Colored Restoration Placement Direct Restorations should ......Colored Restoration Placement Direct Restorations should not be thought of as Temporary Core Buildups! 3 Topics •Minimally

Techniques for Perfecting Tooth Colored Restoration Placement

Ohio State University College of Dentistry CE Fawcett Center 11/8/2019

Daniel H Ward DDS 1

1

Daniel H Ward DDS

November 8, 2019

Let’s be DirectTechniques for Perfecting Tooth Colored Restoration Placement Direct Restorations should

not be thought of as

Temporary Core Buildups!

3

Topics•Minimally Invasive Diagnosis & Treatment•Improved Dentin Bonding•Age-appropriate Restorations•Innovative Bioactive Materials•New Composite Technology•Perfecting Predictable Class II Restorations•Hands-on

Let’s be DirectTechniques for Perfecting Tooth Colored Restoration Placement

•Early detection of disease to

minimize the need to remove

large amounts of diseased tissue

and tooth structure

Minimally Invasive Dentistry Diagnosis

1

“Minimally Invasive Dentistry

(MID) is the application of a

systematic respect for the original

tissue."

?Ericson D. What is Minimally Invasive Dentistry? Oral Health Prev Dent. 2004;2 Suppl 1:287-92.

Minimally Invasive Dentistry Technology

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Daniel H Ward DDS 2

MID Diagnostics

•Digital Radiography

•Instant viewing

•Less Radiation

•Environmental

•Contrast & Brightness Adj

•Patient Display

•Insurance

•Remote access

Digital Radiography

Dexis

•i CAT

CBCT Scan

•CBCT

CBCT Scan

•Oops!

CBCT Scan

•Laser Fluorescence Caries Detection

•Diagnodent

•655 nm laser

•Decay fluoresces

•Numeric display & audible sound

•>30 decay

•Great for patient education & confirmation

MID Diagnostics

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Daniel H Ward DDS 3

Diagnodent

•Stained Grooves •Place tip in occlusal pits

Diagnodent

•Lite Touch Erbium YAG Laser

Hard Tissue Laser

•Tooth Preparation

Hard Tissue Laser

•Restored w High Viscosity Flowable

Diagnodent•Spectra

•405 nm blue light

•Decay porphyrines fluoresce red

•Numeric display in freeze frame

•Utilizes computer software

•Fluorescence Caries Detection

MID Diagnostics

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Daniel H Ward DDS 4

•Blue (1-1.5)-Initial Enamel Caries

•Red (1.5-2)-Deep Enamel Caries

•Orange (2-2.5)-Dentin Caries

•Yellow (>2.5)-Deep Dentin Caries

•Fluorescence Caries Detection

Spectra•SoproLife

•450 nm blue light

•Intra-oral camera switched to emit blue light

•Black cap placed over tip

•Live video

•Light Caries Detection

MID Diagnostics

•Green-normal

•Red-caries

•Light Caries Detection

SoproLife

•Near infra-red trans-illumination

•CariVu

•Near infra-red trans-illumination

•Need proprietary software

•Works with Dexis

MID Diagnostics

•Radiographic View

•Uncertain radiographic findings

MID Diagnostics

•Clinical View

CariVu

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Daniel H Ward DDS 5

•Device around tooth

CariVu

•CariVu Image

CariVu

•Initial Excavation

CariVu

•Prep and Liner

CariVu

•Finished Restoration

CariVu

•Maximal preservation of

healthy dental structures2

Minimally Invasive Dentistry Treatment

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Daniel H Ward DDS 6

Lifetime of tooth often determined by

first dentist intervention

Amalgam Preparation Composite Preparation

“Convenience” Form MID

Fissurotomy bur

201.3VF

Conservative Tooth Preparation

169L330

How do you restore?

?

