Why Carry Out Esthetic Why Carry Out Esthetic Bonded Restorations on Bonded Restorations on

Posterior Teeth?Posterior Teeth?

Prevention 과 oral hygiene 이 잘 유지되고 있는 35 세

환자의 caries free mouth.

Traditional approach Traditional approach using amalgam : using amalgam : 증례증례 (1)(1)

recurrent caries around old composite restoration on M & PM

cavity prep & pin placement for amalgam

completed amalgam filling

Traditional approach using Traditional approach using amalgam : amalgam : 증례증례 (2)(2)

interproximal caries on #14,15 intact occlusal surface traditional approach

• occlusal extension prep for amalgam 술후 사진 .

More conservative approach More conservative approach using adhesive techniqueusing adhesive technique

similar case above maximum sound tissue preservative

cavity form direct composite restoration

Evolution of decayed Evolution of decayed toothtooth

a) “classical” approach• “natural caries decay” 의 진행 ,

수복물의 변성 , mechanical failure 발생 빈법

– (left arrow) unfavorable condition : mesiodistal fissure 로 진행 - premature root canal tx.- protective crowning

– (right arrow) onlay 만으로 더 이상의 진행 prevention.

B) “ adhesive” approach• mechanical failure 발생 감소 .

Fractured tooth Fractured tooth : 증례 (1)

sensitivity to pressure intact on radiography deep fractured fissure on mesial side direct composite restoration 으로

sealing & reinforce : sensitivity 감소

Fractured tooth Fractured tooth : 증례 (2)

frail & wide class 1 amalgam filling.

( No cuspal coverage)

: spontaneous & pressure induced pain 일차적으로 composite inlay 수복으로

symptom 완화 시도 . 술후 방사선 사진 : 와동형성을 심부까지 extension 하지

않음 .

Fractured toothFractured tooth : 증례 (3) superficial class 2 : not visible defect

but thermal change & pressure 에 sensitivity

deep ,discolaorated fissure ( leakage ) endodontic therapy crown for prevent from further crack

progression

prevention form 의

retoration 은 많은 양의 치질 삭제를 요한다 .

Decmentation of gold inlayDecmentation of gold inlay

부적절한 marginal fit 으로 severe secondary caries 발생 .

rich blend color 로 natural anatomy 와 esthetic,optimal function 을

만족시키고 있는 수복형태 .

new esthetic material 의 만족 할만한 long-term

behavior

after 5-year after 9-year

Bonded ceramic inlayBonded ceramic inlay

• 구치부 심미 수복 중 most long lasting.

But, 과정이 복잡하고 가격이 비싸다

after 3-year after 5-year

Traditional approach vs modern approach

HISTORICAL HISTORICAL PERSEPECTIVEPERSEPECTIVE

1) 1) esthetic intracoronal esthetic intracoronal restorationrestoration

: not a modern concept

(1) 1856 prefabricated ceramic inlay

sealed with gold foil

(2) 1882 fired ceramic inlay

(Herbest, Germany)

(3) 1888 fired ceramic inlays over

platinum foil (Land)

(4) 1895 ceramic inlay was introduced

well before amalgam

(5) 1905 resinous adhesive + porcelain

etching (Nyman)

Low fusing ceramic inlay (Ducera) 에 fatigue test (mechanical loading & thermocycling)

: porcelain etching 과 new adhesive 에 의한 adhesion remain

( D:dentin LC:luting composite C:ceramic )

(6) 1871 silicate cement : direct esthetic m. 의 real development begin (Fletcher)

(7) 1937 unfilled resin

(8) 1938 development of epoxy molecule

(Castan Swiss)

(9) 1951 acid conditioning

(Hager, Swiss)

(10) 1952 “hybrid layer” first description

(11) 1955 further development of enamel

etchin (Buonocore)

(12) 1962 Bowen’s Bis-GMA formulation 에 의한 composite resin (Bowen)

: moder adhesive dentistry 의 beginning

(13) 수년 전까지 posterior esthetic material은 amalgam 이나 gold filling 과 경쟁이 되지 않았다 .

