Restorative Dentistry Clinical Reference

Restorative Dentistry Clinical Reference®

Department of Restorative Dentistry

University of Washington

Seattle, Washington

Contributors: Restorative Dentistry Faculty

Edited by: Dr. Glen H. Johnson

2010-2011

Also located at: www.dental.washington.edu/departments/restorative/clin_resource_info.php

Box 357456 • 1959 NE Pacific Street, D770 • Seattle, Washington 98195-7456 Tel. 206-543-5948 • www.dental.washington.edu/departments/restorative/

SCHOOL OF DENTISTRY UNIVERSITY of WASHINGTONDepartment of Restorative Dentistry

To Our Friends and Dental Colleagues Near and Far: We hope you find the web version of our Restorative Dentistry Clinical Reference useful. The primary intended users of this reference are our regular faculty, affiliate faculty, students, dental assistants and dispensary staff. The aim is to provide a convenient, concise, standardized source of information for common clinical materials and procedures employed in our Restorative Dentistry Clinic. Each fall, we also produce a pocket version of the Restorative Dentistry Clinical Reference as a convenient source of information for those directly involved in our educational process. We also place the contents on our Department website to aid outside practitioners and their staff, and to post updates. If you would like this information in booklet form, they are available with a donation to our Department. These funds aid us in maintaining and expanding the Restorative Dentistry Clinical Reference and to further our academic goals. From all of the hard working folks in the Department of Restorative Dentistry at University of Washington, we extend our very best wishes. Sincerely,

Glen H. Johnson, D.D.S., M.S. Professor

Restorative Dentistry Clinical Reference® 1 Edited by Glen H. Johnson, D.D.S., M.S.

Copyright © 2010 by the Department of Restorative Dentistry, University of Washington

Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/

Contents Sec Procedure Page

1 Cavity bases - what and when 2 2 Cavity liners - what and when 2 3 Cavity sealers - what and when 3 4 General Hints with use of the All-Bond 2 bonding system 3

5 Treatment of deep caries with exposure or near exposure of pulp (Dycal; Fuji Lining LC; dentin sealer)

4

6 Dentin sealers under amalgam (All-Bond 2 A&B) 5 7 Filling Material Selection 6 8 Foundation Restorations Choices (crown buildups) 6 9 Bonding in association with large amalgams (All-Bond 2) 7

10 Chemically-cured composite foundation restoration (Ti-Core + All-Bond 2) 8 11 Class 5 restoration options

• Amalgam 8 • Resin composite (Filtek Supreme Plus; All-Bond 2) 8 • Resin Modified Glass Ionomer (Fuji II LC) 9

12 Class 1, 3-6 resin composite restoration (Filtek Supreme Plus +All-Bond 2) 10 13 Ultraconservative Class 1 Restoration (Filtek Flow + All-Bond 2) 10 14 Class 2 posterior composite restoration (Filtek Supreme Plus + All-Bond 2) 11 15 Surface sealer for a composite restoration (Fortify) 16 16 Procedure check list for pulp capping and/or placing restorations 17 17 Bonding to and/or repairing an existing composite 17 18 Repairing porcelain 18 19 Treating root sensitivity (All-Bond 2 A&B) 18 20 Sealing teeth prepared for indirect restorations (Gluma Desensitizer) 19 21 Luting cements - indications and contraindications 22 22 Luting Cements and cementation procedures

• Preliminary procedures 23 • Zinc Phosphate Cement (Fleck’s) 23 • Resin-modified Glass Ionomer (RelyX Luting) 23 • Ceramic/Porcelain Cementation (Variolink II) 24 • ZrO2 Ceramic Crown Cementation (Variolink II, RelyX Luting) 25 • Porcelain Veneer Cementation (Variolink II) 26

23 Post and Post Cementation 28 24 Treating Superficial Enamel Discoloration 30 25 Coltolux Curing Light - power output check 32

Dispensary Materials Available 35 References 39

Updates at http://www.dental.washington.edu/departments/restorative/clin_resource_info.php




A base is used as a replacement material for missing dentinal tooth structure. The primary indication for use of a base is to eliminate undercuts, to facilitate draw of a preparation. Additionally, a base can used to reduce the bulk of a direct or indirect restoration. The rationale for use of a base to gain thermal insulation is not as accepted today. It is believed that sealing dentin (with a sealer) is far more effective in controlling post-operative sensitivity. The base should have adequate strength and modulus of elasticity to support the overlying restoration.

Examples of acceptable bases used in the D-2 and D-3 clinics are

Type Product zinc phosphate cement Fleck’s Cement chemical-cured resin Ti-Core light-cured resin composite Filtek Supreme Plus resin-modified glass ionomer Fuji II LC

A cavity liner is a thin layer (usually less than 1/2 mm) of a flowable material placed on dentin placed to achieve a therapeutic effect (e.g. calcium hydroxide paste) or to create a physical barrier (e.g. glass ionomer, resin-modified glass ionomer). Examples of calcium hydroxide liners include Dycal, VLC Dycal, Life. Examples of resin-modified glass ionomer liners are Vitrebond, Ketac Bond and Fuji Lining LC. See section 5 for treatment of deep caries and pulp exposures. Indications for use of calcium hydroxide are for pulp capping of pulpal exposures and near exposures. Indications for use of other liners (e.g. Fuji Lining LC) are to seal around calcium hydroxide and to seal dentin.

Examples of acceptable liners used in D-2 and D-3 Clinics are

Type Function Product chemical-cured Ca(OH)2 Therapeutic Dycal resin-modified glass ionomer physical barrier and

sealer for Ca(OH)2 Fuji Lining LC

1. Cavity Bases

2. Cavity Liners

The Restorative Dentistry Clinical Reference® is a “work in progress.” The intended users of this reference are regular faculty, affiliate faculty, students, dental assistants and dispensary staff. The aim is to provide a convenient, concise, standardized source of information for common clinical materials and procedures employed in our Restorative Dentistry Clinic. For updates, go to

www.dental.washington.edu/departments/restorative/clin_resource_info.php Happy Clinic Days, Dr. Glen Johnson




A cavity sealer is a thin film which provides a protective coating for freshly cut tooth structure of the prepared cavity.

1. Varnish - A natural gum, such as copal rosin, or a synthetic resin dissolved in an

organic solvent, such as acetone, chloroform, or ether. Examples include Copalite, Plastodent Varnish, and Barrier. Do not use copal resins (e.g. Copalite) in clinic. In lieu of Copalite, we use the adhesive primers, All-Bond 2 Primer A and B.

2. Dental Adhesive Primers - includes the primers and adhesives of dentinal and all-

purpose bonding agents. Examples include All-Bond 2 Primer A and B, Scotchbond MP+, OptiBond, ProBond, Amalgabond.

3. Other cavity sealers - include GLUMA® Desensitizer, Barrier and Protect. The

mechanism for sealing with GLUMA® Desensitizer is that the glutaraldehyde in the solution causes a precipitation of plasma protein in the dentinal fluid to occlude the tubules. Barrier and Protect consist of a fluoride releasing resins that reside on the tooth surface after air-drying to remove the carrier solvent. See section 20 for when and how to use Gluma® Desensitizer.

1. It is not advisable to use ZnO-Eugenol liners or temporary cements in combination with dentin adhesives and resin composites. If used, place the smallest amount possible.

2. After primers are applied, they must be thoroughly air dried with an air syringe to make sure all of the solvent and displaced water is removed in order to form a strong polymer in the dentinal tubules. DO NOT DRY BETWEEN COATS!

3. After application of A & B primers on dentin/enamel, the surfaces should be glossy. If not, repeat application.

4. If you choose the conservative approach to not etch dentin, it is very important to leave the dentin moist prior to primer application. Moist dentin is important with all procedures when using ALL-BOND ® 2.

5. Please us a rubber dam whenever possible, especially with porcelain repair. Moisture leads to failures.

6. If PRE-BOND RESIN is not air thinned, it may set-up prematurely. Applying PRE-BOND just prior to cementation will give the best results.

3. Cavity Sealers

4. ALL-BOND 2 General Helpful Hints

For a nice evidenced-based review of bases, liners and sealers, see pp. 104-8 of your Operative Text2

http://www.bisco.com/instructions/techniqueindex.asp for technique cards




enamelenamelcariescaries

dentindentin

pulppulpexcavated excavated areaarea

7. Bisco DUAL CURE OPAQUER sets with an oxygen-inhibited layer (“sticky layer”). You may bond composite directly to this or wipe it off and apply D/E BONDING RESIN to the opaqued metal and primed porcelain, if present.

8. Lightly air thin the mixture of D/E BONDING RESIN and PRE-BOND RESIN when performing adhesive amalgam technique. This will prevent pooling in the proximal box.

