JR, Navarro MF. Ten-year survival of ART restorations in permanent posterior teeth. Clin Oral Investig. 2011;15(2):265-71

Placement 2 years 10 years

86.8% success

30.6% success

Survival Rate

Multiple Surface Restorations*

(n=62)

(*based on placement of older GI formulations)

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Five Year Restorations


How long do they last?• 8-12 years- single surface

• 5-8 years- multiple surface

• The larger the restoration, the shorter its lifetime


Then what?• Re-prepare surface and place posterior

composite restoration

• Prepare tooth for a crown

Equia

Glass Ionomer/Filled Resin Sealant

Easy, Quick, Universal…

Designed as a system that included surface sealant

Becomes stronger in time

Surface Sealant

• Fills in microcracks and porosity

• Provides a high gloss, smooth surface

• Increase wear resistance and allows material to mature

•Light Cured-Do not etch before applying

•Sealant retains moisture w/in restoration allowing better maturation and hardness before surface is exposed to forces

Surface Sealant

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Restoration w large crack Restoration w large crack

Dentist-Multiple Radiographic Caries Before and After

Equia Forte

Posterior Glass Ionomer

Equia Forte


Stronger Glass Ionomer

For use in posterior teeth

Increased compressive strength (219 MPa)

Increased flexural strength

Greater wear resistance

Increased acid resistance

High fluoride release maintained

Stronger surface sealant

Better designed for Class II posterior restorations

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Equia Forte


RIVA Self Cure HV

Sudden Onset Caries


Sudden Onset Caries


Posterior GI Restorations


•Acid/base and polymerization reaction

•Ionic and micromechanical bonding

•Dual-curing-faster

•Lower fluoride release

•More esthetic & translucent

Resin-Modified Glass Ionomers

•Liner or Base

•Class V Restorations

•Restoration Under Crown

•Temporary prior to crown

•Sandwich technique

•Cements

•Bonding Agent

Resin-Modified Glass Ionomer Uses

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Fuji Lining LC

Resin-Modified Glass Ionomer Liner

Vitrabond

Resin-Modified Glass Ionomer Base

Capsule

Fuji II LC RIVA LC

RMGI Liner

No dentin conditionerneeded due to self-etch

primer component

RMGI BaseReprepare

Dentin conditionerpreferred to achieve optional dentin bond

Quick Temporary prior to Crown Temporary placed 5 years ago

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Sandwich Technique

Resin-modified Bonding Agent–Triturated

–Reduces polymerization shrinkage

stress

–Novel concept

Riva Bond LC

Co-Cure Sandwich Technique*

Acid etch enamel

Condition dentin w PCA -wash

*recommended by Dr Graeme Milicich

Co-Cure Sandwich Technique

Wash thoroughly

Mix GIPlace Glass Ionomer

Spread w/ instrument


Use wet brush to spread out-up sides

Puncture seal and dip brush into RMGI


Light Cure

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Compress-push against margins

Insert Sonic-Fill tipExpress composite


Adjust occlusionPlace anatomyLight Cure Finish and Polish

Class I Composite Class I Composite CoCo--Cure Sandwich Cure Sandwich

TechniqueTechnique

Cut a large deep round divot into Class I Tooth PrepCut a large deep round divot into Class I Tooth Prep

Mix Glass Ionomer and RIVA bondMix Glass Ionomer and RIVA bond

Place GI into divot and spread outPlace GI into divot and spread out

Place brush into RIVA Bond capsulePlace brush into RIVA Bond capsule

Paint over GI and spread outPaint over GI and spread out

Light CureLight Cure

Place Composite and Light CurePlace Composite and Light Cure

•Exposed to occlusion

•Able to control moisture

•Not acid etching

•No shrinkage stress

•Highest fluoride release

•Out of occlusion

•Need quickness

•Need to acid etch

•Need to bond

•↑translucence/esthetic

Resin-Modified Glass Ionomer

Glass Ionomer

Glass IonomersThe “missing link” of esthetic

restorative materials

••Make initial access opening w small burMake initial access opening w small bur

••Use slow speed to remove decayUse slow speed to remove decay

••Use high speed to refine preparationUse high speed to refine preparation

••Smooth margins with a football diamond.Smooth margins with a football diamond.