Biological & physiochemical short comings

2-2 a.b amalgam restoration 의 satisfactory long-term behavior

- amalgam over 20 year

- free of recurrent decay

2-3 a.b gold inlay 의 excellent long term behavior

- 24 year old gold inlay

(14) limitation of esthetic material 의 durabillity

a. marginal degradation

b. wear

c. mechanical failure

<clinical finding>

a. Recurrent decay

b. pulpal injury

c. loss of function

RESTORATIVE RESTORATIVE MATERIALSMATERIALS

Bonded posteriorBonded posterior restorationrestoration 에 이용되는

material 의 기능에 의한 분류

Liner Base Adhesive Luting composite Restorative material

Direct composite fillingDirect composite filling : enamel, dentin 각각에 대한

adaptation 비교

Enamel : perfect adaptation Dentin : separation

Dentin etchingDentin etching (phosporic acid, 10 sec)

exposure collagen fiber network porius structure < 주의 > No over etching!

• Collagen fiber denaturation & weakening 으로 dentinal tubule collapse

Hybrid layer or Hybrid layer or interdiffusion zoneinterdiffusion zone

intertubular dentin 과 peritubular dentin 사이로 resin tag 형성 .

Ceramic bonded inlayCeramic bonded inlay : 1.5year loading

(thermal & functional)

resist

Hybrid layerHybrid layer 에 의한 dentin bonding failure dentin bonding failure

exampleexample

원인 • Maybe spontaneous collagen collapse or

compression during etching & dehydration

Liner application Liner application under Direct compositeunder Direct composite

deepest part 에 pulp protection 위해 calcium hydroxide cement 을 partial lining.

Base,liner applicationBase,liner application 이

marginal sealmarginal seal 에 미치는 영향

Base,liner : fluorecent resin leakage bonding agent : full surface adhesion

Prep for adhesive Prep for adhesive restoraionrestoraion

PM : direct filling M: compomer base 로 resin inlay 위한 형태 형성 .

• Resin restoration volume 감소 .

Conventional glass Conventional glass ionomer cements ionomer cements :

structure

developed by Wilson & Kent by 1972 polycarboxylate cement liquid

(polyacrylic acid) + silicatecement liquid

(aluminisilicate glass)

final state : 2 phase• Matrix : gelation of polyacid by metal ions

from the glass during the initial acid attack• Filler

– large particle : intact glass core sheathed by siliceous hydrogel

– small particle : completely degraded in siliceous hydogel

Compomer 1Compomer 1 : Dyrect 의 structure

Resin 과 유사한 matrix 에 GI filler (aluminosilicate glass) 첨가

Advantage• Ease of manipulation due to long working

time and rapid set ( light activation)• Resistance to early contamination by

water and to dehydration• Higher early strength and superior

mechanical properties • Fluoride release

Compomer 2Compomer 2 : temporary restoration & base

Delay the final steps of the restorative procedure

Base,liner : rationale for using & selecting

Ceramics 1Ceramics 1“heterogeneous conventional dental porcelain”

2 phase : glassy matrix & crystalline inclusion

after firing after HF acid etching : imprints of leucite

crystal• Reinforced heterogeneous porcelain :

higher proportion of alumina & leucite

Ceramics 2Ceramics 2 “glass ceramic(Dicor)”

glassy matrix + crystalline inclusion 1st step : casting of glass (amorphous

glass) after “thermal ceramization” :

development of crystalline structure

Ceramics 3Ceramics 3 “slip casting (In Ceram)

crystalline matrix + infiltrated glass 1st processing : sintering spinell crystals infiltrated by a glass

Ceramics 4Ceramics 4 “low fusing ceramic (LFC,Ducera)

homogeneous porcelain firing phase : melting glass particle final stage : homogeneous glass react

superficially with water & produce a reinforced hydroxylated layer.

Composite resins : structure

Composite resin : surface roughness

Composite resin Composite resin : polymerization

light activated • pore-free structure• homogeneity of activation• possibility of multilayer application

chemically cured• numerous void from hand mixing

Composite resin 1Composite resin 1 : monomodal heterogeneous

microfilled composite

Prepolymerized complex with higher filler density

Filler : pyrolytic silica

Composite resin 2Composite resin 2: monomodal spheroidal

composite

milled rounded , various size particle

Composite resin 3Composite resin 3: hybrid composite

Composite resin 4Composite resin 4 : small hybrid composite

composite kit including composite kit including different opacitiesdifferent opacities

dentin enamel translucent

Ceramic inlay : fracture

CLASSIFICATION OF CLASSIFICATION OF TECHNIQUES AND TECHNIQUES AND

RESTORATIVE RESTORATIVE STRATEGIESSTRATEGIES

Esthetic restorative Esthetic restorative technique for technique for post.teethpost.teeth ; 3 group