9. Desensitizing root surfaces is most effective on a freshly scaled root. A dense pellicle may form over time and make penetration of primers difficult.

10. Open primer bottles a few seconds prior to use and gently squeeze. This will allow built up vapor pressure to be released giving better dropper control

11. Nylon or Vinyl brush tips are the adhesive applicators of choice. Sponges are not recommended

When not to pulp cap: If you experience a carious exposure (not mechanical) >0.5 mm in size and/ or cannot control the hemorrhage, extirpate the pulp and plan root canal treatment. References: Refer to an article by Pameijer and Stanley1 and Summitt, et. al 2 pages 108-9 and TJ Hilton review 3 for evidence-based support for this approach to pulp capping. Procedure: 1. Control the hemorrhage using a cotton pellet. If

hemorrhage cannot be controlled, extirpate the pulp.

2. Apply a thin layer of a calcium hydroxide liner (i.e. Dycal) to and slightly beyond the exposure site, or the site of the near exposure. Allow the calcium to harden (note: water will accelerate the reaction of the chemically-cured Dycal).

3. Mixing Fuji liner. This is a paste-paste formulation with dispenser. Depress the lever to place a small quantity of the two pastes on a pad. Replace the cartridge cover. Mix for 15 seconds. Note that the Fuji liner is preferred over Vitrebond based on cytotoxicity tests.4

4. Place one or two layers of the Fuji liner over the Dycal and slightly beyond the margins, to seal and protect the Dycal. Light cure for 20 seconds.

5. For bonding associated with composite restorations and large “bonded amalgam restorations”, etch enamel and dentin with Uni-Etch (32% H3PO4), rinse and leave moist. Proceed with instructions for placing these restorations. Note that we only use 32% H3PO4 for all of our procedures in our clinics since 10% H3PO4 has been shown to be not as effective for etching enamel as 32%.

5. Treatment of deep caries with exposure or near exposure of a vital pulp




6. When not bonding (i.e. simple amalgams), do not etch. Apply the sealer (5x All-Bond Primer A & B) over the liner and calcium hydroxide as directed above, air dry and light cure.

This “sealing” procedure is employed when the student or attending dentist determines that it might be beneficial to seal the dentin before the amalgam is placed. This is not the “bonded amalgam” procedure described in section 9. Rather this procedure is employed to prevent and control sensitivity by sealing dentin. Note that it is not necessary to etch the dentin in this case. Indications: (1) Always seal following pulp capping procedures (section 5) (2) Deeply excavated areas without pulp capping (3) History of thermal sensitivity of tooth Contraindications: (1) Shallow to moderate depth amalgam preparations (2) Non-vital tooth Procedure: 1. Following preparation of the cavity, rinse and remove excess water with a brief burst

of air. Do not desiccate as All-Bond 2 penetrates better in the presence of moist dentin. Note that it is unnecessary to etch dentin when placing an All-Bond primer as sealer under amalgam.

2. Mix primers A and B. Apply five consecutive coats to dentin. Do not dry between coats. After primer application is complete, dry all surfaces for 5-6 seconds with an air syringe to ensure thorough solvent and displaced water removal. Properly primed surface will appear glossy when coverage is sufficient.

3. Light cure for 20 seconds. 4. If needed, place matrix, then restoration.

6. Application of a dentin sealer under amalgam - All-Bond 2 A&B




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Product ⇒ Valiant PhD

Valiant Snap Set

Filtek Supreme

Ti-Core

Fuji II LC

Ketac-Fil

Filtek Flow

IRM

Foundations/cores √ √1 √ √1 Class 1 √ √ √ Class 2 √ √ Class 3 √ Class 4 √ Class 5 √ √ √ Class 6 √ ultraconservative Class 1 √

composite provisional repair √

composite filling repair √

crown margin repair √ √ √ √ root caries √ √ √ temporary filling √ √2 √3

1 use only when a temporary crown can be placed at the same appointment 2 provisional for cusp fracture 3 use for caries control

Foundation restorations are extensive restorations, which will later serve as the “foundation” for complete veneer, or partial veneer (e.g. ¾ crown) cast restorations. Acceptable foundation materials for the Restorative Clinics

1. High copper, admixed dental amalgam Valiant PhD, Valiant PhD-XT 2. light-cured resin composite Filtek Supreme Plus 3. chemical-cured resin Ti-Core*

*Important –Ti-Core may be used for foundation restorations (i.e. core buildups). These two fast-setting materials can be used for buildups only when the tooth can be prepared adequately to accommodate a temporary crown which must be placed at the same appointment. Since both cure quickly, often there are inadequate proximal contacts. In the case of Ti-Core, the occlusal anatomy is typically flat. For these reasons, Valiant PhD, Valiant PhD-XT or light-cured composite (Filtek Supreme Plus) must be used when a temporary crown cannot be made.

7. Filling Material Selection

8. Foundation Restoration Materials (i.e. core, crown buildups).




Evidence of efficacy - see Summitt et al5 Indications: 1. Large amalgams 2. Incomplete fractures Advantages: 1. Slight increase in amalgam retention (~10%) 2. Seals dentin at same time Disadvantages: 1. costly 2. time consuming 3. technique sensitive Clinical Procedure (ALL-BOND ® 2 Guide #5B) 1. Cavity preparation. 2. Etch enamel and dentin using UNI-ETCH (32% H3PO4) for 15 seconds without

agitation (timing is important). Rinse thoroughly. Remove excess water with a brief burst of air. DO NOT DESICCATE! ALL-BOND ® 2 prefers moist dentin/enamel.

3. Mix PRIMERS A and B. Apply 5 consecutive coats to enamel and dentin. DO NOT DRY BETWEEN COATS! After primer application is complete, dry all surfaces for 5-6 seconds with an air syringe to ensure thorough solvent and displaced water removal. Properly primed surface will appear glossy when coverage is sufficient. If not glossy, repeat step 3. Light cure for 20 seconds.

4. Place the matrix band at this time. 5. Mix an equal volume of D/E BONDING RESIN and PRE-BOND RESIN on a mixing

pad and brush a thin layer onto entire cavity surface. Lightly air thin to avoid pooling. Do this as the amalgam is being mixed to avoid premature setting of the bonding resin.

6. Condense amalgam. Carve and finish as usual. NOTE: Matrix band should be placed after application of mixed Primers and should be lightly lubricated by rubbing wax on matrix surface.

9. Bonding in association with large amalgams




Important - Chemically-cured composite (e.g. Ti-Core) may be used only when the tooth can be prepared and temporary crown placed at the same appointment. Otherwise, amalgam or light-cured composite must be used. This is so that proper contacts and contour are generated. Materials: Ti-Core Composite with All-Bond 2 (All-Bond 2 Guide #7B) Clinical Procedure 1. Etch with 32% phosphoric acid gel for 15 sec. 2. Rinse thoroughly; dry gently but leave most. 3. Mix All-Bond Primer A&B; apply 5 coats; air dry 5-6 sec 4. Check for glossy surface. If not, repeat step 3. 5. Light cure 20 sec 6. Place matrix 7. Mix D/E bonding resin and Pre-bond; apply thin layer to dentin 8. Simultaneous with #7 above, the dental assistant will mix the catalyst and base of

the chemically cured composite (Ti-Core) and load in a Centrix syringe. 9. Inject composite deep into matrix and fill to top 10. Apply strong finger pressure on the occlusal of setting composite using a plastic

Mylar matrix strip to adapt and bond composite well. Hold until initial set.

Option 1: Dental amalgam (use Valiant PhD) Option 2: Resin composite plus dental adhesive

Indication: Use preferentially over resin-modified glass ionomer, unless fluoride release is desired.

Materials: Filtek Supreme Plus + All Bond 2 (All-Bond 2 Technique Guide #1A)

Resin composite Placement Technique

1. Clean and prepare cavity. 2. Etch enamel and dentin using UNI-ETCH (32% H3PO4) for 15 seconds without


10. Chemically-cured Composite Foundation Restoration

Note that this is similar to the procedure for “bonded amalgam”.

11. Class 5 Restoration -- three options




3. Mix PRIMERS A and B. Apply 5 consecutive coats to enamel and dentin. DO NOT DRY BETWEEN COATS! After primer application is complete, dry all surfaces for 5-6 seconds with an air syringe to ensure thorough solvent and displaced water removal. Properly primed surface will appear glossy when coverage is sufficient. Repeat step 3 if not glossy.

4. Brush a thin layer of D/E BONDING RESIN over enamel and dentin. Light cure for 20 seconds.

5. Place composite in layers not to exceed 2 mm; light cure for at least 20 sec. 6. Contour, finish and polish restoration.

Option 3: Resin-modified glass ionomer (Fuji II LC Capsules)

Indications: Use preferentially over composite only when long-term fluoride release is desired and esthetics is not paramount.

