Daniel H Ward DDS

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Daniel H Ward DDS

May 19, 2017

Incorporating Minimally Invasive Techniques into your Office

Treatment Protocols

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Health and appearance conscious

The Public has concerns about:

Appearance

Metals

Patients are more knowledgeable than ever

We must listen more to our patients

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We must provide alternatives for our patients

…but the rightalternatives

Minimally Invasive DentistryMinimally Invasive Dentistry

Conservative approach

Ideal treatment is no treatment necessary

Remove only diseased portion of tooth

Preserve healthy tooth structure for future restorative needs

CACARIES RIES MMANAGEMENT ANAGEMENT BBY Y RRISK ISK AASSESSMENTSSESSMENT

CAMBRA

stands forstands for……

Tooth decay is the destruction of tooth enamel. It Tooth decay is the destruction of tooth enamel. It occurs when foods containing carbohydrates (sugars occurs when foods containing carbohydrates (sugars and starches) such as milk, pop, raisins, cakes or and starches) such as milk, pop, raisins, cakes or candy are frequently left on the teeth. Bacteria that candy are frequently left on the teeth. Bacteria that live in the mouth thrive on these foods, producing live in the mouth thrive on these foods, producing acids as a result. Over a period of time, these acids acids as a result. Over a period of time, these acids destroy tooth enamel, resulting in tooth decay.destroy tooth enamel, resulting in tooth decay.

ADA Website

Tooth DecayTooth Decay CariesCaries

Caries is a point in a persons life at which the process of demineralization of tooth structure by acid from bacteria in the tooth biofilm overwhelms the patient’s ability to remineralize tooth structure.

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CariesCaries--Important PointsImportant Points

Caries is a bacterial infection caused by specific acidogenic bacteria in tooth biofilm. These bacteria are indigenous to humans. There are 30-40 known cariogenic bacteria present in saliva. Most commonly cited are Strep mutans, Strep sobrinus, Lactobacillus, and Actinomyces. These bacteria are acidogenic (acid producing) and aciduric (survive in an acidic environment). They produce lactic, acetic, formic and propionic acids.

Featherstone J. The Caries Balance. Featherstone J. The Caries Balance. Dimensions Dent Dimensions Dent HygHyg.. 2004;2(2):142004;2(2):14--18. 18.


Caries is a transmissible infection. Studies have shown that certain strains of Strep mutans are transmitted from mother to child. Early colonization, even before the teeth erupt, can occur in infants by transmission from mothers and caregivers. Transmission from child to child and adult to adult of Strep mutans have been reported. Children who have been colonized earlier have been shown to have more decay later.

Berkowitz RJ. Acquisition and transmission of Berkowitz RJ. Acquisition and transmission of mutansmutans streptococci. J streptococci. J CalifCalif Dent Assoc. Dent Assoc. 2003;3:1352003;3:135--137.137.


Caries is a multifactorial process of tooth demineralization and remineralization which, until cavitation, is reversible. This progression is determined by the balance between pathological factors and protective factors. Pathological factors include acid-producing bacteria, fermentable carbohydrates, and reduced salivary function. Protective factors include salivary components, fluoride together with calcium and phosphate to remineralize the lesion, and antibacterial therapy.

Featherstone JDB. The caries balance: contributing factors and eFeatherstone JDB. The caries balance: contributing factors and early detection. J arly detection. J CalifCalif DentaDentaAssoc. 2003;31:129Assoc. 2003;31:129--133. 133.

Demin/ReminDemin/Remin

Components of Saliva– Phosphate

– Calcium

Oral pH

Equilibrium

TOOTH

Acid

Calcium

phosphate

Demineralization Remineralization

DemineralizationDemineralization

Calcium

Phosphate


TOOTH

Detection identifies signs (cavitations) and symptoms

Diagnosis identifies the disease (bacterial infection, biofilm disease)

Caries Detection Caries Detection vsvs DiagnosisDiagnosis

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Caries ActivityCaries Activity Caries RiskCaries Risk

Traditional Surgical ModelTraditional Surgical Model Medical ModelMedical Model

Surgical Model-Wait until cavitation occurs and surgically remove

Medical Model-Attempt to influence patient to change oral environment to prevent caries

Paradigm shiftParadigm shift 2002 FDI POLICY STATEMENT2002 FDI POLICY STATEMENT

The FDI World Dental Federation supports the principles of minimal intervention dentistry in the management of dental caries. The Principles are:

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1. Modification of the Oral 1. Modification of the Oral Flora to Favor HealthFlora to Favor Health

Dental caries is an infectious disease, and the primary focus should therefore be on control of the infection, plaque control and reduced carbohydrate intake.