High Viscosity Flowable Composite

Beautifil Flow

Plus X 00G-aenial

Universal

Injectable

•Designed to be the entire restoration

•Use Spherical particles

•Filled >50% by volume

•Good wear resistance

•High flexural strength

•Good polishability

G-aenial Universal Injectable

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Daniel H Ward DDS 7

Set Glass Ionomer Material Surface Modified Pre-Reactive

Glass Ionomer Filler

Surface modified

layerGlass Ionomer phase

Glass Core

Beautifil Flow Plus X 00

Set glass ionomer filler particles

High Viscosity (Low Flow) Flowable Composite

Dispenser Gun

Tray

Compule Tray

Warmer

CALSETThermal Assisted Light Polymerization

W

A

R

M

E

R

● 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

ADVANTAGESThermal 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).

Low Viscosity Flowable Composite

& Warmed Composite

Completed Tooth Restorations

15 Year Old RED Proportion Template

Minimally Invasive Dentistry

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Daniel H Ward DDS 8

Multiple Step Layering Techniques

Buildup dentin

replacement with

opaque darker hybrid

–typically A3-A3.5


Buildup dentin

replacement with




Buildup remaining

form with shade

similar to desired

final color with

hybrid (typically A1-

A2)

Buildup dentin

replacement with



Buildup remaining

form with shade

similar to desired

final color with


A2)

Add special effects to

simulate

imperfections within

tooth structure


Buildup dentin

replacement with



Buildup remaining

form with shade

similar to desired

final color with


A2)

Add special effects to

simulate

imperfections within

tooth structure

Add translucent

incisal hybrid or

microfill


● Darker to Lighter

● Opaque to Translucent

● High Chroma to Low Chroma

● Larger Particle to Smaller Particle

● Low Polishability to High Polishablity

L YERING Principles(from Inner to Outer)

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Daniel H Ward DDS 9

Add dentin shade

•Aura Dentin 6

•Miris

Add General Purpose

Shade

•Aura MC 3

•TPH Spectra

•Coltene Brilliant

Add Characterization

Important-Junction

must be invisible

Add decalcification,

brown, gray zones

(incisal blue)

Add Facial Surface

•Aura Enamel

•G-aenial GT

•Beautifil II

•Esthelite Sigma Quick

•Harmonize Enamel

Optrasculpt Pad

Non-Stick foam pad attachments (Ethylene Vinyl

Acetate)

Two pad sizes for contouring of direct veneers and

large-surface class III and IV restorations

Reference scale to measure the width of the anterior

teeth (RED Proportion)

Gross contouring of

facial surface

Incisal edge

Quick Contouring

•No metal in the center

•Very Flexible

•Double Sided

•Available in Unit Dose

859-014

Coarse, fine

diamonds, finishing

carbides

Enhance to blend

margin, develop

facial surface contour

Astropol to finish

Diacomp Feather Lite

to polish

Astropol

Shaping, Finishing and Polishing

Enhance

7901

Diacomp Feather Lite

201.3VF

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Daniel H Ward DDS 10

Restore adjacent

tooth

Shape, finish and

polish restorations

Restore opposite

teeth

Pre-Operative

Finished Restorations

Direct Contouring Techniques

Technique by Dr

Paul Belevedere

and Dr. Doug

Lambert

Mold Margin Perfect

Matrix

Margin Perfect

Matrix

Pre-Shaped matrix

Place and cut excess

ends of matrix

Hold instrument

against band

Use Heliobond to

adhere to gingiva

MPM in place sealed

against gingival

margin

Etch

Thoroughly wash and

dry

Place bonding agent

and light cure

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Apply composite and

adapt to sides

Trim with diamonds

then finishing carbide

burs

Use brush to push

composite into

corners

Finish and polish

restoration

Shape, finish and

polish restoration

Restore opposite

tooth

Technique by Dr

Paul Belevedere

Treatment by Dr.

Doug Lambert

•Total Etch Technique

•Self Etch Technique

•Selective Etch Technique

Improved Dentin

Bonding

Total-Etch Technique

Challenges

Under-etched enamel

Over-etched dentin

Proper moisture

Incompletely filled dentinal tubules

Post-Operative Sensitivity

Placement of Etchant

Total Etch Technique

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“Moist” Dentin”

Rinsing of Etchant Placement of Resin Primer

Apply multiple coats

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

Proper Moisture Moisture Variability

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Acetone

Alcohol

Water

Bonding Agent SolventsAir only syringe

Air/water syringe

Evaporating the solvent with dry air


• Chlorhexidine

•HEMA


1.Chlorhexidine lowers the surface

tension of water. It is a linear moleculewith positive charges on both ends .

