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Daniel H Ward DDS
May 5, 2017
Uncommon Common Sense:
What YOU need to know NOW about Restorative Dentistry and Materials
Daniel H Ward DDS
May 5, 2017
Let’s Rock!
Things are not always as they APPEAR
It may be your PERSPECTIVE
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It may be your PERSPECTIVE
High Viscosity (Low Flow) Flowable Composite
Beautifil Flow 00
Unique glass ionomer filler particles
Releases fluoride and other ions
Neutralizes pH-Antibacterial
Good polishability
Visibly blends in well
S-PRG (Surface pre-treated Glass Ionomer)
You may never have THOUGHT about it
If we say it long enough we BELIEVE it
Let’s re‐examine some of our IDEAS we think we know
Common sense is often UNCOMMON
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Dentistry is Ever‐Changing How do you Choose?
Lifetime of tooth often determined by first dentist intervention
Minimally Invasive Dentistry
Fissurotomy bur
201.3VF
Conservative Tooth Preparation
169L330
Low Viscosity Flowable Composite
How do you restore? G-aenial Universal Flo
Homogeneous spherical particles
Good wear resistance
High flexural strength (167 MPa)
Filled 50% by volume
Good polishability
Blends in well
High Viscosity Flowable Composite
G-aenial U Flo
Conventional Nano-hybrid
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Dispenser Gun
Tray
Compule Tray
Warmer
CALSETThermal Assisted Light Polymerization
WARMER Low Viscosity Flowable Composite &
Warmed Composite
Completed Tooth Restorations
15 Year Old
Minimally Invasive Dentistry
70% RED Proportion
Minimally Invasive Dentistry
Buildup dentin replacement with opaque darker hybrid –typically A3-A3.5
Buildup remaining form with shade similar to desired final color with hybrid (typically A1-A2)
Add special effects to simulate imperfections within tooth structure
Add translucent incisal hybrid or microfill
Multiple Step Layering Techniques Add dentin shade
•Aura Dentin 6
•Miris
Add General Purpose Shade
•Aura MC 3
•TPH Spectra
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Add Characterization
Important-Junction must be invisible
Add Facial Surface
•Aura Enamel
•G-aenial GT
•Beautifil II
•Esthelite Sigma QuickOptrasculpt
Finish and polish restoration
Restore adjacent tooth
Shape, finish and polish restorations
Restore opposite teeth
Pre-Operative
Finished Restorations
Post-Operative Sensitivity
Bonding Challenges
Hydrodynamic Theory
Hydrodynamic Theory
Fluid flow within dentinal tubules causes PAINBrannstrom M. The Cause of post restorative sensitivity and its prevention. J Endod 1986;12:475-481.
Hydrodynamic Theory
Opened, unsealed dentinal tubules causes PAIN
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Placement of Etchant
Total Etch Technique
“Moist” Dentin”
Rinsing of Etchant
Placement of Resin Primer
Apply multiple coats
Moist Moist
Placement of Resin Primer
“Overwet” Phenomenon
Tay FR, Gwinnett AJ, Wei Sh. The overwet phenomenon: a scanning electron microscopic study of surface moisture in the acid-conditioned, resin-dentin interface. Am J Dent. 1996;9(3):109-114.
Overdrying
Gwinnett AJ. Dentin bond strength after air drying and rewetting. Am J Dent. 1994;7(3):144-148.
Collapsed collagen fibrilsProper Moisture
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Moisture VariabilityAir only syringe Warm air dryer
Air/water syringe Air/water syringe
Evaporating the solvent with dry air
Acid-groupsHydrophilic end
etches tooth structure (self
limiting)
Spacer-chainlink between
functional groups
Methacrylate-groupHydrophobic end
connects to polymer-network
COOH
COOH
CH 2
CH 2
O
OO
O
Self-Etching Primer“Self Etching” Primer
Acidifying Primer accompanies etch
Acid reaction is self-limiting
Lohbauer U, Nikolaenko SA, Petschelt A, Frankenberger R.. Resin Tags do not contribute to dentin adhesion in self-etching adhesives. J Adhes Dent. 2008;10(2):97-103 .
Resin Tags do not Contribute to Dentin Adhesion in SE Adhesion Self-Etch Technique
Challenges
Decreased bond strength to un-etched enamel
Marginal gap formation with un-etched enamel
Bond incompatibility to self-cure and dual-cure resins
More susceptible to hydrolytic degradation resulting in significantly diminished bond strengths over time
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Self etching Primer
Solution: “Etching prepared enamel w phosphoric acid promoted better marginal integrity with self-etching bonding agents.”