BacteriaBacteria

•Poor Oral Hygiene

Older adults may have a difficult time

•Dexterity

•Flossing

•Frustration

BacteriaBacteria--RemovalRemoval•Removes biofilm

BacteriaBacteria--RemovalRemoval•Compensates for poor technique

Sonicare

DietDiet

•Loss of Taste results in increased sugar intake

2. Patient Education and 2. Patient Education and Informed ParticipationInformed Participation

The etiology of dental caries should be explained to the patient, together with the means of prevention through dietary and oral hygiene measures.

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AcidityAcidity

•Critical pH

Enamel exposed to a pH less that 5.5 will begin to demineralize

‐ 216 liters per capita

‐ 42.8 liters per capita

‐ 155 liters per capita

Soft Drink :Soft Drink :

Fruit Juice:Fruit Juice:

Bottled Water:Bottled Water:

Source: Global Market Information Database, published by Euromonitor 2002

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Acidity of Common DrinksAcidity of Common Drinks

Determining the Determining the CariogenicCariogenic Bacteria Bacteria LoadLoad

• Caries Susceptibility Testing Meter

• Rub swab over tooth surface

• Bioluminescencememeasures ATP levels which are elevated by cariogenicbacteria

•CariScreen

1-866-928-4445 www.carifree.com

•Associated Diseases

•Cancer•Diabetes•Sjögren’s Syndrone

XerostomiaXerostomia

“In a published study of 3,313 patients, 21.3% of men & 27.3% of women exhibited dry mouth”

NedersforsNedersfors T, T, IsakssonIsaksson R, R, MornstadMornstad H et al. H et al. PrevelancePrevelance of perceived symptoms of dry of perceived symptoms of dry mouth in an adult Swedish populationmouth in an adult Swedish population--relation to age, sex and pharmacotherapy. relation to age, sex and pharmacotherapy.

Community Dent Oral Community Dent Oral EpidemiolEpidemiol.. 1997;25:2111997;25:211--216.216.

Prevalence of XerostomiaPrevalence of Xerostomia

“In another study approximately 1 in 4 adult patients complained of dry mouth symptoms”

OrellanaOrellana MF, MF, LagravereLagravere MO, MO, BoychukBoychuk DG et al. DG et al. PrevelancePrevelance of xerostomia in of xerostomia in populationpopulation--based samples: A Systematic Review. based samples: A Systematic Review. J Public Health Dent.J Public Health Dent. 2006;1522006;152--158.158.


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“Another study states that dry mouth impacts 30% of the elderly.”

Ship JA, Ship JA, PillemerPillemer SR, Baum BJ. Xerostomia and the geriatric patient. SR, Baum BJ. Xerostomia and the geriatric patient. J Am J Am GeriatrGeriatrSoc.Soc.2002;50:5352002;50:535--543.543.


Do you have any difficulty swallowing?

Does your mouth feel dry when eating a meal?

Do you sip liquids to help in swallowing dry food?

Does the amount of saliva in your mouth seem to be little, too much, or do you notice?

XerostomiaXerostomia--Questions to AskQuestions to Ask

XerostomiaXerostomia--Clinical AppearanceClinical Appearance

Rampant Decay

Tooth Loss

Periodontal Disease

Difficulty Speaking

Candidiasis

XerostomiaXerostomia--EffectsEffects

Quantify S. Quantify S. mutansmutans & Lactobacilli & Lactobacilli levelslevels--measure buffering capacitymeasure buffering capacity

CRT Bacteria and CRT Buffer-Ivoclar

Determining Saliva Volume, pH, and Determining Saliva Volume, pH, and Buffering CapacityBuffering Capacity

Saliva Check-GC

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1.1. Roll back bottom lipRoll back bottom lip

2.2. Dab dry with gauzeDab dry with gauze

3.3. Timer startsTimer starts

4.4. Look for bubbles of Look for bubbles of saliva forming at saliva forming at outlets from the minor outlets from the minor saliva glandssaliva glands

5.5. At 60 seconds check At 60 seconds check with a tissuewith a tissue

Test OneTest One--HydrationHydration

Measures unstimulated saliva from minor salivary glands

1.1. Observe the Observe the consistency of consistency of saliva (watery, saliva (watery, bubbly, frothy, bubbly, frothy, stringy??)stringy??)