2.One positive end is drawn to the

negatively charged tooth, the

other positive end attaches to the negative cell wall of the bacteria.


3. Desensitizer infuses the dentin surface

bringing HEMA and water with it. This wetting optimizes anti-microbial activity. It also helps the collagen fibers stand up for

better hybrid zone bonding

4. The majority of dentin bond

strengths comes from the hybrid zone.

Benefits

• Superior antimicrobial activity

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29

36

28

270 9 18 27 36 45

Deep Dentin

Superficial Dentin

Tensile Bond Strength (MPa)

With HS & C Without HS & C

Benefits

• Superior antimicrobial activity

• Enhances bond strength

• Antimicrobial activity

• Inhibits enzymatic degradation

• Enhances bond strength

• Reduces micro-leakage

• No soft tissue burning

• Economical

Benefits


Materials-4th

Generation

Acetone solvent Alcohol solvent


Materials-5th

Generation

Acetone solvent Alcohol solvent

Self-Etch Technique

Challenges

Decreased bond strength & marginal gap formation w/ un-etched enamel

Bond incompatibility to self-cure & dual-cure resins

Hydrolytic degradation

Enzymatic collagen attack

Acid-groups

Hydrophilic end

etches tooth

structure (self

limiting)

Spacer-chain

link between

functional groups

Methacrylate-group

Hydrophobic 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 Contribute less to Dentin

Adhesion in SE Adhesion

Self etching Primer

● SEM analysis found no marginal gap formation

of enamel etched w phosphoric acid prior to

application of a self-etching 6th generation

bonding agent following thermocycling

● SEM analysis reported marginal gap formation

of enamel not etched w phosphoric acid prior to

application of a self-etching 6th generation

bonding agent following thermocycling

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.

Marginal Gap Formation

Solution 1: “Etching prepared enamel w

phosphoric acid promoted better marginal

integrity with self-etching bonding agents.”

Marginal Gap Prevention

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.

Solution 2:Use OptiBond eXTRa Universal

Marginal Gap Prevention

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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.

When the pH of a dentin bonding agent is too

low, 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 1: Use a self-cure dentin bonding

agent

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.


Dual Cured Resins

Solution 2: Use a dual-cure activator


Dual Cured Resins

“The cured layer of 1-step self-etching

adhesives (6th & 7th generation) 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

Solution1: 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-layering at the adhesive interface. J Dent Res 2012;9:376-381.


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Solution2: 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.

MMP-Matrix Metalloproteases

● MMPs are naturally occurring proteases

involved in dentin formation and trapped during

odontogenesis

● Not bacteria but proteolytic enzymes found

within dentin capable of degrading collagen

within newly created adhesive hybrid layers

● Low pH causes dentin to release these inherent

MMPs which attack exposed collagen fibrils Osorio R, Yamauti M. Osorio E., et al. Effect of dentin etching on metalloproteinase-mediated

collagen degradation. Eur J Oral Sci 2011;119:79-85.

Enzymatic Collagen Attack

MMP-Matrix Metalloproteases

Carrilho et al., JDR 2007; 86; 529

Brackett et al.,Operative Dentistry; 2009;34(4):381-385

In-vivo 12 m w/PBNT (Acetone)

Immediate (MPa)

Control 29.3 (9.2)

CHX 32.7 (7.6)

w/CHX in 12 m

14 mo (MPa)

Control 19.0 (5.2)

CHX 32.2 (7.2)

Potential MMP Inhibitors

Long Term Dentin Bond Stability

● Chlorhexidine (CHX)

● Hemaseal & Cide

● Benzalkonium Chloride

● MDPB (12-methacryloxydodecalpyridinium

bromide)

● GLUMA

Perdigao J, Resi A, Loguercio AD. Dentin Adhesion and MMPs: A Comprehensive Review. J

Esthet Restor Dent 2012: 25:219-241.