Souza-Junior EJ, Prieto LT, Araújo CT, Paulillo LA. Selective enamel etching: effect on marginal adaptation of self-etch LED-cured bond systems in aged Class I composite restorations. Oper Dent. 2012;37:195-204.
Effect of Enamel Etching-Marginal Gaps
Long Term Dentin Bond StabilityMMP-Matrix MetalloproteasesMMPs are naturally occurring proteases
involved in dentin formation and trapped during odontogenesis
Not bacteria but proteolytic enzymes found within dentin capable of degrading collagen within newly created adhesive hybrid layers
Low pH causes dentin to release these inherent MMPs which attack exposed collagen fibrils
Osorio R, Yamauti M. Osorio E., et al. Effect of dentin etching on metalloproteinase-mediated collagen degradation. Eur J Oral Sci 2011;119:79-85.
MMP-Matrix Metalloproteases
Carrilho et al., JDR 2007; 86; 529Brackett et al.,Operative Dentistry; 2009;34(4):381-385
In-vivo 12 m w/PBNT (Acetone)
Immediate (MPa)Control 29.3 (9.2)CHX 32.7 (7.6)
w/CHX in 12 m
14 mo (MPa)Control 19.0 (5.2)CHX 32.2 (7.2)
Potential MMP Inhibitors
Long Term Dentin Bond Stability
Chlorhexidine (CHX)
Benzalkonium Chloride
MDPB ((12-methacryloxydodecalpyridinium bromide)
GLUMA
Epigallocatechin-3-gallate (green tea polyphenol)
Perdigao J, Resi A, Loguercio AD. Dentin Adhesion and MMPs: A Comprehensive Review. J Esthet Restor Dent 2012: 25:219-241.
Disinfect to prevent MMPs
Use Etchant containing 1% Benzalkonium Chloride
TE-Apply 2% Chlorhexidine after acid etching for 30 sec
SE-Apply 2 coats 2% Chlorhexidine prior to application of primer
OR
Long Term Dentin Bond Stability
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Disinfect to prevent MMPs
MDPB (12-methacryloxydodecalpyridinium bromide)
Long Term Dentin Bond Stability
Pashley DH, Tay FR, Imazato S. Hot to Increase the durability of Resin-Dentin Bonds. Compend. 2010;32(7):60-64.
Selective Etch TechniqueApply etch to enamel only for 15 secondsWash thoroughlyPlace self-etching primer
Frankerger R, Lohbauer U, Roggendorf MJ, Naumann M, Taschner M. Selective enamel etching reconsidered:better than etch-and-rinse and self etch? J. Adhes Dent. 2008;10:339-344.
Universal Bonding AgentsBond strength same to total vs self etch
Dentin Bond Strength
Self-Etch Total Etch Moist
Total Etch Wet
Total, Self or Selective Etch Universal Bonding
Materials
Self‐etch Selective‐etch Total‐etch
Total-etch, self-etch or selective-etch technique
Can be used for direct and indirect restorations
Bond to all indirect substrates-metal, ceramics, zirconia, porcelain and lithium disilicate.
Compatible with light-cured, self-cured and dual-cured composite and luting cements.
Universal Bonding Materials
Total, Self or Selective Etch All-Bond UniversalTotal-etch, self-etch or selective-etch
Single bottle for direct and indirectrestorations
High bond strengths to metal, ceramics, zirconia, porcelain & lithium disilicate.
Compatible with light-cured, self-cured and dual-cured composite and luting cements since pH is 3.2
Becomes hydrophobic upon setting
Total, Self or Selective Etch
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MDP Universal Bonding Materials
Total, Self or Selective Etch
Cross-linking of polymer chains
Hydrophobic upon setting
Universal Bonding Materials
Total, Self or Selective Etch
Bulk Fill CompositesBulk Fill Composites
Allow many posterior restorations to be built up in 1 segment
Descriptions– “Stick the stuff in the hole and cure”– Evolutionary– Monolithic
Physical Advantages– Deeper depth of cure– Less Polymerization Shrinkage– Less Polymerization Shrinkage Stress– Reduced likelihood of air voids between layers
Bulk Fill CompositesBulk Fill Composites
Modes of Action– Improved initiators– Greater translucency allows better light transmission– Delayed gel state formation– Increased elasticity
Materials– Flowable– Conventional
Advantages– Quicker, easier– Less chance of enamel and cusp fractures– Increased likelihood of adequate resin polymerization
Bulk Fill Flowable CompositesBulk Fill Flowable CompositesLow Shrinkage StressStress
•Surefill SDR
• Voco Xtra
•Beautifill Bulk Flowable
•Venus Bulk Fill
Surefill SDRSurefill SDR
•Reduced polymerization shrinkage stress
• Bulk fill to 4mm
•Increased sensitivity to light
Great placement with metal tips
•Self-leveling
•A1, A2, A3 Universal shades
Roggendorf MJ1, Krämer N, Appelt A, Naumann M, Frankenberger R. Marginal quality of flowable 4-mm base vs. conventionally layered resin composite. J Dent. 2011;39:643-647.