Test TwoTest Two--ViscosityViscosity

Measures quality of saliva-serous vs mucous(poor buffer)

1. Expectorate some resting saliva into the plastic cup.

2. Test the pH using the pH strips

Test ThreeTest Three--pHpH

Measures pH of stimulated saliva

normalnormal>5.0 >5.0 mLmL

lowlow3.53.5--5.0 5.0 mLmL

very lowvery low<3.5 <3.5 mLmL

ValueValueVolume Volume of Salivaof Saliva

1. Chew the unflavouredgum for 5 minutes, collecting the stimulated saliva in the measuring cup

2. Discard the gum once finished

3. Record amount of saliva collected

Test FourTest Four--QuantityQuantity

Measures stimulated saliva from major salivary glands

Green = 4 points

Blue = 2 points

Red = 0 points Normal/hiNormal/hi

ghgh1010--1212

lowlow66--99

very lowvery low00--55

Buffering Buffering abilityability

Combined Combined totaltotal

1. Using the pipette dispense 1 drop of saliva on each of the 3 squares ensuring the entire surface is covered by saliva

2. Invert buffer strip so excess saliva is absorbed into the underlying tissue

3. Read results after 5 mins.

Test FiveTest Five--BufferingBuffering

Measures bicarbonate level of stimulated saliva

Record and analyze results

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Determining Presence of Strep Determining Presence of Strep MutansMutans

Saliva Check Mutans

XerostomiaXerostomia--Aid ProductsAid Products

Biotene

XerostomiaXerostomia--Aid ProductsAid Products

Salese lozenges

•Long Lasting, Slow Release

•Cellulose based

•Contains ACP, Essential Oils, Xylitol

•Bicarbonate neutralizes pH

•Dissolves biofilm

• Freshens Breathe

1-877-419-2646 www.nuvorainc.com

EnvironmentEnvironment

•Chemotherapeutics

3. Remineralization of Non3. Remineralization of Non--CavitatedCavitatedLesions of Enamel & DentinLesions of Enamel & Dentin

Saliva plays a critical role in the demineralization/remineralization cycle, and its quantity and quality should therefore be assessed. There is strong evidence that ‘white spot’ lesions of enamel and non-cavitated lesions of dentin can be arrested or reversed. Such lesions should therefore be managed initially by remineralization techniques. The extent of the lesion should be objectively recorded such that any progression can be identified at recall.

ACPACP--CPP CPP RemineralizationRemineralization

TOOTH


(hydroxyapatite)

Acid

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•Amorphous calcium phosphates stabilized by

casein phosphopeptides

•Molecule serves as a delivery vehicle for

Calcium and Phosphate at the tooth surface in

a slow release amorphous form

ACPACP--CPPCPP(amorphous calcium phosphate- casein phosphopeptides)

ACPACP--CPPCPP

•Increases phosphate and calcium in plaque

•Derived from milk products-highly

concentrated

•Lactose Intolerance OK

•If allergic to milk NO

CPP coating allows attachment to biofilmand stabilizes ACP

In presence of acid Calcium and Phosphate ions are released

CPP EffectsCPP Effects

CPP-ACPACP

•Prevents enamel demineralization

•Promotes remineralization of non-caviated

enamel subsurface lesions

•Seals off dentinal tubules reducing sensitivity

Action of ACPAction of ACP--CPPCPP(amorphous calcium phosphate- casein phosphopeptides)

MI PasteMI Paste

Provides bio-available calcium and phosphate to the oral cavity

Aides remineralization Reduces localized

hypersensitivity when used after scaling or tooth whitening

Remains on tooth surface 3 hours

After tooth whitening

For pregnant mothers

For children 6 & under

During or after ortho

Desensitization

Poor Oral Hygiene

Extra protection for teeth

MI Paste MI Paste vsvs MI Paste PlusMI Paste Plus

Use MI Paste

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MI Paste PlusMI Paste Plus

Addition of 0.2% NaF

900 ppm NaF (toothpaste =1100 ppm)