Direct technique Semidirect technique indirect technique

Basic requirement for Basic requirement for successful bondingsuccessful bonding

Perfectly healthy soft tissue Margins preferably placed supra or

juxta gingivally Clean & dry operating field ysing rubber

dam– “ wet bonding” = on dentin humid substrate ,

no saliva or blood bonding

Indications for Indications for adhesive restorationadhesive restoration

excellent oral hygiene low caries susceptibility true esthetic demend

Direct techniqueDirect technique

small & medium size intraoral cavity

Semidirect techniqueSemidirect technique

1-3 teeth (within different quadrant) 의 wide class II,III or occlusal coverage

Indirect techniqueIndirect technique

full arch or quadrant rehabillitation

Fractured buccal wall due to resin polymerization

stress in largr cavity

Modification of the Modification of the conventional prep. for a conventional prep. for a

luted restorationluted restoration

Direct technique• if thickness of the remaining wall is

enough,more prefarable Luted restoration

• significant tissue loss

Marginal sealMarginal seal

Direct filling• minimal enamel thickness at the gingival

margin (1mm at least) & bevel : satisfactory marginal seal

• butt margin : leakage

Luted restiration• perfect marginal seal regardless of

finishing design or enamel thickness• dentin margin : modern adhesive technique

으로 best adaptation & seal

Technique selection by Technique selection by gingival enamel gingival enamel

thicknessthickness Direct technique

• small restorations with thick margin Luted technique

• large prep. with thin enamel margin (less than 1mm thickness & height)

Hybrid restorationHybrid restoration

amalgam base : sealing dentin margin composite surface : esthetic

Functional strain Functional strain distributiondistribution

last molar : maximum decrease progressively toward the

anterior teeth

Anatomic factor influencing Anatomic factor influencing the strength of the restored the strength of the restored

toothtooth

cuspal inclination enamel thickness extension of the pulp horn cusp form & demension cervical concavity & other defect

(erosion,abrsion lesion)

Relationship with Crown Relationship with Crown inclination and restored inclination and restored

tooth strengthtooth strength

amalgam filled mandibular post.teeth 의 lingual inclination 으로 인하여 functional stress 하에서 non-supporting cusp fracture

candidate for adheive restoration

Relation to cervical Relation to cervical concavityconcavity

conventional amalgam filling : risk of mesiodistal fracture

candidate for adhesive restoration

Conservative treatmentConservative treatment :fissured or partially fractured

tooth

Combined techniqueCombined technique

Complete rehabilitation after completion of the orthodontic phase

Fractured worn restoration removal New direct composite filling Ceramic overlay was placed on the

premolar to restore the vertical dimension & proper function

Full upper arch restoration using

composite inlay & PFM crown

Prosthetic indicationsProsthetic indications

The ultimate goal of adhesive dentistry is to reduce and postpone the prosthetic solution

The extent of delay or existing restoration may contraindicate an adhesive option

Tooth PreparationTooth Preparation

Tissue characteristics Tissue characteristics related to preparations related to preparations

for adhesive Technique 1for adhesive Technique 1

Thick enamel margin bevel transitional line between the bottom of

the cavity & bevel exposed prism on bevel

• perpendicular to their long axes

Tissue characteristics Tissue characteristics related to preparations related to preparations

for adhesive technique 2.for adhesive technique 2.

Thin gingival enamel margin SEM view of cavity border enamel prism

• less structural arrangement• minimally to adhesion

Tissue characteristics Tissue characteristics related to preparations related to preparations

for adhesive technique 3.for adhesive technique 3.

Preparation extending into cervical dentin enamel is missing on the gingival margin SEM view of outer dentin

• few number of dentinal tubule• mostly cross sectioned

Tissue characteristics Tissue characteristics related to preparations related to preparations

for adhesive technique 4.for adhesive technique 4.

Changes in prism orientation along the entire DEJ

Tissue characteristics Tissue characteristics related to preparations for related to preparations for

adhesive technique 5.adhesive technique 5. : Section of the cervical region

changes in the orientation and organization of rod in the last millimeters of enamel • apical inclination

• approximately 30% of teeth

• obstacle for bonding because the margins present unsupported prisms

Tissue characteristics related Tissue characteristics related to preparations for adhesive to preparations for adhesive

technique 6technique 6 : Different orientation of the tubule on the various surface of class II

cavity

bevel provides sections of tubule that are more perpendicular to their long axes than with a butt preparation

General principles 1General principles 1“Principle of maximum preservation”

conventional approach• extension for prevention

modern rule• selective removal of decayed tissue

proximal ridge,enamel bridge,sound occlusal surface have to be preserved (even where the enamel is not fully supported by dentin)

General preinciples 2General preinciples 2 : Technique selection

by remaining sound tissue amount & morphology

cavity prep for direct filling vs for semidirect inlay

General principles 3General principles 3 : direct technique 증례

small lesion in the buccodistal groove necessitated the coverage the fragile distal cusp.

extreamly frail wall 은 composite shrinkage 로 발생되는 stress 로부터 protection 해주어야 한다 .