Disinfect to prevent MMPs

Use Etchant containing 1%

Benzalkonium Chloride

TE-Apply 2% Chlorhexidine

after acid etching for 30 sec

SE-Apply 2 coats 2%

Chlorhexidine prior to

application of primer

OR


Disinfect to prevent MMPs

MDPB (12-methacryloxydodecalpyridinium bromide)


Pashley DH, Tay FR, Imazato S. Hot to Increase the durability of Resin-Dentin Bonds. Compend.

2010;32(7):60-64.

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Self-Etch Technique

Materials-6th

Generation

Selective-Etch Technique

Challenges with Self-

Etching Primers:

Improved Enamel Bonding

But…

Selective-Etch Technique

Challenges with Self-

Etching Primers:

Poorer Dentin Bonding

THE SolutionSelf-etch Selective-etch Total-etch

Universal Bonding Agents

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.


All-Bond Universal

Total-etch, self-etch or selective-etch

Single bottle for direct and indirect

restorations

High bond strengths to metal, ceramics,

zirconia, porcelain & lithium disilicate.

Compatible with light-cured, self-cured

and dual-cured composite and luting

cements since pH is 3.2

Becomes hydrophobic upon setting


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Contain MDPContain MDP


Contain MDP


OptiBond Universal

Proprietary Agents

OptiBond eXTRa


AGEAPPROPRIATE

RESTORATIONS

0

30,000,000

60,000,000

90,000,000

120,000,000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Nu

mb

er o

f P

erso

ns

60+

Population 60+ by Age: 1900-2050Source: U.S. Bureau of the Census

Age60-64

Age65-74

Age75-84

Age85+

Number of people aged 60+

28 M

42 M

57 M

92 M

US Population is Aging

0

0

0

0

0

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Per

cen

tag

e 60

+

Percentage 60+ by Age: 1900-2050

Source: U.S. Bureau of the Census

Age

60-64

Age

65-74

Age

75-84

Age

85+

Percentage of people aged 60+

14%

17%18%

25%

10

5

15

20

25

30

US Population is Aging

109 110

111 112

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• Xerostomia

• Root exposures

• Difficulty maintaining oral hygiene

• Some unable to tolerate long

appointments

• Difficulty coming to office

• Fixed Income

US Population is Aging US Population is Aging

● Don’t miss appointments

● Appreciative

● Pay bill

● Often need more treatment

● Refer new patients

● Say Thank You!

60+ Patients are Wonderful

One-Visit Technique

● Immediate placement natural tooth fiber-reinforced bonded pontic

•Perio abcess

•Sub-gingival

distal decay

•Carefully extract

tooth

•Suture

•Scale and root

plane adjacent teeth

•Cut off root of

extracted tooth

•Remove decay and

restore with glass

ionomer

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•Tryin and prepare

slots

•Shape root area to

support tissue

•Cut lingual slot

when trying inline

with 2 adjacent

teeth

•Measure space

and cut Ever Stick

fibers

•Place tooth

•Etch and bond

•3 months later

•3 months later

Before

Happy patient says

that I just

“straightened” his

crooked tooth

Multiple Medications

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.

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In a published study of 131 different prescribed medications the most common side effect cited was xerostomia.

Smith RG, Burtner AP. Oral side-effects of the most frequently prescribed drugs. Spec

Care Dent. 1994;14:96-102.


• 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

Oral Environment Challenges-Antacids

Ingredients:Calcium carbonate, adipic acid, corn starch,

crospovidone, dextrose, flavors, malodextrin, sucrose, talc,

colors.

Oral Environment Challenges-Bottled Water

Fluoride-free water Fluoridated water

Oral Environment Challenges-Illegal Drugs

“Meth mouth” or chronic marijuana use

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➢Xerostomia patients

➢High carbohydrate users

➢Non-fluoridated water users

➢Drug abusers

Need TherapeuticRestorations

Bioactivity

Having an effect upon a living organism, tissue, or cell.

Biologically active.