If F- concentration too high-CaF deposited on surface preventing absorption

150 micron penetration

White spot lesions

Desensitization


Medical compromised pts

Xerostomia

High Acid Environment

High Caries Risk pts

Extra Protection

MI Paste MI Paste vsvs MI Paste PlusMI Paste Plus

Use MI Paste Plus

MI Paste Application

Apply after toothbrushing

No food or drink for 30 minutes

May apply with trays for 3-5 minutes

MI Paste Uses

Temperature sensitivity

Dentinal hypersensitivity

After tooth-whitening


Xerostomia

Excess soft drink consumption

During pregnancy

Saliva substitute

Open dentinal tubules

Occluded dentinal tubules

Apply MI Paste:

After toothpaste and fluoride application

Before bleaching/scaling and days after

Ongoing throughout day and night

MI Paste works well in SGH (salivary gland hypofunction)pts-use all day/night

Home use in trays at night

Recaldent gum all day long

For longest time possible

MI Protocols for Adults

Jane Chalmers BDSc MS PhD

University of Iowa

5% Na F (22,600 ppm)

2% ACP-CPP

Releases Ca, PO4 ,F

Excellent retention

Desensitization

Does not clump

Extra protection for teeth

MI VarnishMI Varnish

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MI Varnish Application

Place after prophy but not mandatory

Dry teeth before applying Do not brush or floss for 4

hours Avoid hard, hot, sticky

foods and alcohol containing products for 4 hours

Do not use fluoride for 24 hours

MI Varnish Mechanisms

No water so it does not precipitate Ca allowing for longer retention

Greater amount of fluoride in saliva

Highest amount of fluoride uptake is in demineralized areas

Fluoride effects are present 1-7 days

4. Minimal operative intervention 4. Minimal operative intervention of cavitated lesionsof cavitated lesions

An operative (‘surgical’) approach should only be used when specifically indicated, e.g., when cavitation is such that the lesion cannot be arrested, or when there are aesthetic or functional requirements. Operative intervention should focus on the preservation of natural tooth structure and be limited to the removal of friable enamel and infected dentin. This can be done with hand, rotary, sonic, ultrasonic, air abrasive or laser instruments, depending on the circumstances. Each prepared cavity is therefore unique, and is primarily dependent on the extent of infected dentin rather than on a predetermined cavity design. Preparation of minimal cavities enables their restoration with adhesive materials such as glass-ionomer cement and/or resin composite. Some studies suggest that glass-ionomer cement may aid in the remineralization of demineralized, firm, non-infected dentin; however, further clinical studies are needed.

Composite

The most USED

and ABUSED

Material in Dentistry

Composite

Amalgam Preparation

Composite Preparation

“Convenience”Form MID

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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? 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

High Viscosity (Low Flow) Flowable Composite High Viscosity (Low Flow) Flowable Composite

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)

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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).

Dispenser Gun TrayComax Dispenser

CALSETCALSETThermal Assisted Light PolymerizationThermal Assisted Light Polymerization

Low Viscosity Flowable Composite & Warmed Composite

Completed Tooth Restorations 5. Repair of Defective 5. Repair of Defective RestorationsRestorations

Removal of restorations results in an inevitable increase in cavity size as a consequence of removal of sound tooth structure. Depending on the clinical judgment of the dentist, repair could be considered as an alternative to replacement in some circumstances.

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Minimally Invasive Dentistry?

“Dentistry begets Dentistry”

Minimally Invasive Dentistry?

“The more dentistry you do for a patient, the more dentistry they will eventually need.”

Treatment performed at age 18

•Black Triangles

•Opaque Crowns

•Dark Roots visible

•Recurrent decay

Smile Evaluation

•Long Central Incisors

•Inadequate buccal corridor display

•Steep Curve of Spee

•ColorSmile Template

Provisionalization

•Teeth Prepared-unprepared 2nd molars

•Fabricate desired shape in provisionals

•Allow patient to wear, evaluate and accept

Final Impressions & Lab Communication

•Once approved take final impressions-send model of provisionals

•Send photos of desired color shade tab, stump shades and provisionals

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Final Impressions & Lab Communication

•Tryin and seat crowns

•Notice lower anterior teeth

15 Year Old


70% RED Proportion


Buildup dentin replacement with opaque darker hybrid –typically A3-A3.5

Buildup remaining form with shade similar to desired final color with hybrid (typically A1-A2)

Add special effects to simulate imperfections within tooth structure

Add translucent incisal hybrid or microfill

Multiple Step Layering Techniques

Add dentin shade

•Aura Dentin 6

•Miris

Add General Purpose Shade

•Aura MC 3

•TPH Spectra

Add Characterization

Important-Junction must be invisible

Add Facial Surface

•Aura Enamel

•G-aenial GT

•Beautifil II

•Esthelite Sigma QuickOptrasculpt

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Finish and polish restoration

Restore adjacent tooth

Shape, finish and polish restorations

Restore opposite teeth

Pre-Operative

Finished Restorations

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

DentinDentin 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

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Oh NO, not another bonding lecture!