Technique 1. Select shade 2. Apply GC Cavity Conditioner for 10 sec 3. Rinse thoroughly, dry gently, but avoid desiccation and contamination. 4. Tap capsules to loosen powder. Depress plunger. Click once in capsule

applier to activate. 5. Mix capsule for 10 sec at high (4300 cycles/min). 6. Apply filling material in increments not to exceed 2 mm. 7. Light cure 20 sec. 8. Repeat steps 5 and 6 until filled. 9. Finish and polish immediately 10. Apply thin layer of Fortify resin to seal and protect the surface.




Use Filtek Supreme Plus with All-Bond 2 (see the ALL-BOND 2 Guide #1A)

Clinical Procedures 1. Clean and prepare cavity. 2. Etch enamel and dentin using UNI-ETCH (32% H3PO4) for 15 seconds without


3. Mix PRIMERS A and B. Apply 5 consecutive coats to enamel and dentin. DO NOT DRY BETWEEN COATS! After primer application is complete, dry all surfaces for 5-6 seconds with an air syringe to ensure thorough solvent and displaced water removal. Properly primed surface will appear glossy when coverage is sufficient. If not shiny, repeat step 3.

4. Brush a thin layer of D/E BONDING RESIN over enamel and dentin. Light cure for 20 seconds.

5. Place Filtek Supreme Plus composite in layers not to exceed 2 mm, light cure for at least 20 sec.

6. Contour, finish and polish restoration.

Filtek Flow, Filtek Supreme Plus; + All Bond 2

Indications: Minimally invasive carious lesion or defect in the anatomical grooves of a

posterior tooth. A flowable composite (Filtek Flow) can be used if the defect resides within enamel and a composite (Filtek Supreme Plus) must be used if the defect extends into dentin.

Contraindications for Flowable Composite: 1. Any anatomical feature other than the occlusal, lingual and buccal grooves. 2. If the preparation width is larger than the ½ round bur 3. If the caries or defect extends into dentin. 4. Need for local anesthetic (for defect removal) Materials: (see All-Bond 2 Technique Guide #1A) 1. Filtek Flow and All Bond 2 can be used if no contraindications exist. 2. Given any of the contraindications above, use Filtek Supreme Plus resin composite

and All Bond 2 (see section 12 above) for the filling material. Resin composite is better formulated to match the material properties of dentin and exhibits less wear in areas of occlusal function.

12. Resin composite Restorations (Classes 1, 3-6)

13. Ultraconservative Class I Filling




Technique for Flowable Composite (Filtek Flow): 1. Use the D801 round diamond bur or ¼ or ½ round carbide bur (in slow or high-

speed handpiece) to eliminate areas that are stained, defective, or carious. 2. The bonding procedure is the same as for all composite restorations, thus you will

etch, prime and bond. See section 12. 3. Inject flowable composite (Filtek Flow) into the prepared

fissures by moving the syringe tip from distal to mesial areas, maintaining constant pressure on the syringe to prevent voids.

4. Run the explorer tip through the prepared fissure(s) to eliminate entrapped bubbles and facilitate flow of the composite.

5. You may use a fine-tipped brush or small sponge tip to adapt composite to cavosurface and to eliminate excess.

6. Light-cure for 40 seconds, moving the light guide slowly to cover all areas of the restoration.

7. Check the occlusion and remove excess with a slow speed round bur. 8. Polish with rubber points found in the composite finishing kit. Fee Code: 1. If the restoration is within enamel, use the code for sealant. 2. If the groove restoration enters dentin, Filtek Supreme Plus must be used. Thus

use the code for a one surface composite restoration.

Advantages of Class 2 Posterior Composites 1. esthetics 2. seal (resistance to microleakage) 3. conservation of tooth structure 4. slight tooth reinforcement 5. low thermal conductivity 6. no corrosion Disadvantages of Class 2 Posterior Composites 1. increased chair time 2. difficult technique (placement, anatomy, contacts, embrasures) 3. shorter clinical half-life than amalgam 4. occasional postoperative sensitivity 5. minimal radiopacity of some products 6. higher coefficient of thermal expansion than dentin 7. biocompatibility of some components unknown 8. polymerization shrinkage 9. increased incidence of recurrent caries compared to amalgam

14. Class 2 Posterior Resin composite Restorations




Indications for Class 2 Posterior Composites 1. patient requirement for an esthetic restoration 2. proper isolation of entire cavosurface margin attainable 3. natural centric occlusal contacts remain 4. demonstrated maintenance of good oral hygiene 5. low caries rate 6. few, if any, non-tooth colored restorations 7. conservatively-sized restorations Contraindication for Class 2 Posterior Composites 1. history/evidence of parafunctional wear due to bruxing and/or clenching. 2. poor oral hygiene 3. history/evidence of recurrent caries 4. deep subgingival areas requiring restoration 5. proper isolation cannot be achieved 6. patient desire for removal of clinically acceptable amalgams (UW policy) 7. large molar restorations

Materials 1. In addition to your tray with standard instruments, request a composite finishing kit, a

set of separating rings, and precontoured Dixieland Bands from the Dispensary. 2. Filtek Supreme Plus nano resin composite is the best choice for Class 2

composites since they can be inserted, adapted, contoured and formed somewhat easier than other composites which can slump some prior to curing.

3. Palodent System - separating rings and sectional matrices. 4. Elliot-style separator and soft, pre-contoured Dixieland Band and Tofflemire holder

(in reserve) 5. All-Bond 2 kit with Fortify resin 6. Bard Parker handle & #12 scalpel blade 7. Sof-Lex Kit - disks and strips 8. UW Composite Polishing Kit (#10) in dispensary Kit contains green (prepolish) and

tan (polish) rubber points, cups and discs, where the rubber is impregnated with diamonds. Twelve- and thirty-bladed carbide burs for contouring are also in the kit.

Technique

For a nice review of the Class 2 technique, read pp. 305-31 of your Operative Text2




1. ISOLATION. Always isolate with rubber dam.

2. PRE-SEPARATION. When placed between teeth, the spring action of the steel ring supplies a constant, gentle wedging force to create orthodontic-type separation of teeth. When possible, place the ring prior to, and during cavity preparation to help gain additional proximal separation. Secure the ring with the rubber dam forceps as shown below, and place the ring into the interproximal space

to be restored. Note that the prongs of the ring point toward the gingiva, and that the ring can be placed in either direction to facilitate preparing the tooth. There are two rings, circular and elongated. Either can be used for separation and in either direction, but note that the circular ring is held with the forceps differently than the elongated ring.

3. PREPARATION. Employ a conservative preparation as for amalgam. Do not bevel

the proximogingival or occlusal margins. It is much easier to locate a non-beveled finish line on the occlusal during contouring and finishing.

4. BONDING. Etch dentin and enamel for 15 sec with 32% phosphoric acid. Rinse

thoroughly; dry but leave the dentin somewhat moist. Apply 5 coats of All-Bond Primer A&B and thoroughly dry with air. Apply a thin layer of D/E Bonding Resin to the enamel and dentin and light cure 20 sec. Take care not to pool the resin on the pulpal floor or gingivoproximal area.

5. MATRIX SELECTION. There are three styles of dead-soft, pre-contoured sectional

matrixes as shown. Whether restoring one or two proximal surfaces, it is best to use the sectional matrix. The standard matrix on the left is most commonly used. The next (mini-matrix) is designed for use with primary teeth and patients with poorly erupted posterior teeth. The “plus matrix” on the right, is designed for larger proximal boxes. Note flaps that can accommodate an extended gingival floor, a high marginal ridge or extended proximal walls. The longer flap is to be placed in the gingival area. The standard and mini-matrixes have notches on one edge to denote the occlusal orientation.

6. MATRIX APPLICATION. ONLY ONE PROXIMAL SURFACE IS TO BE RESTORED AT A TIME.

Remove the ring(s) if used to pre-separate the teeth. Place a sectional matrix into one of the proximal areas to be restored. Select a proper fitting wooden wedge and insert it into the gingivoproximal using the cotton pliers. Then use the large end of your amalgam condenser to advance the wedge as much as possible. The sectional matrix can be carefully adapted if the contact is not closed, but it should not be




burnished as for amalgam since this may create a rough proximal contour that is difficult to polish.

7. SEPARATION. Apply the steel ring to the proximal

using your rubber dam retainer forceps. The tines of the ring may be positioned in front, on, or behind the wedge. Lightly adapt the wings of the matrix against the tooth to aid in forming contours. IMPORTANT. Take care to protect your and your patient’s eyes when placing the steel ring. And only place them with a rubber dam in place to prevent patient aspiration of a “flying separator”.