Tooth preparation for Tooth preparation for direct fillings 1direct fillings 1

: different design most conservative approach for

superficial carious lesion “adhesive preparation” for more deeply

invasive preparation• ovoid cavity design with some area of

unsupported enamel

“micro cavity” ,”tunnel cavity”, “buccolingual cavity for conservative treatment of proximal lesion

“bevelled conventional” preparation for replacement of existing metallic restoration

Tooth preparaion forTooth preparaion for direct fillings 2 direct fillings 2

: two different design 증례

Tooth preparation for Tooth preparation for luted restoraions 1luted restoraions 1

: different design

unrestored severe carious lesion• selective removal of decayed tooth• internal tapered design obtained by liner and base

replacement of large existing restoration• modification with base

Tooth preparation for Tooth preparation for luted restorations 2luted restorations 2

: Preparation for indirect ceramic overlays

no sharp angle (esp. internal line angle)

Margin design ofMargin design of luted restorations 1 luted restorations 1

: butt margin

prism on occlusal margin • parallel to long axes

prism on gingival enamel margin• same

Margin design ofMargin design of luted restortions 2 luted restortions 2

: hollow-ground chamfer ( concave bevel)

prism on occlusal margin • more or less transversly sectioned

prism on base of the chamfer• almost perpendicular to long axes• more appropriate for eching

Margin design ofMargin design of luted restorations 3 luted restorations 3

: 증례 (1)

fracture of hollow- ground chamfer occlusal margin

Margin design ofMargin design of luted restorations 4 luted restorations 4

: 증례 (2)

concave bevel design for buccal finishing line only• other concave beveled margin will enlarge

the occlusal surface

Cavity configuration and Cavity configuration and Geometry of luted Geometry of luted

retorations 1retorations 1

semidirect intraoral technique • require more taper than 15 degree • to faciliate removal

indirect technique & semidirect extraoral technique• small internal undercuts are tolerated • by die spacer (indirect) or grinding locally

after removal from the elastic model (semidirect extraoral)

Cavity configuration and Cavity configuration and Geometry of luted Geometry of luted

restorations 2restorations 2 : parameters of general preparation design

Restoration margins should not coincide with occlusal contacts(esp.ceramic)

Minimal thickness & width of occlusal isthmus, occlusal coverage

Optimal overhang of the restorative material necessary to obtain a satisfactory proximal contact

Extension into critical esthetic zones must be considered with caution

DIRECT TECHNIQUESDIRECT TECHNIQUES

General indications for direct technique

Direct filling method 1Direct filling method 1 : bulk technique

only for minimal cavity volume

Direct filling method 1Direct filling method 1 : 증례 (1)

initial occlusal groove caries

Direct filling method 1 Direct filling method 1 : 증례 (2)

superficial proximal caries

Direct filling method 2Direct filling method 2 : multilayer technique

In narrow but deeper cavity composite resin shrinkage

compensation

Direct filling method 2Direct filling method 2 : 증례

Replacement of failed restoration

Direct filling method 2 :Direct filling method 2 : procedure(1) -

“conventional horizontal layering”

Decayed 1st upper molar Proximal extension of the prep Failure to place a clear plastic matrix band Metallic band & wooden wedge

• for class II cavity,conventional metallic matrix improves polymerization by light reflex

Direct filling method 2Direct filling method 2 : procedure(2)

Base of light curing GI Additional horizontal increment were

made to complete the proximal wall Remaining cavity volume was filled with

three last increments Internal characterization

Direct filling method 2Direct filling method 2 : final

Tunnel approachTunnel approach

Very superficial proximal lesion Only when decayed tissue can be

completely removed without excessive weakning of the occlusal ridge

Three-sited light cure Three-sited light cure techniquetechnique : rationale provide optimal proximal adaptation & seal