Clinical Class I Restoration

••Completed PreparationsCompleted Preparations

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Bur Block Setup

#1 rd #4 rd Jazz Flame Jazz Cup Gw-256-021 56-018 230C 201.3VF 379-023 849-011(Pirhana)

56 169L 330 7901 7404 7406

Er:YAG Laser

Lite-Touch

••Often use no anesthesiaOften use no anesthesia

••Restoration blends well into toothRestoration blends well into tooth

Er:YAG Laser

Lite-Touch

••Laser inside handpieceLaser inside handpiece

••More efficient and easier to useMore efficient and easier to use

••Less ExpensiveLess Expensive

Er:YAG Laser

••Use for limited bone reUse for limited bone re--sculptingsculpting

••Biological WidthBiological Width

Ivoclar P-1

••Place glass ionomer base/linerPlace glass ionomer base/liner

••Etch enamel then dentin, wash and dryEtch enamel then dentin, wash and dry

••Place & scrub multiple coats bonding Place & scrub multiple coats bonding agent, wait, evaporate solvent and cureagent, wait, evaporate solvent and cure

••Place composite and adapt to sidesPlace composite and adapt to sides

•If large use incremental layers

•Cure thoroughly

Posterior Finishing Burs

Occlusal Anatomy OcclusalSecondary Anatomy

Buccal/ lingual gingival-IP

12 fluted carbide burs

ProcedureProcedure Trim and shape composite

Adjust occlusion

Blend margin between tooth and composite

Define secondary anatomy

Restore occlusal fissures

Restore buccal/ lingual contour

Reduce and smooth composite surface

Interproximal shaping at gingiva and above contact

Popular InstrumentsPopular Instruments Football or egg-shaped

7406

H379

15106-5

Flame-shape

H-274

5379-5

Needle shape

Safe-end SE6

7901

15121-5

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Ivoclar

Astropol

SS White

Jazz

Caulk Enhance/POGO

••Blend margins with finishing carbidesBlend margins with finishing carbides

••Adjust occlusionAdjust occlusion

••Finish and polishFinish and polish

Etch, wash/dry and apply surface sealantEtch, wash/dry and apply surface sealant

OOPS!

Endodontic Root Canal Endodontic Root Canal Therapy?Therapy?

Asymptomatic

Single small exposure

Able to achieve hemostasis

Perhaps not IF:

Traditional Pulpal ProtectionIndirect Pulp Capping

Best not to expose pulp• Asymptomatic• Sound 2mm around margins• Stop when next scoop will expose pulp• Place GI or Ca(OH)2

Traditional Pulpal ProtectionIndirect/Direct Pulp Capping

What are we trying to accomplish?

• Mechanical Sealing of the Pulp• Stimulate hydroxyapatite formation• Dentin bridge formation

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How does this happen?

• Material sets hard and adheres to dentin• Alkaline pH• Release of Ca++ ions Ca+2

OH-

H2O

Ca+2

OH-


Ca(OH)2 Paste• DyCal– Dentsply/Caulk (paste/paste)

• Multi-Cal– Pulpdent (non-setting)

Ca(OH)2 in VLC resin• Prisma VLC DyCal (light cured)

• Life– Kerr (light cured)

Unproven Pulpal ProtectionIndirect/Direct Pulp Capping

Resin Dentin Bonding?• Dentin Bonding Agent-Composite

“Contact with acid and pulp tissue started the bleeding process thus damaging the bonding technique resulting in no cellular differentiation and new dentin formation. The use of dentin bonding agents should be avoided for vital pulp therapy.”

Silva GA, Lanza LD, Lopes-Junior N, MoreiraA, Alves JB. Direct pulp capping with a dentin bonding system in human teeth: a clinical and histological evaluation. Oper dent. 2006;31:291-307.

Unproven Pulpal ProtectionIndirect/Direct Pulp Capping

Glass Ionomer/RMGI?

“Poly Acrylic Acid (PAA) inhibits apatite formation in the body environment. PAA released from the glass-ionomer cements inhibits the apatite formation on tooth surfaces. It might be considered difficult to obtain bioactive glass-ionomer cements”

Kawashita M, Kokubo T, Nakamura T. Effect of polyacrylic acid on the apatite formation of a bioactive ceramic in a simulated body fluid: fundamental examination of the possibility of obtaining bioactive glass-ionomer cements for orthopaedic use. Biomaterials. 2001;22:3191-6.

Improved Pulpal ProtectionIndirect/Direct Pulp Capping

Ca(OH)2 Paste• Ultra-Blend Plus– Ultradent

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Pulpal Protection – Indirect/DirectPulp Capping

MTA (Mineral Trioxide Aggregate)

• ProRoot-Dentsply• Biodentine-Septodont• Thera-Cal LC-Bisco

Bismuth oxide Bi2O3

Gypsum CaSO4 · 2 H2O

Tetracalcium aluminoferrite (CaO)4.Al2O3.Fe2O3

Tricalcium aluminate (CaO)3.Al2O3

Dicalcium silicate (CaO)2.SiO2

Tricalcium silicate (CaO)3.SiO2

Biodentine

Latest Pulpal ProtectionIndirect/Direct Pulp Capping

Resin Modified Calcium Silicate• Theracal

Latest Pulpal ProtectionIndirect/Direct Pulp Capping

Light cured apatite forming MTA in a unique hydrophilic resin (polyethylene glycol methacrylate) that releases calcium

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Hilton TJ. Keys to Clinical Success with Pulp Capping: A Review of the Literature. Op Dent 2009;34:615-625.