•What are MMP’s and what agents can affect their effects?

•What is the effect of the width of the hybrid layer and dentin bond strengths?

•What new Self-Etching Primer Dentin Bonding Agent has bond strengths to un-etched enamel greater than 40 MPa ?

Oh NO, not another bonding lecture!

•Is there a relationship between post-operative sensitivity and dentin bond strengths?

•What are the characteristics of alcohol, acetone and water based solvents of dentin bonding agents?

•What are Universal Dentin Bonding Agents?

Etched Dentin

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

Etched Dentin

•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

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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

Overdrying

SEM Perdigao

Un-collapsed collagen fibrils Collapsed collagen fibrils

Proper Moisture

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Moisture Variability

Acetone

Alcohol

Water

Bonding Agent Solvents

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



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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•SEM analysis found no marginal gapformation of enamel etched w phosphoric acid prior to application of a self-etching 6th

generation bonding agent (Clearfill SE) following thermocycling•SEM analysis reported marginal gap formationof enamel not etched w phosphoric acid prior to application of a self-etching 6th generation bonding agent (Clearfill SE) 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.

Effect of Enamel Etching-Marginal Gaps

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

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

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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.

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

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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

Long Term Dentin Bond StabilityMMP-Matrix MetalloproteasesMMPs 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.

Long Term Dentin Bond StabilityCysteine Proteases (Cathepsins)

Lysosomal enzymes that become activated in lysosomes by a low pH

Secreted by osteoclasts in bone resorption

Regulated by chondroitin

Collagenase activity breaks down collagen and hydrolyzes collagen into small peptides

Terasariol Il, Geraldeli S., ,Minciotti Cl., et al., Cysteine catepsins in human dentin pulp complex. J Dent Res 2011; 90:506-11.

MMP-Matrix Metalloproteases

Carrilho et al., JDR 2007; 86; 529Brackett 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)

Benzalkonium Chloride

MDPB ((12-methacryloxydodecalpyridinium bromide)

Galardin (mimics MMP-binds Zn atom) (inhibits tumor growth and metastasis)

Epigallocatechin-3-gallate (green tea polyphenol)

Perdigao J, Resi A, Loguercio AD. Dentin Adhesion and MMPs: A Comprehensive Review. J Esthet Restor Dent 2012: 25:219-241.

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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.

De Munck J, Van Landuyt K, Peumans M, Poitevin A, Lambrechts P, Broem M, Van Meerbeek B. A Critical Review of the Durability of Adhesion to Tooth Tissue: Methods and Results. J Dent Res. 2005;84(2):118-132.

Dentin Bonding Challenges

• SE 1-step adhesives are too hydrophilic and permeable even after polymerization

• The best way to minimize these weaknesses is to apply a neutral-pH, hydrophobic adhesive resin layer in a separate step

• Acidic components cause incompatibility with self-cured composites.

• 3-step, etch-and-rinse adhesives remain the “gold standard” in terms of adhesive durability.

Dentin Bonding Solutions

De Munck J, Van Landuyt K, Peumans M, Poitevin A, Lambrechts P, Broem M, Van Meerbeek B. A Critical Review of the Durability of Adhesion to Tooth Tissue: Methods and Results. J Dent Res. 2005;84(2):118-132.

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.