• traditional GI base to reduce resin bulk

• placement of translucent matrix & reflecting wedge

• placement 1st resin increment on the bottom of proximal prep

• indirectly cured through the wedge

• 2nd ,third increment

• cured through the cusp

Three-sited light cure Three-sited light cure techniquetechnique

: 증례

Replacement of the amalgam filling due to recurrent caries

Clear matrix & translucent reflecting wedge 1st composite layer on the gingival floor &

cured through the wedge 2nd increment was placed buccaly to fill the

main volume & cured through the cusp

Three-sited light cure Three-sited light cure techniquetechnique : 증례

3rd increment filled the remaining proximal space

in the occlusal part• oblique layer & cured through the

remaining wall last increment & shaping

Three-sited light cure Three-sited light cure technique technique

: final

CONTA PROCONTA PRO

special clear,plastic instrument to improve quality of contact point

used to force the matrix against the neighboring teeth to abtain tight proximal contact

< 사용방법 >• The tapered channel at the top of the

instrument is first filled with composite• place in the cavity box• wedged & moved to push the matrix• removal 후 small band of resin remain in

the cavity• restorative step

Polymerization Polymerization shrinkage control 1shrinkage control 1

: polymerization tip

composite condensation & polymerization at the same time

Polymerization Polymerization shrinkage control 2shrinkage control 2

: ceramic ingot or prefabricated ceramic inlay

Oblique incremental Oblique incremental techniquetechnique

medium class I cavity horizontal layering 에서 발생되는

opposing wall 에대한 tension 발생을 막고 marginal quality improvwmwnt

Oblique techniqueOblique technique : 증례

Replacement of an occlusal amalgam filling

buccolingual extension of the cavity colored liquid resin

Oblique techniqueOblique technique : 증례

additional small incremental resin shaping with spatula & brush final

Anatomic layering of direct Anatomic layering of direct composite restorationcomposite restoration

dentin layer enamel layer translucent layer

InstrumentInstrument : simple set

sharp point spatula round condenser

SEMIDIRECT SEMIDIRECT TECHNIQUESTECHNIQUES

Semidirect techniqueSemidirect technique 의 의 indicationindication

1) accessible large lesion extended to CEJ

2) restoration replacement of limited number of tooth (at the same time)

Transitional restoration of Transitional restoration of

young patientyoung patient

: low cost 로 luted restoration 제작 가능하므로 성인기에 이를 때 까지 prosthetic solution 을 delay 시킬 수 있는 바람직한 수복재 역할

Young ptYoung pt 에서의 적용례 에서의 적용례 22

: reduced coronal height, pulp less single tooth 의 conservative & economic therapeutic option

Direct filling methodsDirect filling methods 의 의 common problem in class II common problem in class II

lesionlesion : adequate proximal contour & contact 형성이

어렵다

<solution>

luted restoration semidirect tech 은 one appointment 로 chairside 에서 제작

Intraoral semidirectIntraoral semidirect

composite inlaycomposite inlay 제작 제작 과정과정

a. 술 전b. prep & GZ base ( 약간의 undercut 허용 )

c. insulating medium

d. incremental resin build

e. shaping

f. 분리 후 post curing

g. cementation

h. complete

Cavity design for intraoral Cavity design for intraoral

semidirect semidirect techtech

: even. One or two surface prep require to prevent locking

Semidirect intramural Semidirect intramural

techniquetechnique 을 이용한 수복예을 이용한 수복예a. initial view

b. extended cavity 에 separator 바르고 matrix place

c. composite filling & shaping

d. locking 으로 인해 rotary instrument 로 removal

Microretention by coarse diamond bur

Semidirect extraoral Semidirect extraoral techniquetechnique

a. failed amalgam & provisional filling

b. frail fissured cervical enamel & substantial cavity width & volume

c. working model < fast setting silicon material

d. separated die 상에 three layer composite filling (chairside)

e. enamel. Incisal layer & characterized color resin

f. completion

g. try in

I. Cementation

Special silicone dieSpecial silicone die 를 이용한 를 이용한 resin restoration resin restoration 제작 제작

과정과정

a. Color, viscosity, setting time 이 적절한 special silicone die

b. shaping

c. surface characterization is easy

Very natural appearance. within short working

time

simple post-curing methodsimple post-curing method

: boning water for five minute

< 단점 > more superficial staining

Post-curing occlusion check Post-curing occlusion check (photothermal treatment) (photothermal treatment) after a few minuteafter a few minute 내내

- continuing polymerization 으로 인한 internal marginal

-stress 저하- hardness & wear. Resistance 증가

Advantage of post curingAdvantage of post curing

1) maximal conversion rate

2) definitive dimensional stability in a few minute

3) improve margin quality

Try inTry in

if necessary, some composite and

he added on non-postcured material

Prosthetic rehabilitationProsthetic rehabilitation

root canal treated tooth 를 포함한 .