Bioactive

Google Image Word Search

• Under acidic attack release ions

• Primarily fluoride, calcium, phosphates

• Activa restorative and base material

• Theracal pulp capping material

• Theracem cement

• Glass Ionomers

• Others

Bioactive

RestorativeMaterials

Glass Ionomer

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Fuji IX Self Cure

Glass Ionomer

RIVA Self Cure

Glass IonomerFX-II Self Cure

Glass Ionomer

Glass Ionomer Restorative

•Self-curing:Acid/Base setting reaction

•Ionic Bonding to tooth Calcium

•No polymerization shrinkage stress

•More highly filled-reduced wear

•Expansion/contraction similar to tooth

•High Fluoride Release-Bioactive

Glass Ionomer Properties

•Cervical carious lesions

•Crown margin repairs

•Pediatric Patients

•Sealants

•Crown buildups

•Sandwich Technique

•Crown buildups

•Long term interim restorations

Glass Ionomer Uses

Patient on multiple medications

Glass Ionomer Cervical Caries

Remove decay and place matrices


Treat dentin with PAA


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Place, shape and wait 2:30


Shape with very fine diamonds & water


Dry and place Surface Sealant

No phosphoric acid


15 year old drug abuser


Excavate

Bulk placement


Place surface

sealant

Light cure sealant


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Hold down gingiva &

blend using fine

diamond & copious

water spray

Blend margin with fine carbide


Wash & dry

Apply Surface Sealant

Finished restorations


Class V root caries


Class V root caries


Repair around crown margins


Repair around crown margins


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Class II

Glass Ionomer Pediatrics

Class II Restored

Glass Ionomer Pediatrics

Internal Cracks

Glass Ionomer Crown Buildup

Completed buildup

Glass Ionomer Crown Buildup

Place

Glass Ionomer Sealants

Partially erupted

vulnerable tooth Etch with

phosphoric acid

5 Years Later

Glass Ionomer Sealants

Place surface

sealant Light cure

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Glass Ionomer Closed Sandwich

Gain access to

decay using a high

speed

Use slow speed and

then spoon excavator

Stop if you feel you will

expose pulp


Condition dentin with

poly-acrylic acid for 10

seconds and wash

CARD

OSO

et a

l. J Dent 2

010SEM of dentin treated with

PCA

Note unopened tubules


Condition enamel only

with phosphoric acid

for 10 seconds and

wash


Place glass ionomer

base

Place Universal Dentin

bonding agentAllow to set

Re-prep if needed


Place composite

and light cureFinish and Polish

Glass Ionomer Open Sandwich

Preparation with

dentin cervical

margin

Etch enamel with

phosphoric acid -20 sec

Condition dentin with

polyacrylic acid-10 sec

Wash thoroughly

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Place glass ionomer

base

Allow to set, then

reshape and wash &

dry if needed

Place Universal

Bonding Agent

*Alternative-Place RMGI

bonding agent over

unset GI and light cure

*recommended by Dr Graeme Milicich


Buildup tooth with

composite

Shape with fine

diamonds and

finishing carbides

Finish and Polish


Straight -contoured

Restorationmesial view

Glass Ionomer

Composite

RMGI

Bonding Agent

Crown Needed

Long-term Interim Restoration

Tooth Excavation


Band w contact opening


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Completed Glass Ionomer Restoration

Long-term Interim Restoration Posterior Glass Ionomer•Long-term provisional restoration

•High-caries risk patients

•Deep sub-gingival molar interproximal restorations

•Thin buccal walls

•Cracked teeth

•Transitional restoration before a crown

Equia Forte RIVA Self Cure HV

Posterior Glass Ionomer

Restoration with large crack



Conditioning and Placement


Surface Sealant placed

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Before and After Dentist-Multiple Radiographic Caries



GI Placement Before and After


High caries risk patient


High caries risk patient


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Summary

● 5-10% of teeth restored

● High caries situations

● Thin buccal or lingual walls

● Deep internal cracks

● Deep subgingival Class II near pulp

● Decalcified chalky margins

● Long Term Interim Restorations

● Invaluable adjunctive material

Posterior Glass Ionomer Resin-Modified Glass Ionomer(RMGI)