Are you permitted to restore two proximals simultaneously? You should separate and restore only one contact at a time since it is more difficult to attain the needed separation when filling two proximal areas at the same time. Only with explicit permission from your clinical instructor, may you restore both contacts simultaneously. When restoring MOD preparations, the Palodent System allows one to place two round rings in opposite directions or one round ring first, then the elongated one in the same direction as shown above. If the sectional matrixes do not function well, then try the dead soft, pre-contoured Dixieland Band (below) with the Tofflemire holder.

8. COMPOSITE PLACEMENT. Place composite in 2 mm increments (maximum) and

cure each increment for 40 sec. Begin with the proximal boxes. As increments near the marginal ridge area, take care to form the proximal and occlusal embrasures with the IPC instrument to avoid excess and to reduce the time for finishing. Similarly, the occlusal anatomy should be formed to the extent possible before light curing.




9. PROXIMAL CURE. Remove the ring separator and wedge, and bend the flanges of the matrix back to check the proximal surfaces for adequacy of filling. If needed, add composite to deficient areas and cure. Under any circumstances, cure the facial and lingual proximal areas, each for 40 sec.

10. PROXIMAL CONTACT. At this point, check the adequacy of the proximal contact with floss. If restoring a second proximal contact on the same tooth, proceed with restoring this surface even if the first contact is light. If curing is complete and a contact is open or too light, note instructions below for re-establishing a Class 2 proximal contact. Make this repair before finishing and polishing.

11. FINISHING AND POLISHING. If necessary, use the #12 scalpel blade to remove

excess on the gingival and proximal. Use a careful technique to prevent tissue injury and to promote shearing of excess, rather than bulk fracture which can become submarginal. The brown, plastic-backed Sof-Lex series of disks are ideal for finishing and polishing proximal and other smooth surfaces. The twelve- and thirty-fluted finishing burs should be used on the occlusal to remove excess and further define the anatomy. Finally, use the rubber points, disks and/or cups in the “composite polishing kit” to create a smooth occlusal surface. The small, blue, rubber-backed Sof-Lex discs can also be used to finish the occlusal surface, and always for smooth surfaces. Proximal surfaces are best polished with Epitex Finishing and Polishing Strips.

Composite Finishing and Polishing Instruments course finish fine finish DC1M green point DC2M green disk DC3M green cup gray SofLex strips

12 bladed carbide bur on kit 7404;7801;7901 12-bladed carbides course; medium SofLex disks

DC1 tan point DC2 tan disk DC3 tan cup

30-bladed carbides fine & xfine SofLex disks blue SofLex strips

12. RESIN GLAZE. An instructor should check the restoration while the rubber dam is

still on. If acceptable, clean the surface with etchant and apply Fortify resin. See section below for instructions on the use of the Fortify sealer.

13. CHECK THE OCCLUSION. Remove the rubber dam, check and adjust the

occlusion. Thereafter, re-polish these areas. Using your hand mirror, show the patient your fine work. ☺

Repairing a Proximal Contact 1. INDICATIONS. If at the time of restoring a tooth, or during an exam (i.e. existing

composite restoration), you note a open or light proximal contact, one should follow this procedure to re-establish a proper contact. Remember open contacts can lead to tooth migration and/or food impaction. So let’s make it right.

2. PLACE OR RE-PLACE RUBBER DAM. 3. PREPARATION. A small proximal box must be prepared into the existing

composite, generally extending to the proximal walls and below the contact, but not necessarily to the gingival floor. You can also air-abrade the prepared surface of an older composite to facilitate bonding.




4. BONDING. Once prepared, repeat etching and bonding with All-Bond 2 as before. Note that this is the same procedure as given in section 15 – Bonding or Repair of an Existing Composite.

5. MATRIX BAND. Place a sectional matrix into the proximal area as mentioned

above. Check to see that the matrix is against the approximal surface. 6. SEPARATION. Do not use the circular ring for separation if its use just resulted in

an open/light contact. We need a fail-safe separator at this point. Apply the Elliot posterior separator to the gingivoproximal and tighten the screw snugly for gingival adaptation of the band and to separate the teeth. Advise your patient that they will feel pressure from the separation. It is necessary to have adequate facial and lingual tissue anesthesia since the Elliot separator applies pressure also to the gingiva.

7. FILLING & CONTOURING is accomplished as before.

If the proximal contact is too strong and/or slightly rough to flossing, re-separate the proximal surface after band removal to reduce and polish the proximal surface using Sof-Lex strips. Check the contact with floss.

Composite Surface Sealing (ALL-BOND® 2 Guide #1D) Indication: Application of FORTIFY Composite Surface Sealant is required for restorations subject to functional wear (e.g. occlusal surfaces) and suggested for other restorations including resin-modified glass ionomer (Fuji II LC). This is to be done after final polishing and finishing. Evidence has shown significantly decreased occlusal wear of sealed restorations in the first year of service. 1. Rinse tooth and restoration with copious amounts of water to remove all debris. 2. Etch the surface of the composite restoration and approximately 1-2 mm of enamel

beyond the tooth/composite margin with UNI-ETCH (32% H3PO4) for 15 seconds. Rinse and dry thoroughly.

3. Using a sponge tip, carefully apply a thin layer of FORTIFY to etched enamel and composite surface with a disposable brush tip. Do not air thin. Take care when placing Fortify, as excess can pool, and when cured, becomes difficult to remove.

4. Light cure for 20 seconds. 5. Check occlusion.

15. Surface Sealer for a Composite Restoration




Step Composite Casting Amalgam Amalgam

Build-up Ti-Core Build-up

caries removal √ √ √ √ √ control hemorrhage √ √ √ √ √ apply thin layer Ca(OH)2 √ √ √ √ √ apply Fuji liner LC √ √ √ √ √ place base as needed as needed as needed etch with 32% H3PO4 √ √ √ apply All-Bond A+B √ √ √ √ air dry 5-6 sec √ √ √ √ light cure for 20 sec √ √ apply metal matrix √ √ √ Prebond + DE bond resin √ √ apply DE bonding resin √ √ √ light cure for 20 sec √ √ apply plastic matrix √ place filling √ √ √ √

See Allbond-2® technique card #4; Evidence: Gordon et al6, D’Alpino et al7, Rathke et al8, Gordan et al9 1. Pumice tooth. 2. Prepare the fractured or defective composite surface with a medium to coarse

diamond bur, carbide bur, or disk to create a fresh composite surface. Make sure enough material has been removed to provide for some bulk of composite and ease of filling and finishing. Place a long cavosurface margin bevel. One can also use the sandblaster shown next, to enhance the bond.

3. Apply UNI-ETCH (32% H3PO4) for 15 seconds over the entire composite surface to be repaired. Also etch any enamel which will be included in the repair procedure.

4. Rinse with water and dry thoroughly. 5. Mix PRIMERS A and B. Apply 5 consecutive coats to the composite and tooth

structure that was etched. DO NOT DRY BETWEEN COATS! After primer application is complete, dry all surfaces for 5-6 seconds with an air syringe to insure thorough solvent and displaced water removal. Properly primed surfaces will appear glossy when coverage is sufficient.

6. Brush a thin layer of D/E RESIN over the primed surfaces. Light cure for 20 seconds

7. Proceed with composite layering and finishing.

16. Procedure Check List for Pulp Capping and/or Placing Restorations

17. Bonding to and/or Repairing an Existing Composite




Porcelain/Acrylic Repair (ALL-BOND ® 2 Guide #2) 1. Place rubber dam! Clean surface of porcelain and metal with pumice. 2. Bevel porcelain margin with a diamond bur. 3. For optimum results, sandblast metal and

porcelain with microabrasion unit. If microabrasion unit is not available, abrade with medium diamond bur.

4. Apply UNI-ETCH (32% H3PO4) for 5-10 seconds to cleanse and acidify the porcelain surface. Rinse and dry.

5. Apply Porcelain Primer (silane) to porcelain surface for 1-2 minutes. Air dry. Mix PRIMERS A & B and apply 2 coats to metal and porcelain. Air dry for 5-6 seconds with air syringe.

6. If acrylic is present, treat the same as porcelain. Omit silane. 7. Shake opaquer catalyst and base well before using. Mix Bisco DUAL CURE

OPAQUER base and catalyst and apply a thin layer to metal. Light cure for 30 seconds to prevent slumping. If metal is not present, omit metal opaquer step.