Selective Etch TechniqueHigh Viscosity allows precise placementContains BAC

28

Universal Dentin Bonding

Bond 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 All-Bond UniversalTotal-etch, self-etch or selective-etch

Single bottle for direct and indirectrestorations

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

Total, Self or Selective Etch

Total Etch vs. Self EtchShear bond strength of Universal Adhesives on Tooth Structures MPa*

*Manufacturer supplied data

MDP Universal Bonding Materials


29

Universal Bonding Materials


•GI Sandwich Technique-Never open the dentinal tubules



Resin-Modified Glass Ionomer Resin-Modified Glass Ionomer

Never open dentinal tubules

Less post-operative sensitivity

Fluoride release

Long-term consistent bond to dentin

RMGI Liner

No dentin conditionerneeded due to self-etch

primer component

RMGI BaseReprepare

Dentin conditionerpreferred to achieve optional dentin bond

30

Pre-Operative

Completed Preparation

Fuji II LC Resin Modified Glass Ionomer Base

Kalore

10. It’s not necessary

9. It takes more time

8. It costs more money

7. I don’t understand which product to use

6. Not necessary with today’s Hundredth generation bonding agents

TOP TEN REASONS:GI isn’t used under every restoration

5. I don’t know how to use

4. Not as strong: I “bond” everything-holding tooth together and making it stronger

3. It doesn’t bond as well to dentin as resin

2. Fluoride release is transient

1. Old fashioned: used before better bonding agents were available

TOP TEN REASONS:GI isn’t used under every restoration

Social Media Communication Cell Phone Text MessagingCell Phone Text Messaging Appt Reminder/Late Cancel

31

Custom Email MessagingCustom Email Messaging Appt Reminder/Confirmation Custom Email MessagingCustom Email Messaging Appt Reminder/Confirmation

Custom Email NewslettersCustom Email Newsletters Holiday Promotions Custom Email NewslettersCustom Email Newsletters Promotions

Custom Email NewslettersCustom Email Newsletters Regular Newsletters Custom Email MessagingCustom Email Messaging Birthday Wishes

32

Custom Email Patient SurveysCustom Email Patient Surveys Automated Post-Appointment Custom Email Patient SurveysCustom Email Patient Surveys Automated Post-Appointment

Custom Email Patient SurveysCustom Email Patient Surveys Automated Post-Appointment Online Patient ReviewsOnline Patient Reviews Monitor Online Reviews

Online Patient PortalOnline Patient PortalAutomated Post-Appointment

Pay Bills Online Online DashboardOnline DashboardSummary

33

Management ResearchManagement Research--MapsMapsResearch Locale Demographics New Mobile Apps

Mobile DevicesMobile Devices

Distribute Testimonials OnlineIncrease internet marketing

HealthgradesHealthgrades

March 1, 2016

Increase internet marketing

HealthgradesHealthgrades

December 1, 2016

If you cannot see it you cannot treat it!

Orascoptic Designs for Vision

Surgitel

34


Ultra-Light Optics

Nano Freedom DentLight


Flecta Mirror

A Day at the OfficeA Day at the Office

Digital Dental Photography

• Xerostomia

• Difficulty maintaining oral hygiene

• Root exposures

• Some unable to tolerate long appointments

• Difficulty coming to office

• Fixed Income

US Population is Aging

US Population is Aging

DonDon’’t miss appointmentst miss appointments

AppreciativeAppreciative

Pay billPay bill

Often need more treatmentOften need more treatment

Refer new patientsRefer new patients

Say Thank You!Say Thank You!

60+ Patients are Wonderful

OneOne--Visit TechniqueVisit Technique

Immediate placement natural tooth Immediate placement natural tooth fiberfiber--reinforced bonded reinforced bonded ponticpontic

35

•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

•Tryin and prepare slots

•Shape root area to support tissue

•Cut lingual slot when trying in

•Place groove inline with 2 adjacent teeth

•Prepare Ever Stick fibers

•Place tooth

•Etch and bond

•3 months later •3 months later

36

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.Chalmers J. Personal Communication. 2006.


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

Smith RG, Smith RG, BurtnerBurtner AP. Oral sideAP. Oral side--effects of the most frequently prescribed drugs. effects of the most frequently prescribed drugs. Spec Spec Care Dent.Care Dent. 1994;14:961994;14:96--102. 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

37

Oral Environment Challenges-Antacids

Ingredients:Calcium carbonate, adipic acid, corn starch, crospovidone, dextrose, flavors, malodextrin, sucrose, talc, colors.

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

Look, we all know that Glass Ionomers are weak!

•Which wears more resin modified glass ionomers or pure glass ionomers?

•According to research what is the average 10 year survival rate of posterior single surface glass ionomers?

38

Look, we all know that Glass Ionomers are weak!