•Dual-curing:Acid/Base & Polymerization Reaction

•Ionic & Micromechanical Bonding

•Shrinkage stress if cured prior to set

•Higher tensile, bond strength and wear

•More Translucency

•Fluoride Release-Bioactive

RMGI Properties

•Liner or Base

•Class V Restorations

•Crown Buildups

•Temporary prior to crown

•Sandwich technique

•“Dental Duct tape”

RMGI Uses

Fuji II LC RIVA LC

Resin-Modified Glass IonomerCapsules

Resin-Modified Glass IonomerPaste/Paste

Fuji Filling LC Fuji Automix LC

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RMGI Liner

No dentin conditioner needed due to

self-etch primer component

RMGI Base

RMGI Base

Place RMGI & light cure

Re-prepare if necessary

Etch tooth and base

with phosphoric acid

Place composite

RMGI Class V-Capsule

Corrosive root caries

Prepare teeth & place

retention

Etch enamel only with

phosphoric acid*

*Sauro S, Faus-Matoses V, Makeeva I, et al. Effects of Polyacrylic Acid Pre-Treatment on Bonded-Dentine Interfaces Created with a Modern

Bioactive Resin-Modified Glass Ionomer Cement and Subjected to Cycling Mechanical Stress. Materials 2018 Oct;11(10):1884.

RMGI Class V-Capsule

Bulk placement

Light cure immediately

(Or wait to reduce

polymerization shrinkage stress)

Hold gingiva down with

instrument & shape with

fine diamonds and finishing

carbide with water

Etch tooth & restoration with

phosphoric acid, rinse, dry

& place surface sealant

RMGI Class V-Paste/paste

Place retraction cord

Prepare tooth with

undercuts

Etch enamel only with

phosphoric acid*

194 195

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198 199




RMGI Class V-Paste/paste

Bulk placement

Light cure

Hold gingiva down with

instrument & shape with

fine diamonds and finishing

carbide with water

Apply surface sealant or

gently polish with slow

speed coated abrasives

RMGI-Crown Buildup

Place tip and express

material

Light cure & then allow

to fully self-cure

Quick preparation &

removal of provisional

RMGI-Crown Buildup

Seated Zirconia CrownCompleted preparation

Monday morning?

RMGI-Temporary prior to Crown

Fractured cusp,

no pain, late

Friday afternoon

No prep-Place

RMGI

Bulk placement & light cure

RMGI-Sandwich Technique

Decayed tooth

Excavate

thoroughly

Finished & Surface sealant applied

RMGI-Sandwich Technique

Reshape base-

curved floor Placement prior

to curing

200 201

202 203

204 205




Base/Liner Restorative

•Higher compressive & flexural strength

•Glass ionomer filler particles

•Ionic resin matrix

•Calcium, phosphate & fluoride release

•Dual cure, self cure, light cure

•Bioactive

ACTIVA

Pulp Capping

OOPS!

Direct Pulp Capping

Endodontic Root Canal Therapy?

●Asymptomatic

●Single small exposure

●Able to achieve hemostasis

Perhaps not IF:

Indirect Pulp Capping

Best not to expose pulp

• Asymptomatic• Sound 2mm around margins• Stop if next scoop will expose pulp• Place Ca(OH)2

Hilton TJ. Keys to Clinical Success with Pulp Capping: A Review of the Literature. Op

Dent 2009;34:615-625.

206 207

208 209

210 211




Indirect Pulp Capping

Calcium Hydroxide Liners

• Limelight• Ultra-Blend Plus• Thera-Cal

Goals

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

Direct Pulp Capping

Mechanism

Ca+2

OH-Ca+2

OH-

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

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.

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.