8. Apply thin layer of D/E BONDING RESIN to porcelain and opaqued metal. Light cure for 20 seconds.

9. Proceed with composite layering and finishing. Microfil composites are not recommended.

Desensitizing Root Surface (ALL-BOND ® 2 Guide #6A) Also needed: 2% Chlorhexidine (e.g. Bisco CAVITY CLEANSER) 1. Clean dentin surface by scrubbing with 2% Chlorhexidine and pumice. (Dip cotton

pellet soaked with 2% Chlorhexidine into flour of pumice). 2. Rinse thoroughly with warm water. 3. Blot gently with moistened cotton pellet. To minimize patient discomfort, do not air

dry. 4. Mix PRIMERS A & B. Apply five consecutive coats to enamel and dentin. DO NOT

DRY BETWEEN COATS! After the fifth coat, dry for 5-6 seconds with an air syringe to ensure thorough solvent and displaced water removal.

5. REPEAT STEP 4. 6. Light cure for 10 seconds. 7. With care, apply a thin layer of Fortify resin with a sponge tip and light cure. Take

care when placing Fortify, as excess can pool, and when cured, becomes difficult to remove.

18. Repairing Porcelain

19. Treating Sensitive Root Surfaces with a resin sealer




8. Charge for this service: Code 9911 - Application of desensitizing resin for cervical and/or root surface, per tooth. Do not use this for sealers, bases and liners under restorations. And if using a resin root sealer to desensitize, do not use code 9910 (application of desensitizing medicaments) as this is more for fluoride varnishes.

Based on the work of Dr. Martin Brännström at the Karolinska Institute in Stockholm, Sweden, it is universally accepted that a common cause of pulpal sensitivity is bacterial ingress into dentinal tubules and/or movement of dentinal fluids and concomitant irritation of nerve bundles within the tubule. A pressure differential can cause fluid movement in the tubules. This may be brought about by drying dentin with a three-way syringe or by hot and cold stimuli. This is why we caution folks to never over dry exposed dentin and to always keep the exposed dentin physiologically moist.

With this introduction, the rationale for sealing sensitive root surfaces and prepared teeth is to control post-operative sensitivity by limiting fluid movement and to prevent ingress of bacteria. Often the term microleakage is used to describe the cause of symptoms of tooth sensitivity. This refers to a communication between the oral environment and dentinal tubules allowing bacterial ingress and pressure changes causing fluid movement. For reference, a compilation of Dr. Brännström’s studies can be found in the monograph entitled “Dentin

and Pulp in Restorative Dentistry” by Dr. Martin Brännström10. A modified illustration from his monograph is provided above.

The product chosen for use in the in the Department of Restorative Dentistry clinics is called GLUMA® Desensitizer from Heraeus/Kulzer (1-800-343-5336). The composition is 5% glutaraldehyde, 35% hydroxyethylmethacrylate (HEMA) and 60% water. The mechanism for sealing is precipitation of plasma protein in the dentinal fluid to occlude the tubules11. This study also demonstrated that the glutaraldehyde component, and not HEMA, produced the precipitate. A clinical study also substantiated the effectiveness of the sealer in reducing post-cementation sensitivity12. In other studies, it was shown that a resin sealing

system (e.g. composite bonding system) reduced the retention of cemented castings when zinc phosphate cement was used13, whereas the retention was unaffected for any cement when the GLUMA® Desensitizer was used.14 Given laboratory and clinical

20. Sealing Teeth Prepared for Indirect Restorations




evidence that GLUMA® Desensitizer is safe and effective, the decision was made to use this product over other systems.

Why don’t we use GLUMA® Desensitizer as sealer under amalgam and to seal sensitive roots? Good question!! The reason is that Allbond 2 A+B has been shown to penetrate dentin effectively without removal of the smear layer (i.e. etching of dentin) and the polymer laid down with the A+B primer is very complete and durable. Given the risk of decreased retention of castings cemented with zinc phosphate when Allbond 2 A+B primer is used to seal prepared teeth,

this tipped the scales toward selection of GLUMA® Desensitizer for this purpose. This is the rationale for this apparent inconsistency. Why do you think a resin sealer might decrease retention of castings cemented with zinc phosphate, but the GLUMA® Desensitizer not? You have the tools to deduce this, so give it some thought. In case your eyes are led principally to bold print, note that Allbond 2 A+B, and NOT GLUMA® Desensitizer, is to be used in our clinics to treat sensitive root surfaces and as a sealer under amalgam. In these cases we are not concerned about loss of retention of a restoration when the resin sealer is used. When should you use GLUMA® Desensitizer? In general, use it on exposed dentin of vital teeth that are prepared for an indirect restoration. It is not to be placed on the foundation (i.e. buildup). Since the product is costly and the procedure will consume important chair time, use the material judiciously and note the specific indications which further compel the use of this sealer on prepared teeth. Specific Indications for Use of GLUMA® Desensitizer 1. History of thermal sensitivity of tooth to be restored. 2. Radiographic evidence of a pulp with little recession or large pulp horns. 3. Preparation of a virtually unrestored tooth (e.g. bridge abutment). 4. Over-reduction of tooth, thereby encroaching on the pulp. 5. History of thermal sensitivity during provisionalization period. Contraindications for Use of GLUMA® Desensitizer 1. Non-vital tooth 2. Previous history of allergic reaction to glutaraldehyde or HEMA Directions for use at the time of Preparation 1. Prepare the tooth for the indirect restoration as normal. 2. Prior to cementing the temporary crown, apply the GLUMA® Desensitizer. 3. Make sure the tooth is physiologically moist, and not overly wet, nor dry. 4. Using a continuous rubbing motion with a small cotton pellet or the Kerr “tufted”

Applicator, apply the GLUMA® Desensitizer liquid to the exposed dentinal surface for 30 seconds. Although only one coat is required, supply fresh liquid to different areas of exposed dentin so glutaraldehyde is always available to form a precipitate in the tubules.

5. Dry thoroughly with air. 6. Do not rinse and avoid contact of the GLUMA® Desensitizer with soft tissue.




Caution: If contact with soft tissue occurs, flush the area immediately with water. Extended contact with tissue will cause redness and burning. There is another caution from the manufacturer. If using cotton rolls for isolation, do not allow the liquid to be absorbed into the cotton as this exposure may cause a redness or burning of the gingival tissue. If cotton rolls are wetted with the GLUMA® Desensitizer, remove the rolls and rinse the tissue. Then re-isolate the area. 7. Proceed with cementation of the provisional restoration. Directions for use at the time of cementation 1. Remove the temporary crown and all of the temporary cement. 2. Seat the indirect restoration by adjusting the proximal contacts, checking the

adaptation of the restoration to the finish line and by adjusting the occlusion. 3. Polish the gold and/or porcelain indirect restoration. 4. Clean the indirect restoration by cleaning the internal with a soft tooth brush and

liquid soap. Thereafter, place the completed restoration in a plastic baggy with soap and water to clean it completely. Rinse thoroughly and dry.

5. Clean the preparation with a prophy cup using a slurry of flour of pumice and 2% chlorhexidine.

6. Rinse and leave moist, but not wet. 7. Using a rubbing motion with a small cotton pellet or Kerr “tufted” Applicator, again

apply the GLUMA® Desensitizer liquid to the exposed dentinal surface for 30 seconds. Although only one coat is required, you may need to supply fresh liquid to several areas of exposed dentin to provide a continuous source of glutaraldehyde.

8. Dry thoroughly with air. 9. Proceed with cementation of the casting using the luting cement indicated for this

clinical situation.

Sealing Technique Summary: Using a rubbing motion with a small cotton pellet or the Kerr “tufted” Applicator, apply the GLUMA® Desensitizer liquid to the exposed dentin for 30 seconds. Although only one coat is required, you may need to supply fresh liquid to several areas of exposed dentin to provide a continuous source of glutaraldehyde, the important ingredient.




Luting Cements Type Indications Contraindications Fleck’s* (Mizzy)

zinc phosphate

complete veneer metal and metal-ceramic crowns; partial coverage castings (inlays, onlays, partial veneer crowns); posts; cast post/cores

porcelain/ceramic restorations

RelyX Luting (3M ESPE)

dual-cured, resin-modified glass ionomer

complete veneer metal or metal-ceramic crowns; preferred when minimal resistance and retention form exists

porcelain/ceramic restorations; partial coverage castings; posts; cast post/cores; and if a temporary cement with eugenol was used.