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Polymerization Shrinkage Polymerization Shrinkage StressStress(MPa)(MPa)
Bulk Fill Posterior CompositesBulk Fill Posterior CompositesLow Shrinkage StressStress
• Voco Xtra Fill
• Beautifill Bulk Flow
• Aura Bulk Fill
• Tetric Evo-Ceram Bulk Fill
• Sonic Fill
Sonic Energy Assisted Light Sonic Energy Assisted Light PolymerizationPolymerization
Sonic FillSonic Fill
Improved flowability of composites
Improved marginal adaptation
5mm depth of cure
Increased sculptability and ease in shaping anatomy
Composite designed specifically for use
ADVANTAGESADVANTAGESSonic Energy Assisted Light Sonic Energy Assisted Light
PolymerizationPolymerization
Sonic Energy Assisted Light Sonic Energy Assisted Light PolymerizationPolymerization
Sonic FillSonic Fill
Sonic Energy Assisted Light Sonic Energy Assisted Light PolymerizationPolymerization
Sonic FillSonic FillTriodentTriodent or or PalodentPalodent PlusPlus
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Multiple Medications
Oral Environment Challenges-Xerostomia
Oral Environment Challenges-Xerostomia
“40% of all prescription drugs have dry mouth listed in the PDR as a possible side effect”
Chalmers J. Personal Communication. 2006.Chalmers J. Personal Communication. 2006.
Oral Environment Challenges-Xerostomia
• Incidence increases with # of drugs taken
• 50% of patients taking 4 or more medications had Dry Mouth
Oral Environment Challenges-Carbohydrates
Nutrition Facts: Serving Size: 8.3 fl. oz Calories: 140 Total Fat: 0g Sodium: 200mg Protein: 0g Total Carbohydrates: 28g Sugars: 28g
Nutrition Facts:16 fl oz; calories 140; total fat 0g; sodium 220mg; potassium 60mg; total carbs 28g; sugars 28g
Oral Environment Challenges-Bottled Water
Fluoride-less water Fluoridated water
Oral Environment Challenges-Illegal Drugs
“Meth mouth” or chronic marijuana use
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Xerostomia patients
High carbohydrate users
Non-fluoridated water users
Drug abusers
Need TherapeuticRestorations
Composite Challenges
•Post-operative sensitivity
•Recurrent decay
•Achieving proper moisture
•Polymerization shrinkage
•Increased time-layering
•Technique sensitivity
Low post-op sensitivity
Fluoride Release
Moisture variability
No shrinkage
Bulk placement
Simple-more forgiving
Glass Ionomer
Fuji IX Self Cure Glass Ionomer
Glass IonomerBase/Restorative
SDI Self Cure Glass Ionomer
•More highly filled-reduced wear
•Self-curing in 2.5-5 minutes
•No polymerization (setting) shrinkage stress
•Expansion/contraction similar to tooth
•High fluoride release
•Bioactive
Glass IonomerCharacteristics
•Multiple cervical carious lesions
•Pediatric Patients
•Sealants
•Class V restorations
•Sandwich Technique
•Crown buildups
•Long term interim restorations
•Cements
Glass Ionomer Uses
High caries rate individuals
Glass Ionomer RestorationsGlass Ionomer Restorations
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Remove decay and place matrices
Glass Ionomer RestorationsGlass Ionomer Restorations
Treat dentin with PAA
Glass Ionomer RestorationsGlass Ionomer Restorations
Place, shape and wait 2:30
Glass Ionomer RestorationsGlass Ionomer Restorations
Shape with diamonds w/ water
Glass Ionomer RestorationsGlass Ionomer Restorations
Dry and place Surface Sealant
No phosphoric acid
Glass Ionomer RestorationsGlass Ionomer Restorations
Pediatric Patients
Glass Ionomer RestorationsGlass Ionomer Restorations
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Pediatric Patients
Glass Ionomer RestorationsGlass Ionomer Restorations
Long term interim restoration
Glass Ionomer RestorationsGlass Ionomer Restorations
Long term interim restoration
Glass Ionomer RestorationsGlass Ionomer Restorations
Long term interim restoration
Glass Ionomer RestorationsGlass Ionomer Restorations
Long term interim restoration
Glass Ionomer RestorationsGlass Ionomer Restorations
Dentist-Multiple Radiographic Caries