Direct Pulp Capping

Ca(OH)2 Paste• DyCal– Dentsply/Caulk• Multi-Cal– Pulpdent

Ca(OH)2 in VLC resin• Prisma VLC DyCal • Life– Kerr

Direct Pulp Capping

Materials

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

Direct Pulp Capping

MTA (Mineral Trioxide Aggregate)

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

Tricalcium silicate (CaO)3.SiO2

Dicalcium silicate (CaO)2.SiO2

Tricalcium aluminate (CaO)3.Al2O3

Tetracalcium aluminoferrite (CaO)4.Al2O3.Fe2O3

Gypsum CaSO4 · 2 H2O

Bismuth oxide Bi2O3

Direct Pulp Capping

Resin Modified Calcium Silicate• Theracal

Direct Pulp Capping

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

Biodentine

Hilton TJ. Keys to Clinical Success with Pulp Capping: A Review of the Literature. Op Dent

2009;34:615-625.

Direct Pulp Capping

STOP!

Control bleeding

Water, saline,

chlorhexidine, sodium

hypochlorite

Place Theracal & cure

Finish Excavation

218 219

220 221

222 223

http://en.wikipedia.org/wiki/Alite

http://en.wikipedia.org/wiki/Belite

http://en.wikipedia.org/wiki/Tricalcium_aluminate

http://en.wikipedia.org/wiki/Calcium_Aluminoferrite

http://en.wikipedia.org/wiki/Gypsum

http://en.wikipedia.org/wiki/Bismuth_oxide




Direct Pulp Capping

Cover with RMGI

Summary

● Best is to avoid

● Asymptomatic

● 1 small exposure

● Able to control bleeding

● Irrigate with chlorhexidine

● Biodentine most effective

● Theracal-practical, less expensive

● Other products available

Direct Pulp Capping

Google Image Word Search

Bioactivity-The Future

Self-Healing

New Composite

Technology

•Designed to be the entire restoration

•High Strength, Low Wear

•Good Handling

•Translucency/Opacity

•Blending ability

•Polishability

Universal Composite• GrandioSO

• Mosaic

• Brilliant Ever Glow

• Venus Pearl

• Spectra TPH ST

• Harmonize

• Tetric Evo-Ceram

• G-aenial Sculpt

• Filtek Supreme Ultra

• Beautifil II

• Esthelite Sigma Quick- Omnichroma

Translucency

Universal Composite

224 225

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Open Margin Cracked Enamel

(white line)

Effects of Polymerization Shrinkage STRESS

Fractured Cusp

DX-511

MW 895

BIS-GMA

MW 512

UDMA

MW 470

TEGMA

MW 286

MW=Molecular Weight

New Resin Technology

Concerns about bis-GMA (Estrogenity)

Shrinkage of bis-GMA,TEGMA

Higher molecular weight-less shrinkage

DX-511


GC Products-G-aenial Sculpt

Kerr products

Pulpdent products

Venus Pearl


Non bis-GMA

Layering

● 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

Bulk Fill Composites

230 231

232 233

234 235




Bulk Fill Composites

● Modes of Action– Initiators more light sensitive– 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– Fewer air voids

Bulk Fill Flowable Liner/Base Composites

•Surefill SDR

•Voco Xtra

•Beautifil Bulk Flowable

•Venus Bulk Fill

Surefill 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.

•Excellent with very smaller preparations

•Challenging anxious patients

•Cusp-buildup technique

•Increased translucency

•Results are surprisingly very good

Bulk Fill Flowable

Restorative Composites

G-aenial Bulk

Injectable

Beautifil Bulk

Flowable

Bulk Fill Flowable Restorative Composites

Bulk Fill Posterior CompositesLow Shrinkage Stress

• Voco Xtra Fill

•Beautifill Bulk Flow

•Reveal

•Aura Bulk Fill

•Tetric Evo-Ceram Bulk Fill

•Sonic Fill

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Sonic Energy Assisted Light Polymerization

Sonic Fill 3

● Improved flowability of composites● Improved marginal adaptation

● 5mm depth of cure

● Increased sculptability and ease in shaping anatomy

● Composite designed specifically for use

ADVANTAGESSonic Energy Assisted Light Polymerization


Sonic Fill


Sonic Fill

Perfecting Predictable Class II

Restorations

Christensen JJ. Duplicating the form and function of posterior teeth with Class II resin-based

composite. Gen Dent. 2012;60:104-108.