Variolink II** (Ivoclar); both used with Allbond 2 (Bisco)

dual-cured resin

used exclusively for all-porcelain/ceramic restorations (ceramic veneers, inlays, onlays, complete veneer crowns)

all other cementations

Comspan (Dentsply Caulk); use bonding resin in kit

resin used exclusively for base metal, acid-etched, resin-retained bridges. (a.k.a. Maryland Bridge)

all other cementations

* Zinc Phosphate is the only cement to be used when cementing cast post/cores, manufactured posts

and partial coverage cast-metal restorations (inlays, onlays, partial veneer crowns). ** five shades with try-in pastes

Type

Zinc Phosphate

Resin-mod glass ion

Dual-cured Resin

Resin composite

Brand Restoration Fleck’s RelyX

Luting Variolink II Compspan

cast metal inlay or onlay Yes No No No partial coverage cast crown Yes No No No complete cast metal or metal ceramic crown Yes Yes No No

complete cast metal or metal ceramic FPD Yes Yes No No

cast post & core Yes No No No manufactured post Yes No No No ceramic veneer No No Yes No ceramic inlay or onlay No No Yes No ceramic crown (Emax, Finesse) No No Yes No ZrO2 crowns (Procera, LAVA)* No Yes Yes** No resin-retained FPD No No No Yes * See page 25 for specific procedures as they differ from conventional ceramic. ** Variolink II is preferred for anterior crowns since it has more translucence.

21. Indications and Contraindications for Use of Luting Cements available in the Restorative Dentistry Clinic at the University of Washington




Seating/Cleaning of Casting and Preparation 1. Remove the temporary crown and the temporary cement. 2. Seat the casting restoration by adjusting the proximal contacts, checking the

adaptation of the restoration to the finish line and by adjusting the occlusion. 3. Polish the gold and/or porcelain as needed. 4. Clean the internal of the casting with a small tooth brush and liquid soap. 5. Thereafter, place the casting in a plastic bag with 2% chlorhexidine and clean in an

ultrasonic bath. Rinse thoroughly and dry. 6. Clean the preparation using a prophy cup and a slurry of flour of pumice and 2%

chlorhexidine. 7. Rinse, dry some but leave dentin slightly moist. 8. Apply dentin sealer if needed. 9. Isolate the quadrant for cementation with cotton and saliva ejector.

Fleck’s (Mizzy)

Zinc Phosphate Cementation Tips 1. Chill the mixing slab 2. Employ careful mixing technique (P:L ratio!) 3. Always check the consistency - cement strings 1-2 cm 4. Line internal of the casting with a layer of cement. 5. Seat with firm pressure; check occlusion and

adaptation for proper seating. 6. Have patient bite firmly on cotton until cement

has achieved initial set. 7. Clean cement after completely hard. Video: zinc phosphate mixing technique http://www.dental.washington.edu/departments/restorative/clin_resource_info.php

Rely X™ Luting™ (3M ESPE)

RelyX Luting Cementation 1. Roll the powder bottle; dispense 3 level

scoops. 1 scoop per drop liquid. 2. Hold liquid bottle vertically, squeeze gently to

dispense 3 drops of liquid for one crown (6 for two).

3. Mix all of the powder into the liquid rapidly. 4. Continue mixing for 30 seconds. 5. Line internal of casting with a layer of

cement.

22. Cements and Cementation Procedures

Zinc Phosphate Cement

Zinc Phosphate min:sec Mixing time 02:00 Working time 04:00 Setting time 07:00

Resin-modified Glass Ionomer Cement




6. Seat with firm pressure; check occlusion and adaptation for proper seating. 7. Have patient bite firmly on cotton roll until cement has achieved initial set. 8. Clean excess cement when set (no earlier than 3 min after seating)..

Cement: Variolink II (Ivoclar) Type of crowns: Lithium Disilicate (Emax – Ivoclar; Finesse - Dentsply) and ZrO2 Crowns (LAVA; Procera) Variolink II Cement - Tooth Preparation (see All-Bond Technique Guide 3B and Cement Instructions) 1. Check restoration fit; use Try-In paste if color is to

be altered. Otherwise, use Liquid Strip glycerin gel to seat ceramic restoration.

2. Etch dentin with UNI-ETCH (32% H3PO4) for 15 seconds without agitation (timing is important). Rinse thoroughly. Remove excess water with a brief burst of air.

3. Mix PRIMERS A and B. Apply 5 consecutive coats to dentin. DO NOT DRY BETWEEN COATS! After primer application is complete, dry all surfaces for 5-6 seconds with an air syringe to ensure thorough solvent and displaced water removal. Properly primed surface will appear glossy when coverage is sufficient. Light cure for 20 seconds.

4. Apply a thin layer of PRE-BOND RESIN to dentin immediately prior to cementation. AIR THIN. DO NOT LIGHT CURE!

Variolink II Cements - Ceramic Preparation (see All-Bond Technique Guide 3B and Cement Instructions) 1. Clean internal of the ceramic restoration with UNI-ETCH (32% H3PO4) for 15

seconds. Rinse thoroughly and dry. 2. Apply silane to internal of the ceramic restoration for 30 sec and dry. 3. Apply a thin layer of D/E bonding resin to this surface. DO NOT LIGHT CURE.

RelyX Luting Cement min:sec Mixing time 00:30 Working time 02:30* Setting time 05:30* *Important - that the w.t. and s.t. are shortened significantly at elevated temperatures.

All-Ceramic Crown Cementation




Variolink II - Cementation (see All-Bond Technique Guide 3B) 1. Mix equal amounts of base and catalyst pastes on a mixing pad for 10 seconds. 2. Line internal of ceramic restoration with a layer of cement and place some cement

onto the preparation. 3. Seat with slow, even pressure; check occlusion and adaptation for proper seating. 4. Maintain seating pressure and remove

some of the excess with a brush lightly coated with D/E resin.

5. Liquid strip may be applied to margins. 6. Light cure all sides of the restorations for

40 sec at each position. 7. Clean excess cement; adjust and finish as

needed.

RelyX Luting or Variolink II

This type of crown consists of a CAD/CAM produced zirconium oxide coping over which traditional feldspathic veneering porcelain is applied and fired. The ZrO2 coping is “tough” and cannot be etched internally to facilitate bonding. For this reason, the procedures for cementation are different that those given above for alumina and feldspathic porcelain restorations. Type of crowns: LAVA (3M ESPE), Procera Zirconia (Nobel Biocare)

Zirconia Coping Surface Preparation (normally done by the dental laboratory) Sandblast the internal of the coping with 50 micron grit alumina for a maximum 15

seconds using 4-5 bars of pressure. Clean the crown in an ultrasonic bath containing isopropyl alcohol for 3 min.

Cleaning of Prepared Tooth before try-in (chair-side) Remove excess temporary cement. Prophy with a mixture of flour of pumice and water. Rinse and dry gently, leave moist taking care to not desiccate surface. If needed

cover the tooth preparation with a moist 2x2 gauze. Do not allow contamination of the prepared tooth. If so, repeat above steps.

Cleaning of ZrO2 Crown after try-in (chair-side) After try-in of crown, rub the interior of the crown with 37% phosphoric acid gel with

an applicator in order to dissolve saliva and other protein remnants. Rinse thoroughly with water for 1 minute. Dry gently with air Dehydrate with isopropyl alcohol and air dry.

Cementation with RelyX Luting & Variolink II (see previous instructions)

Variolink Cement min:sec Mixing time 00:10 Working time 03:30* *Important - note that the w.t. and s.t. are shortened significantly in the absence of oxygen or at elevated temperatures.

Zirconium Oxide-based Crown Cementation




By Dr. Gabriela Ibarra, Clinical Associate Professor

Cement: Variolink II (Ivoclar) Type of veneers: Feldespathic, IPS Empress (Ivoclar Vivadent) Variolink II Cement - Tooth Preparation (see All-Bond Technique Guide 3B and Cement Instructions) 1. Remove temporary restoration and pumice tooth. If there was no temporary

restoration placed, you still need to pumice the tooth to clean it. Use floss or sandpaper strips to clean interproximally. Avoid tissue damage.

2. Place either mylar strips, plumber’s tape or shim stock strips interproximally on both sides of the tooth to be veneered. This will avoid accidental etching of the adjacent teeth.

3. Etch with UNI-ETCH (32% H3PO4) for 15 seconds, rinse thoroughly and dry (if only enamel present). If there is an area of exposed dentin within the preparation, be careful not to over-dry it.

4. Mix Primers A and B and apply 5 consecutive coats to the area of exposed dentin. Do not dry between coats. Dry surface for 5-6 seconds to evaporate the solvent. Surface should appear glossy. Light cure for 20 sec.

5. Apply a thin layer of D/E RESIN to the tooth surface immediately before cementation. Air thin. DO NOT LIGHT-CURE.

Variolink II Cements - Veneer Preparation (see All-Bond Technique Guide 3B and Cement Instructions) 1. Try-in each veneer dry. Check the fit and marginal integrity. 2. Try-in each veneer with its adjacent veneers with water. This will allow you to check

for sequential fit problems. If the shade match is crucial, a try in with a supplied try-in paste (translucent, light, dark) is recommended.

a. Apply a thin layer of the try-in paste to the internal aspect of the veneer and proceed to seat the restoration.

b. Check the color match. Work without the operatory light to avoid setting of the paste and to have a better appreciation of the shade.

c. Try-in pastes are usually water-soluble and need to be cleaned off with water spray and dried with oil-free air. If the try-in paste is not water-soluble, you will need to clean the veneer with acetone.

d. You may need to repeat the process with a different shade of try-in paste if the color match is not satisfactory.