How many of you have How many of you have problems with Mandibular Nerve problems with Mandibular Nerve

Blocks?Blocks?

Really, Final

Answer?

Trustworthy, loyal helpful, friendly, courteous, kind

obedient..

YES NO….?


Blocks?Blocks?

30-Minute Time Course for Pulpal Analgesia - Lidocaine IANBsData from 30 PRP Studies (1991 - 2008), n = 1162 Subjects, Lidocaine/Epi IANB


Blocks?Blocks?

Mean 30-Minute Time Course for Pulpal Analgesia - Lidocaine IANBsData from 30 PRP Studies (1991 - 2008), n = 1162 Subjects, Lidocaine/Epi IANB

10 minutes (60%)


Blocks?Blocks?

30-Minute Time Course for Pulpal Analgesia - Articaine IANBsData from 5 PRP Studies - 222 Subjects (1990 - 2008)


Blocks?Blocks?

Mean 30-Minute Time Course for Pulpal Analgesia - Articaine IANBsData from 5 PRP Studies - 222 Subjects (1990 - 2008)

10 minutes (60%)

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Pharmacology of Local Pharmacology of Local AnestheticsAnesthetics

• Local Anesthetics is an acidic solution with a pH of ~ 3.9• It is an Inactive form to extend shelf life• Body must raise pH of the local anesthetic to ~ 7.4 for it to be

active• Takes up to 6-15 minutes • Sodium Bicarbonate neutralizes the anesthetic solution• Buffered anesthetic brings pH level close to physiologic pH

prior to injection

Pharmacology of Local Pharmacology of Local AnestheticsAnesthetics

• Buffered anesthetic brings pH level close to physiologic pH prior to injection

• Very quick onset (2-3 minutes)-able to determine proper injection site soon

• More comfortable injection with less burning• More profound anesthesia—6,000 times more active

anesthetic at time of injection• CO2 microbubbles created during mixing improves ability of

anesthetic to cross nerve membrane

Buffered and nonBuffered and non--buffered buffered anestheticanesthetic--time vs. efficacy of time vs. efficacy of

IANBIANB

Mean 30-Minute Time Course for Pulpal Analgesia – Lidocaine, Articaine , Buffered Lidocaine IANBsData from published and company Studies

2 minute Buffered as effective 2 minute Buffered as effective as 10 minute nonas 10 minute non--buffered buffered anestheticanesthetic--efficacy of IANBefficacy of IANB


67%

8 minute Buffered anesthetic 8 minute Buffered anesthetic gives 90+% efficacy of IANBgives 90+% efficacy of IANB


67%Cartridge Connector Mixing PenBicarbonate Solution

Onset by OnpharmaOnset by Onpharma

32

AnutraAnutra

Advantages– Increased onset of

analgesia-feedback

– Increased efficacy of analgesia

– More comfortable injection

Challenges– New routine

– Cost

Buffered AnesthesiaBuffered Anesthesia

Anutra– $500/month

– Commitment to system

– Used on every patient

– Once setup easy to use and saves time

Onset– $50/10 injections

– Less change to routine

– Used only on difficult injections

Buffered AnesthesiaBuffered Anesthesia

1‐844‐268‐8721www.AnutraMedical.com

If you are interested…

Onset Anutra

1‐877‐336‐6738www.onpharma.com

GC products

Kerr products

Venus Pearl

New Resin TechnologyNew Resin TechnologyNon Non bisbis--GMA CompositesGMA Composites Bulk Fill CompositesBulk Fill Composites

Allow many posterior restorations to be built up in 1 segment

Descriptions– “Stick the stuff in the hole and cure”– Evolutionary– Monolithic

Physical Advantages– Deeper depth of cure– Less Polymerization Shrinkage– Less Polymerization Shrinkage Stress– Reduced likelihood of air voids between layers

33

Bulk Fill CompositesBulk Fill Composites

Modes of Action– Improved initiators– Greater translucency allows better light transmission– Delayed gel state formation– Increased elasticity

Materials– Flowable– Conventional

Advantages– Quicker, easier– Less chance of enamel and cusp fractures– Increased likelihood of adequate resin polymerization

Bulk Fill Flowable CompositesBulk Fill Flowable CompositesLow Shrinkage StressStress

•Surefill SDR

• Voco Xtra

•Beautifil Bulk Flowable

•Venus Bulk Fill

Surefill SDRSurefill SDR

•Reduced polymerization shrinkage stress

• Bulk fill to 4mm

•Increased sensitivity to light

Great placement with metal tips

•Self-leveling

•A1, A2, A3 Universal shades

Roggendorf MJ1, Krämer N, Appelt A, Naumann M, Frankenberger R. Marginal quality of flowable 4-mm base vs. conventionally layered resin composite. J Dent. 2011;39:643-647.