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Equia Forte
Posterior Glass Ionomer
Stronger Glass Ionomer
For use in posterior teeth
Increased compressive strength (219 MPa)
Increased flexural strength
Greater wear resistance
Increased acid resistance
High fluoride release maintained
Stronger surface sealant
Better designed for Class II posterior restorations
Sudden Onset Caries
Posterior Glass Ionomer47 year old female
Been in the practice over 30 years
Regular re-care appointments
Significant changes in health history
No restorations in 8 years
Radiographs revealed multiple interproimalradiolucencies not present 12 months previous
Required 16 restorations
Need caries resistant restorations
Preparations
Posterior Glass Ionomer
Preparations
Posterior Glass Ionomer
Posterior GI Restorations
Posterior Glass Ionomer
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Long term interim restoration
How long do they last?• 8-12 years- single surface 65% 10 yr
• 5-8 years- multiple surface 35% 10 yr
• The larger the restoration, the shorter its lifetime
Zanata RL, Fagundes TC, Freitas MC, Lauris JR, Navarro MF. Ten-year survival of ART restorations in permanent posterior teeth. Clin Oral Investig. 2011;15(2):265-71
•Acid/base and polymerization reactions
•Dual cured-faster
•Shortens time needed to control moisture
•More esthetic and translucent
•Fluoride release
•Higher tensile, bond strength and wear
Resin-Modified Glass Ionomer Characteristics
•Liner or Base
•Class V Restorations
•Restoration Under Crown
•Temporary prior to crown
•Sandwich technique
•Cements
Resin-Modified Glass Ionomer Uses
Resin-Modified Glass Ionomer Base/Restorative
Capsule
Fuji II LC RIVA LC
Fuji Filling LC
Resin-Modified Glass Ionomer Base/Restorative
Ketac Nano
Paste-Paste
Gingival recession & root caries
• 1st molar and bicuspid
• Remove decay‐place retention
Resin-Modified Glass Ionomer
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Gingival recession & root caries
• 1st molar and bicuspids
• Remove decay‐place retention
Condition with PA
• Pre‐treat with dentin conditioner (Poly‐
acrylic acid)
Resin-Modified Glass Ionomer
Material Placed and Light Cured
• Place excess material
• Light Cure
Resin-Modified Glass Ionomer
Final Restorations
• Shape restorations
• Hold back gingiva and shape with fine
diamond
• Etch with phosphoric acid, wash and dry
• Place surface sealant and light cure
Material Placed and Light Cured
• Place excess material
• Light Cure
Resin-Modified Glass Ionomer
Quick Temporary prior to Crown
Temporary placed 6 years ago Sandwich Technique
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•Exposed to occlusion
•Able to control moisture
•Not acid etching
•No shrinkage stress
•Highest fluoride release
•Out of occlusion
•Need quickness
•Need to acid etch
•Need to bond
•↑translucence/esthetic
Resin-Modified Glass Ionomer
Glass Ionomer
OH SH*T!
Endodontic Root Canal Endodontic Root Canal Therapy?Therapy?
Asymptomatic
Single small exposure
Able to achieve hemostasis
Perhaps not IF:
Traditional Pulpal ProtectionIndirect Pulp Capping
Best not to expose pulp• Asymptomatic• Sound 2mm around margins• Stop when next scoop will expose pulp• Place GI or Ca(OH)2
Traditional Pulpal ProtectionIndirect/Direct Pulp Capping
What are we trying to accomplish?
• Mechanical Sealing of the Pulp• Stimulate hydroxyapatite formation• Dentin bridge formation
Traditional Pulpal ProtectionIndirect/Direct Pulp Capping
How does this happen?
• Material sets hard and adheres to dentin• Alkaline pH• Release of Ca++ ions Ca+2
OH-
H2O
Ca+2
OH-
20
Unproven Pulpal ProtectionIndirect/Direct Pulp Capping
Resin Dentin Bonding?• Dentin Bonding Agent-Composite
“Contact with acid and pulp tissue started the bleeding process thus damaging the bonding technique resulting in no cellular differentiation and new dentin formation. The use of dentin bonding agents should be avoided for vital pulp therapy.”