3. Acid etch the internal aspect of the restoration with 4% hydrofluoric acid (HF) for 3-4 minutes. Rinse and dry. It is recommended that you etch the veneer chairside before cementation, rather than have the lab do it. Safety Alert - Be careful when handling this acid.

Porcelain Veneer Cementation




4. Apply the silane coupling agent to the internal aspect of the veneer. Let seat for 60 seconds and dry. AVOID CONTACT OF THE SILANE WITH THE EXTERNAL SURFACE OF THE VENEER.

5. Immediately before cementation, apply a thin layer of D/E RESIN to the internal surface of the veneer. Air thin. DO NOT LIGHT-CURE.

Variolink II – Veneer Cementation (see All-Bond Technique Guide 3B) 1. Load the veneer with an even layer of the base material, making sure the margins

are covered. Veneers can be cemented with only the base of the cement (not the catalyst) since they are very thin and quite translucent.

2. Using finger pressure, push gently, but firmly, on the veneer until it’s seated in place. Clean the gross excess material from the margins with an explorer.

3. Increase finger pressure and hold for a few seconds, bringing the veneer to a complete seat. Remove excess cement with a sable brush from difficult to access areas such as the interproximal and cervical embrasures. Be careful not to brush the cement out of the margins.

4. At this point, you can tack the veneer by light curing an area of the incisal edge with a very small diameter tip (2mm) for 10-20 seconds. Do not light-cure the proximal or cervical areas.

5. Remove the mylar strips by pulling to the lingual and floss the proximal areas to remove residual cement.

6. Cover the restoration margins with a glycerin gel and light-cure for 60 seconds from the buccal, incisal, lingual and proximal aspects. If the tip of the curing light is not large enough to include all the margins of the veneer, each margin will have to be light-cured separately for 60 seconds. The glycerin gel will avoid an oxygen inhibition layer at the margins.

7. Use a #12 scalpel blade to remove any overhangs from the cervical or interproximal areas very carefully. The blade is very sharp and you can initiate gingival bleeding. You can also use a sharp scaler or gold knife.

8. If necessary, a diamond finishing strip can be used to finish the proximal surfaces, followed by Epitex strips. Margins can be finished with very fine diamonds (under 25µm) and finishing flexible disks

9. . Adjust occlusion with fine diamonds under water spray and polish with silicon points and disks.

10. Apply a neutral fluoride varnish.

For additional information on insertion of porcelain veneers, refer to p 485 of your Operative Text2




By Dr. Douglas Verhoef, Clinical Associate Professor

Materials: ColteneWhaledent® ParaPost® System Guidelines for Posts

Prefabricated Stainless Steel post (ParaPost®X System)

Round to slightly oval canal shape. Most anterior teeth and premolars with ≥2mm

ferrule. Many molars do not require posts due to

adequacy of remaining tooth structure and depth of pulp chamber. If necessary, one SS post is placed in palatal or distal canal. A second smaller post can be placed into another canal at a different angulation and requires less length.

Prefabricated fiber post (ParaPost® Fiber Lux)

All-ceramic crowns Must have optimal ferrule to prevent fracture Generally not indicated for maxillary canines Core material is light-cure composite

Core Materials - CVGC and EVC crowns

Amalgam or composite is permitted, but decision to be made based upon strength, need for longevity, esthetics, need for bonding. Consult with instructor before appointment.

Ti-Core may be used, but only of the crown is prepared the same day. See Section 10.

Cast Post Any shape canal OK, but necessary for irregular shape.

Tooth will demonstrate minimal ferrule when restored.

May be fabricated at slight angle from long axis of root if tooth is tipped.

Direct technique utilizes serrated plastic pattern and Duralay resin to create desired core shape.

Indirect technique utilizes smooth plastic post and subsequent impression.

Much higher cost due to lab fee and 2nd appointment.

23. Posts and Post Cementation




Design of Post Length: Several suggested optimal lengths have been proposed in the literature. No single “rule” is applicable for all clinical applications. In ALL situations there must be 4-5mm of remaining gutta percha seal at the apex of the root. In ALL situations it is advantageous to maximize the length, but without compromising the integrity of the root thickness. The diameter of the post should be instrumented to engage vertical walls of the canal space except in highly tapered canals (Fig. a below). Among the suggested lengths are (see figures below):

The length of the post should be greater than or equal to the length of the crown (Fig #1).

The length of the post below the level of the bone should be greater than or equal to the length of the post/core above the level of the bone. (Fig #2)

The length of the post should be greater than the length of the core. (Fig #3)

Cements for Posts: • Stainless Steel Zinc Phosphate with lentulo spiral • Stainless Steel (minimum length) RelyX Luting with endo explorer • Fiber Posts RelyX Luting with endo explorer




Technique Summary (references 15, 16, 17, 18,19) • Examine enamel defect(s) while the tooth is hydrated to assess the degree of defect

removal needed. • Isolate of the tooth or teeth with a double application of heavy weight rubber dam. • Apply the usual patient protective items including clothing drapes and protective eye

wear. • Disks or abrasive points can be first used to remove some of the defect. • Place flour of pumice into a glass dappen dish and add a few drops of 18%

hydrochloric acid with a medicine dropper to create a thick paste. • Fashion the wooden end of a cotton-tipped applicator to resemble the end of a

straight chisel. • Pick up a small amount of the acid-pumice paste and apply to the defect by rubbing

the abrasive mix with the end of the wooden applicator. Rub for 5 seconds and gently rinse for 10 seconds using only water in the air-water syringe. Use high volume evacuation to remove water and abrasive; dry gently.

It is best to visualize the effect of acid-abrasion treatment by moistening the tooth. If the defect is still prominent, repeat the step described above. Note that under a rubber dam, the defect will appear more noticeable than for a totally hydrated tooth. Therefore, limit the degree of removal to the point where there is noticeable change, but a hint of the defect can still remain.

• Polish the enamel with the Sof-Lex series of disks and strips. Apply APF fluoride gel to the enamel.

• Additional appointments can be scheduled as needed for additional treatment.

24. Treating Superficial Enamel Discoloration




Additional Information: Time needed 30-60 minutes/appointment Billing bleaching of vital a teeth




Optilux Curing Radiometer

o Obtain the Optilux radoimeter from the Dispensary. Use only this brand of radiometer since others often give high or low readings.

o Hold the tip of the light wand flat on the sensor, turn on the light. The value for

this particular light normally reads about 700-800 mW/cm2. Do this two to three times in succession. Often power output will decay a bit as the light is turned on a few times.

o Given a value significantly lower than this (i.e. <500 mW/cm2), the QTH bulb may need to be checked. See Leng or Dave in Dental Maintenance (543-5958) for a second check. They can replace the bulb if needed. Other causes of low values may be a faulty light guide (tip) or feature this, composite bonded to the tip!

o If you replace the bulb, check the output again to make sure you’ve got power. o This test is accomplished so simply and the rewards are potentially enormous.

Do this quarterly to make certain you are curing resin composite, adhesives and liners polymers with adequate power. To not do so, is really bad news since the restorations or liners may be inadequately polymerized at deeper levels.

25. Coltolux Curing Light – Power Output Check













ADHESTIVE/BONDING AGENTS • Bisco's All Bond 2 - Includes:

Primer A & B, D&E Bond, Prebond, Opaquer, Porcelain etch, and Silane coupler

ADHESIVE PLACEMENT TIPS • True-Grip (tacky sticks to hold

inlays, veneers, etc.-They come in 2 sizes - Standard or Mini (Clinicians Choice)

ANTIBIOTICS • Amoxicillin 500 mg • Clindomycin 150 mg AMALGAM • Valiant PhD Regular set

(Ivoclar/Vivadent) • Valiant PhD-XT (extended

working time) Ivoclar/Vivadent ANESTHETICS, Local • Xylocaine 2% (1:100,000 and

1:50,000) • Polocaine 3% • Septocaine 4% ANESTHETICS, Topical • Hurricane (unit dosed topical) • Hurricane (spray) ASTRINGENTS AND HEMMORAGE CONTROL • Astringident (15% ferric sulfate) • Viscostat gel (20% ferric sulfate) ARTICULATING PAPER/and DETECTORS • Articulation Ribbon, red silk • Articulation Ribbon, green • Accu-Film/Exacta-Film (ArDent) • Fit Checker (GC) • Occlude (Pascal)

ARTICULATING FORCEPS (Miller) • Metal - in instrument trays • Paper -disposable (From AR-

Dent) BITE REGISTRATION MATERIALS • Regisil 2X (Dentsply Caulk) BLEACHING MATERIALS • Opalescence Patient Kit (10%) • Block out resin (Ultradent) • Sof-Tray sheets 5x5 0.035",

Ultradent BRUSHES & APPLICATORS • Benda Brushs From Centrix • Kerr's Applicator sticks - multi-

brushes BURS (for crown removal) • Dentsply bur CARIES INDICATOR • Caries Indicator (Henry Schein) CAVITY CLEANSERS • Bisco's Cavity Cleanser (2%

chlorhexidine) CAVITY LINERS • Caulk's Dycal (chemical cured ) • Fuji Lining LC CEMENTS, For Gold and PFM • Fleck's cement liquid • Fleck's Zinc Phosphate, Lt.