Tofflemire vs. Sectional

Matrices

Tofflemire System

➢ Thin contact at the

marginal ridge

➢Non-anatomical

➢ Food trap below contact

➢ Increased likelihood of: fracture, recurrent caries and periodontal disease.

Sectional Matrices

✓Broad contacts at the

proper height of contour

✓Anatomically shaped contacts

✓Tight Contacts

✓Proper contacts that floss properly for better gingival health

242 243

244 245

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Sectional Matrices Interproximal Contact

Retainers

TrioDent/Palodent Plus

Universal Ring Narrow Ring

Interproximal Contact

Retainers

Garrison Composi-tite 3-D Fusion

Short Ring Tall Ring Wide Ring


Bands


Bicuspid

Molar

Sub-gingival Molar


Bands



Wedges

Wave Wedges

Pin Tweezers


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Wedges


Fusion WedgesTweezers Challenge:

Adjacent Class II Composite Restorations

Prepare

enamel

margins

Place contoured

band, wedge & V-Ring

Selective etching

Wash thoroughly

Apply bonding agent

Remove wedge

peel band back

Cure IP

Remove band &

cure

Fill box 2/3’s full

Compress w 1P

Finish buildup

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

254 255

256 257

258 259




Peel back

band

Cure from

both sides at

gingiva

Place

Composite as

before

Light Cure

Evaluating Curing Units*

Light Output

Collimation

Angle of light tip*Blue Light Analytics

Wavelengths

Ergonomics

Ease of Use

5mm

Finish and

polish

Adjust

occlusion

Adjacent Class II

Composite Restorations

Restore center tooth

using Toffelmire

Adjust mesial & distal

so gingiva is visible

Preparations Maxillary

Right quadrant

260 261

262 263

264 265




Quadrant restored

Place band & retainer

Maxillary arch

restored

Place Toffelmire band

& retainer on center

tooth

Preparations Maxillary

Left quadrant

Hands-On

Class IV

Tryin Putty Matrix

Load Incisal Composite into Matrix Seat Composite filled Matrix

266 267

268 269

270 271




Cure Composite-Remove Putty Place Body Composite

Body Added Roll Margin Perfect Matrix

Stretch Margin Perfect Matrix Placing bond around MPM

272 273

274 275

276 277




Holding out while bonding in place Trim excess bonded MPM

MPM bonded in place Incisal Layer placed

Shape Incisal Edge w coarse disc Shape Facial w coarse disc

278 279

280 281

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Shape Facial w finishing carbide Shape Facial w medium disc

Shape Facial w mounted disc Smooth Facial w Fine disc

Polish Facial w Super-fine disc Finished Restoration

284 285

286 287

288 289




Finished Restoration Finished Restoration

Hands-On

Class II

Tryin wedges

Place mesial band, wedge & retainer Contour band

290 291

292 293

294 295




Place distal band, wedge & retainer Burnish distal contact

Insert Sonic Fill tip into mesial box & fill 2/3 Push composite to buccal & lingual

Instrument pushed composite to b & l Tap-tap with 1-P

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Tapped down composite Reinsert tip into composite and fill

Tamp composite down and outward Trace IP contact outward

Fill distal box in similar manner Flat instrument then 1-P outward

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Light cure 40 seconds-occlusal Remove retainer & wedges

Peel back bands Light cure 20 seconds each position

Remove bands-Cure 20 seconds each position Remove bands

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Shape IP w 7901 Shape open contact so gingival visible

Insert band, wedge & retainer Burnish contact

Insert Sonic Fill and fill 2/3 Compress to B & L with flat blade

314 315

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318 319




Tap down with 1-P Fill and tamp down & out

Complete shaping Light cure 40 seconds

4x side curing for 20 seconds each Trim and shape IP

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Blend margins w finishing football Finishing w point

Finishing & polishing w cup Post Cure 20 seconds

Polished restorations Finished restorations

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Thank You!

[email protected]

www.drwardhandouts.com

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Documents

Colored Restoration Placement Direct Restorations should ......Colored Restoration Placement Direct Restorations should not be thought of as Temporary Core Buildups! 3 Topics •Minimally