Silva GA, Lanza LD, Lopes-Junior N, MoreiraA, Alves JB. Direct pulp capping with a dentin bonding system in human teeth: a clinical and histological evaluation. Oper dent. 2006;31:291-307.
Unproven Pulpal ProtectionIndirect/Direct Pulp Capping
Glass Ionomer/RMGI?
“Poly Acrylic Acid (PAA) inhibits apatite formation in the body environment. PAA released from the glass-ionomer cements inhibits the apatite formation on tooth surfaces. It might be considered difficult to obtain bioactive glass-ionomer cements”
Kawashita M, Kokubo T, Nakamura T. Effect of polyacrylic acid on the apatite formation of a bioactive ceramic in a simulated body fluid: fundamental examination of the possibility of obtaining bioactive glass-ionomer cements for orthopaedic use. Biomaterials. 2001;22:3191-6.
Improved Pulpal ProtectionIndirect/Direct Pulp Capping
Ca(OH)2 Paste• Ultra-Blend Plus– Ultradent
Pulpal Protection – Indirect/DirectPulp Capping
MTA (Mineral Trioxide Aggregate)
• ProRoot-Dentsply• Biodentine-Septodont• Thera-Cal LC-Bisco
Bismuth oxide Bi2O3
Gypsum CaSO4 · 2 H2O
Tetracalcium aluminoferrite (CaO)4.Al2O3.Fe2O3
Tricalcium aluminate (CaO)3.Al2O3
Dicalcium silicate (CaO)2.SiO2
Tricalcium silicate (CaO)3.SiO2
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Biodentine
High concentration MTA (self setting)
Resin Modified Calcium Silicate
Light cured apatite forming MTA in a unique hydrophilic resin (polyethylene glycol methacrylate) that releases calcium
Theracal
Social Media Communication Cell Phone Text MessagingCell Phone Text Messaging Appt Reminder/Late Cancel
Custom Email MessagingCustom Email Messaging Appt Reminder/Confirmation Custom Email MessagingCustom Email Messaging Appt Reminder/Confirmation
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Rescheduling/Reactivating PatientsRescheduling/Reactivating PatientsIncrease Production
$61,365.00 brought in from patients who did
not pre-appointin 2016
$61,365.00 brought in from patients who did
not pre-appointin 2016
Custom Email NewslettersCustom Email Newsletters Holiday Promotions
Custom Email NewslettersCustom Email Newsletters Regular Newsletters Custom Email MessagingCustom Email Messaging Birthday Wishes
Custom Email Patient SurveysCustom Email Patient Surveys Automated Post-Appointment Custom Email Patient SurveysCustom Email Patient Surveys Automated Post-Appointment
23
Custom Email Patient SurveysCustom Email Patient Surveys Automated Post-Appointment Online Patient ReviewsOnline Patient Reviews Monitor Online Reviews
Online Patient PortalOnline Patient PortalAutomated Post-Appointment
Pay Bills Online Management ResearchManagement Research--MapsMapsResearch Locale Demographics
New Mobile Apps
Mobile DevicesMobile DevicesIncrease internet marketing
HealthgradesHealthgrades
March 1, 2016
24
Increase internet marketing
HealthgradesHealthgrades
May 1, 2017
Online Patient Scheduling
LimelightLimelight
Complete Phone
WeaveWeave
Syncs digital phone with your practice management system to instantly show caller information on computer screen
Looks like a phone app
Go down checklist
Complete Phone
WeaveWeave
Complete Phone
WeaveWeave
Ability to text message
Ask patients for recommendations*
Connects Phone to Practice Management SoftwareWeaveWeave
1.When the phone rings,
it tells your practice management software
who’s calling.
2.Prompt lets you know
who’s calling and gives you access to the
patient’s info with a click or by picking up the
phone.
3.Patient’s
appointment info, to-do list, insurance
info, notes, balance and more are
displayed.
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Other FeaturesWeaveWeave
Phone ServiceAppointment Reminders and Recalls
Conversational Text Messaging
Mobile App
Reports
Reviews
Connect your phones to your patient
communication software.
See positive reviews from patients and address negative
reviews before they are posted for others to see.
Texting works
like a smart
phone..
Set automated, pre-made or personalized text reminders and recall messages.
Easier for patients to communicate with your office.
See stats on phone usage.
ConsiderationsWeaveWeave
Advantages Challenges
•Ability to Maximize phone calls for scheduling and collections•Messaging Capabilities•Cost Savings•Excellent Customer Service
•Learning Curve•Internet Reliability•Weave Growing Pains
Thank You!
www.drwardhandouts.com