Yellow • Fleck's Zinc Phosphate, Sno-

White • RelyX Luting (resin-mod glass

ionomer)




CEMENTS: RESIN (For porcelain and ceramic only) • Ivoclar's Variolink II (multiple

shades and try-in pastes • Ivoclar's Liquid Stripes (for

eliminating air inhibited layer of cement margins before curing and for a try-in cement for ceramic veneers and crowns)

CEMENTS: Temporary • TempBond NE (Kerr) • Temerex (for longer provisionals) • IRM (Caulk) • IRM liquid (Caulk) • Cavit (ESPE) • Neotemp (Waterpik) CHEEK RETRACTORS • Metal ( for retraction of cheeks,

impressions, etc. COMPOSITES & GLASS IONOMERS • 3M ESPE Filtek Supreme Plus • EDS' Ti-Core (chemical -cured) • GC Fuji II LC (resin-modified

glass ionomer) • 3M ESPE Ketac-Fil Aplicaps COMPOSITE SEALER • Bisco's Fortify (apply after finish

of restorations) • Ivoclar's Liquid Strips (for

covering composites - & Fortify to eliminate air

inhibited layer. COMPOSITE POLISHING SUPPLIES • 3M's Soflex discs and strips • Brasseler Composite polishing

kits COMPOUND • Red stick compound (Kerr)

• Green stick compound (Kerr) CROWN FORMS • Clear plastic (Anteriors and

premolars) • Polycarbonate • Ion-aluminum shells CROWN SECTIONING AND REMOVAL • T-bar for bending crown

framework DESENSITIZING AGENTS • Gluma (to reduce crown

sensitivity) • All Bond "A" & "B" primer (roots

sensitivity) ELECTROSURGERY • Unit from Coltene-Whaledent • Tips: straight FLOURIDES • Duraflor 5% sodium floride

varnish • For in office application:

- "Minute Foam - Oral B - Fluoro Care 2% NaFl gel - Nupro - acidulated and neutral

FRACTURE FINDER • Tooth Slooth IMPRESSION MATERIALS • Tray adhesive (3M ESPE) • Impregum F (Remov Pros) • Aquasil Ultra Monophase

(Dentsply Caulk) • Aquasil Ultra XLV • Aquasil Tray adhesive • Jeltrate Alginate (Dentsply Caulk) • Cinch




MATRIX BANDS • Dixieland precontoured bands

(soft) – Teledyne Getz • Matrix Bands "T" • Matrix Bands, .002, #1 • Matrix Bands, ultra thin, #1 • Matrix Bands, ultra thin, #2 • Copper band set with pliers set • Caulk's automatrix MATRIX BANDS FOR COMPOSITE • Teflon tape (plumber tape) • Dixieland bands precontoured • Bitine ring with sectional matrices MEDICATIONS • Amoxicillin 500 mg • Clindomycin 150 mg • Hydogenperoxide 3% OCCLUSAL CLEARANCE TABS • 1, 1.5 & 2 mm tabs (Kerr) PORCELAIN POLISHING KITS • Kit with series of polishing

wheels, etc which will reproduce the glaze like surface desired.

POST SYSTEMS • Twist Drills (all sizes issued in

one box) • Parapost plastic posts for casting

& impressioning • Parapost (threaded stainless

steel) PULP CAPPING MATERIALS • Dycal (Caulk) • Fuji Lining LC RESIN/TEMPORARIES • Caulk's Temporary Resin,

Shades 62, 65 & Incisal • DuralayResin (red) for cast posts

and indexing

• Filtek Flow (ProTemp repair) • ProTemp (A2, A3) SALIVA EJECTORS & MOISTURE CONTROL • Svedoptor • Cotton roll holders • "Dry-Tips" SEALANTS • ClinPro Sealant • Liquid etchant SHADE GUIDES • Vita: Set of 2 ( 1 by Value, other

by Chroma TEMPORARY RESINS • Caulks resin and monomer • Shade 62 • Shade 65 RESINS - ORTHO • Ortho Resin, Clear • Ortho Resin, red RESINS - OTHER • Duralay: (red) for custom post

fabrication) and for connecting segments of bridges to facilitate solder of bridge in lab

TISSUE RETRACTION • UltraPak – Braided Retraction

Cord, (00, 0, 1, 2, 3) VITALITY TESTING • Electrical pulp tester • Endo Ice WEDGES (contoured) • Premier Interdental Wedges




References 1 Pameijer, C.H. and Stanley, H.R. The disastrous effect of the total etch

technique in vital pulp capping. Am J Dent 1998; 11:S45-S54. 2 Fundamentals of Operative Dentistry, third edition, Quintessence

Publishing, 2006 James Summitt, J. William Robbins, Thomas H. Hilton, Richard S. Schwartz, Chapter 5, Pulpal Considerations, pp. 91-112.

3 Hilton, TJ. Keys to clinical success with pulp capping: A review of the literature. Operative Dentistry 2009, 34-35, 615-625.

4 Geurtsen W. Biocompatibility of resin-modified filling materials. Crit Rev Oral Biol Med. 2000;11(3):333-55.

5 Summitt, JB, Burgess JO, Berry, TG, Robbins, JW, Osborne, JW, Haveman, CW. The performance of bonded vs. pin-retained comlex amalgam restorations. J Am Dent Assn (132):923-931, July 2001.

6 Gordon, VV et al. Two-Year Clinical Evaluation of Repair versus Replacement of Composite Restorations. J Esthetic and Restorative Dentistry, 2006; 18; 144-153.

7 D’Alpina, PH et al. Efficacy of composite surface sealers in sealing cavosurface marginal gaps. J. Dent. 34:, 252-269, March 2006.

8 Rathke, A, Tymina Y, Haller, B. Effect of different surface treatments on the composite-composite repair bond strength. Clin Oral Invest 2009; 13:317-323.

9 Gordan V. V., Garvan C. W., Blaser P. K., Mondragon E., and Mjor I. A. A Long-Term Evaluation of Alternative Treatments to Replacement of Resin-based Composite Restorations: Results of a Seven-Year Study J Am Dent Assoc, December 1, 2009; 140(12): 1476 - 1484.

10 Dentin and Pulp in Restorative Dentistry, Martin Brännström (1982), Wolfe Medical Publications Ltd., Wolfe House, 3 Conway St., London, W1P 6HE

11 Schüpbach, P., Lutz, F., Finger, W.J. Closing of dentinal tubules by Gluma Desensitizer. European J Oral Sci 1997; 105: 414-421.

12 Felton, D. A., Bergenholtz, G., Kanoy, B.E. Evaluation of the desensitizing effect of Gluma Dentin Bond on teeth prepared for complete-coverage restorations. Int J Prosthodont 1991; 4: 292-8.

13 Johnson G.H., Hazelton L.R., Bales D.J., Lepe X. The effect of a resin-based sealer on crown retention for three types of cement. Journal of Prosthetic Dentistry, 91:428-435, May 2004.

14 Johnson, G.H., Lepe, X., and Bales, D.J.: Crown Retention with Use of a 5% Glutaraldehyde Sealer on Prepared Dentin. Journal of Prosthetic Dentistry, 79: 671-676, June 1998.

15 McCloskey, RJ. A technique for removal of fluorosis stains. J Am Dent Assn (109):63-64, July 1984

16 Croll, TP and Cavanaugh, RR. Enamel color modification by controlled hydrochloric acid-pumice abrasion. I. Technique and examples. Quintessence International 17(2):81-86, 1986.

17 Croll, TP and Cavanaugh, RR. Further color modification by controlled hydrochloric acid-pumice abrasion. II. Further examples. Quintessence International 17(3):157-164, 1986.




18 Croll, TP. Enamel microabrasion for removal of superficial

dysmineralization and decalcification defects. J Am Dent Assn 120:411-415, April 1990.

19 Price, BT et al. An evaluation of a technique to remove stains from teeth using microabrasion. J Am Dent Assn (134):1066-1071, August 2003.

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Restorative Dentistry Clinical Reference