Polymerization Shrinkage Polymerization Shrinkage StressStress(MPa)(MPa)

Bulk Fill Posterior CompositesBulk Fill Posterior CompositesLow Shrinkage StressStress

• Voco Xtra Fill

•Beautifill Bulk Flow

•Aura Bulk Fill

•Tetric Evo-Ceram Bulk Fill

•Sonic Fill

Sonic Energy Assisted Light Sonic Energy Assisted Light PolymerizationPolymerization

Sonic FillSonic Fill

34

Improved flowability of composites

Improved marginal adaptation

5mm depth of cure

Increased sculptability and ease in shaping anatomy

Composite designed specifically for use

ADVANTAGESADVANTAGESSonic Energy Assisted Light Sonic Energy Assisted Light

PolymerizationPolymerization





Interproximal Contacts

Composite Direct Placement Composite Direct Placement ChallengesChallenges

Christensen JJ. Duplicating the form and function of posterior teeth with Class II resin-based composite. Gen Dent. 2012;60:104-108.

Microband Focu-tip Trimax

Interproximal ContactsInterproximal ContactsOriginal Attempted SolutionsOriginal Attempted Solutions

Not enough pressure to separate teeth

Fly off

Wedge in the way

Interproximal ContactsInterproximal ContactsSectional Matrix ChallengesSectional Matrix Challenges

35

TofflemireTofflemire vs. Sectional vs. Sectional MatricesMatrices

Tofflemire System

Thin contact at the marginal ridge

Non‐anatomical Foodtrapbelowcontact

Increasedlikelihoodof:fracture,recurrentcariesandperiodontaldisease.

SectionalMatrices

Broad contacts at the proper height of contour

Anatomicallyshapedcontacts

TightContactsPropercontactsthatflossproperlyandpromotegingivalhealth

Interproximal ContactInterproximal Contact

RetainersRetainers

TrioDent/Palodent

Universal V3 Ring Narrow V3 Ring


Also Available as:Also Available as:

Palodent Plus

Universal Ring Narrow Ring


BandsBands

TrioDent/Palodent Plus

Bendable tab

Side holes for easy removal

Holes allow grip with Pin-Tweezers

Marginal Ridge Contour

Pin Tweezers


BandsBands


Bicuspid

Molar

Sub-gingival Molar

36


Anatomical WedgesAnatomical Wedges

Wave Wedges

Pin Tweezers


Challenge:

Adjacent Class II Composite Restorations

Prepare enamel margins

Place contoured

band, wedge & V-Ring

Selective etching

Wash thoroughly

Apply bonding agent

Fill box 2/3’s full

Compress w 1P

Cure

Finish buildup

Cure

Sonicfill

Remove wedge peel band back

Cure IP

Remove band & cure

ContacEZ

Re-contour diamond/finishing

carbides

Finishing strips

Place V-Ring on adjacent tooth

Burnish desired contact area

Selective etching

Place Universal bonding agent

Light Cure

37

Peel back band

Cure from both sides at

gingiva

Place Composite as before

Light Cure Finish and polish

Adjust occlusion

Adjacent Class II Preparations Band and Retainer on Mesial of Adjacent Interproximal Tooth

Push band in using placement instrument

Add first increment-push B & L

38

Add second increment to top Add final increment-push against margins

Form occlusal anatomy and light cure

Disassemble retainer and matrix band-light curing IP each step

Remove Interproximal excess-shape contact area w dia/carbide

Blend and shape IP margins

39

Shape Occlusal with Egg Shaped Finishing Carbide-Blend margins

Adjust occlusion (if no dam placed) -shape anatomy w 245 bur

Finish and polish Place both bands and wedges

First place mesial retainer Place distal retainer

40

Burnish contacts (Bond in mouth) add f2 increments to mesial-adapt well

Repeat process on distal Fill occlusal, shape and light cure

Remove retainer-light cure IP Remove wedge-light cure IP

41

Remove band-light cure IP Shape Occlusal with Egg Shaped Finishing Carbide-Blend margins

Blend and shape IP with Pointed finishing carbide

Shape along gingiva w pointed finishing carbide

Shape Occlusal IP for EZ flossing Adjust occlusion-shape anatomy w 245 bur

42

Polish with cups(in mouth use IP finishing strips

Polish with points

Post-Cure (Optional etch & surface sealant)

Finished Restorations

Thank You!

www.drwardhandouts.com

[email protected]

Documents

CDA-Anaheimd1ue90e5sp4tcv.cloudfront.net/2855/images/Asset296428_v1.pdf · CDA-Anaheim Daniel H Ward DDS Graduated 1979 OSU Private Practice‐Columbus, Ohio Assistant Clinical Professor