•Which form(s) of glass ionomer can be used as an RUC under bonded crowns? Under conventionally cemented crowns?

•Will placement of large glass ionomers always result in less total tooth and restored surface than placement of composites?

Fuji IX Self Cure Glass Ionomer

Glass IonomerBase/Restorative

SDI Self Cure Glass Ionomer

•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 •Multiple cervical carious lesions

•Pediatric Patients•Sealants•Class V restorations•Sandwich Technique•Crown buildups•Long term interim restorations•Cements

Glass Ionomer Uses

High caries rate individuals

Glass Ionomer RestorationsGlass Ionomer Restorations

Remove decay and place matrices


39

Treat dentin with PAA


Place, shape and wait 2:30


Shape with diamonds w/ water


Dry and place Surface Sealant

No phosphoric acid




Spoon out decay and refine prep


40

Place and rinse Poly-acrylic acid


Mix Gi and quickly place and push out


Allow to set 2:30


Hold down gingiva and shape


Dry and place surface sealant




41

Pediatric Patients


Pediatric Patients


Class V root caries


Class V root caries


Repair around crown margins


Repair around crown margins


42

Long term interim restoration








Decalcified areas in partially erupted tooth

Treat with phosphoric acid

Glass Ionomer SealantsGlass Ionomer Sealants

Activate, mix and place glass ionomer

Place Surface Sealant over glass ionomer and light

cure


43

Glass Ionomer Sealants

5 Year Recall


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)

Preparation w cervical margin in

dentin

Open Sandwich Technique

Acid etch enamel

Condition dentin w PCA

44

Place glass ionomer base


Place RMGI bonding agent and cure

*recommended by Dr Graeme Milicich

Build up tooth with composite


Shape with diamonds and fine carbides

Finished occlusal view


Mesial View

Glass Ionomer

Composite

RMGI

Restoration Under Crown

Internal Cracks


Deep decay w affected dentin



45






Do Not Use in Anterior Teeth to replace Large Defects

RUC with crack

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)

46


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

47

Restoration w large crack Restoration w large crack

Large restoration with internal fractures Dentist-Multiple Radiographic Caries

Before and After

Equia Forte

Posterior Glass Ionomer

RIVA Self Cure HV

48

Sudden Onset Caries

Posterior Glass Ionomer47 year old female

Been in the practice over 30 years

Regular re-care appointments

Significant changes in health history

No restorations in 8 years

Radiographs revealed multiple interproimalradiolucencies not present 12 months previous

Required 16 restorations

Need caries resistant restorations

Preparations


Preparations


Posterior GI Restorations


•Acid/base and polymerization reaction

•Ionic and micromechanical bonding

•Dual-curing

•Fluoride release

•Bioactive

Resin-Modified Glass Ionomers

•Acid/base and polymerization reactions•Dual cured-faster•Shortens time needed to control moisture•More esthetic and translucent•Fluoride release•Higher tensile, bond strength and wear

Resin-Modified Glass Ionomer Characteristics

49

•Liner or Base•Class V Restorations•Restoration Under Crown•Temporary prior to crown•Sandwich technique•Cements

Resin-Modified Glass Ionomer Uses

Resin-Modified Glass Ionomers-Advantages

Brackett WW, Dib A, Brackett MG, Reyes AA, Estrada BE. Two-year clinical performance of Class V resin-modified glass-lonomer and resin composite restorations. Oper Dent. 2003;28:477-81

37 pairs of caries-free unprepared abfraction lesions were treated with resin modified and resin composite restorations (single bottle total etch dba). Retention of the composite restorations at six months was below the minimum specified in the ADA Acceptance Program for Dentin and Enamel Adhesives. At two years retention was 96% for the resin-modified glass ionomer and 81% for the resin composite. The resin composite restorations generally had a better appearance, with a 100% alpha rating in color match, versus 85% for the resin-modified glass ionomer.

•Better retention

Resin-Modified Glass Ionomer Base/Restorative

Capsule

Fuji II LC RIVA LCFuji Filling LC

Resin-Modified Glass Ionomer Base/Restorative

Ketac Nano

Paste-Paste

Class V Restoration 294

Gingival recession & root caries

• 1st molar and bicuspid

• Remove decay‐place retention

Resin-Modified Glass Ionomer

50

295

Gingival recession & root caries

• 1st molar and bicuspids

• Remove decay‐place retention

Condition with PA

• Pre‐treatwith dentin conditioner (Poly‐

acrylic acid)


296

Material Placed and Light Cured

• Place excess material

• Light Cure


297

Final Restorations

• Shape restorations

• Hold back gingiva and shape with fine

diamond

• Etch with phosphoric acid, wash and dry

• Place surface sealant and light cure

Material Placed and Light Cured

• Place excess material

• Light Cure



Quick Temporary prior to Crown Temporary placed 5 years ago

51

Sandwich Technique

Resin-modified Bonding Agent–Triturated

–Reduces polymerization shrinkage

stress

–Novel concept

Riva Bond LC

•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


Glass Ionomer

•Core-Cemented posterior crowns

•Entire Class I or II (Long Term Interim)

•Class V-high caries

•All deciduous posteriors

•Sandwich technique-Co Cure

Glass Ionomer Preferred Uses

•Core-all crowns

•Base Class I or II-re-prepared sandwich

•Class V-more esthetic

•Quickly placed short-term interim restorations


Preferred Uses Bioactive

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

active.

Exchange ions to and from biological structure

Regenerative/remineralization

Promote healing

Release Calcium, Fluoride, Phosphate

Maintains alkaline pH

Antimicrobial

52

GI Initial setting and early strength Fluoride release

Calcium Aluminate Long term-increased strength and retentionApatite formation Sealing at marginal interface Sustained long term properties w/o degradingHigher pH (not acidic)-virtually no sensitivity

Ceramir Ceramir

Forms apatite crystals(a group of phosphate minerals, usually referring to hydroxyapatite, fluorapatite and chlorapatite, named for high concentrations of OH−, F−, Cl− or ions, respectively, in the crystal. The formula of the admixture of the four most common end members is written as Ca10(PO4)6(OH,F,Cl)2, and the crystal unit cell formulae of the individual minerals are written as Ca10(PO4)6(OH)2, Ca10(PO4)6(F)2 and Ca10(PO4)6(Cl)2.)

Ceramir

Forms apatite crystals Powder and water are mixed Dissolution results in nano-crystal formation Gibbsite and Katoite forms

Gibbsite

Tooth apatite

Mixed zoneChemically formed apatiteGibbsite(Calcite)

Katoite

Ceramir

Forms apatite crystals Powder and water are mixed Dissolution results in nano-crystal formation Gibbsite and Katoite forms Crystals form on tooth and restoration Long-term stable bond Ceramir Dentin

Physical Properties– Creates Apatite when in contact with phosphates– No shrinkage– Hydrophilic system with Alkaline pH– Thermal properties similar to tooth structure– Low film thickness -15 microns– 160 Mpa compressive strength– Anti-bacterial-inhibits caries– Gets stronger over time– Acid resistant– Bonds well to metal, porcelain, ceramics, zirconium

Ceramir Ceramir

Jeffries SR, Fuller AE, Boston DE. Preliminary Evidence that Bioactive Cements Occlude Artificial Marginal Gaps. J Esthet Restor Dent. 2015.

Self Adhesive Resin Cement


Glass Ionomer

Calcium AluminateRMGI

Calcium Silicate

53

0:00

Ceramir

2:00

Ceramir

4:00

Ceramir Ceramir

Bioactive

TheraCem

Releases fluoride and calcium

Bioactive

Activa

Liner/Base

Releases fluoride and calcium

Restorative Material

54

ppm

Releases Calcium as pH lowers

Activa

Releases Phosphates as pH lowers

Activa

Versatile Material

Activa

Liner/Base

LinerIndirect Pulp Cap

Versatile Material

Activa

Direct restorativeCrown RepairCore Buildup

Restorative Material

Advanced Engineering for People

Biomimetic

• Replacing damaged structure with material

that will mimic the function of the original

Biomimetics is the term used to describe the substances, equipment,

mechanisms and systems which humans imitate natural systems and

designs.

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

55

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 lightGreat 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•Beautifil Bulk Flow•Aura Bulk Fill•Tetric Evo-Ceram Bulk Fill•Sonic Fill

Sonic Energy Assisted Light Sonic Energy Assisted Light PolymerizationPolymerization

Sonic FillSonic Fill

56

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

57

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

58


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

59

Peel back band

Cure from both sides at

gingiva

Place Composite as before

Light Cure Finish and polish

Adjust occlusion

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Daniel H Ward DDS