Uncommon Common Sensed1ue90e5sp4tcv.cloudfront.net/2855/images/Asset305718_v1.pdf · Decay Removal Composite Direct Placement Challenges Thoroughly remove decay only Amalgam ... Intra-oral

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Daniel H Ward DDS

March 3, 2017

Uncommon Common Sense:

What YOU need to know NOW about Restorative Dentistry and Materials

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Things are not always as they APPEAR

It may be your PERSPECTIVE

It may be your PERSPECTIVEYou 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

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Common sense is often UNCOMMON

Dentistry is Ever‐Changing

How do you Choose?Health and appearance

conscious

The Public has concerns about:

Appearance

Metals

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Patients are more knowledgeable than ever

We must listen more to our patients

We must provide alternatives for our patients

…but the rightalternatives

Composite

The most USED

and ABUSED

Material in Dentistry

Composite

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Uncommon, common sense

•What is the most important restoration that determines the long term prognosis of a tooth?

•Are flowable composites always an inferior restoration?

•Does fluoride present within the enamel of an un-prepared tooth margin result in a better bond between resin and tooth?

Uncommon, common sense

•Does the addition of fluoride to a resin result in efficacious fluoride release?

•Should preparations for tooth to be restored with a composite be the same as for a tooth to be restored with amalgam?

•What is the effect of warming composite immediately prior to placement?

Decay Removal

Composite Direct Placement Challenges

Thoroughly remove decay only

Amalgam Preparation

Composite Preparation

“Convenience”Form MID

Lifetime of tooth often determined by first dentist intervention

Minimally Invasive Dentistry

Fissurotomy bur

201.3VF

Conservative Tooth Preparation

169L330

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Low Viscosity Flowable Composite

How do you restore? G-aenial Universal Flo

Homogeneous spherical particles

High Viscosity (Low Flow) Flowable Composite

Mean particle size 200 nm Particle size range 40-5000 nm

G-aenial U Flo Conventional Nano-hybrid

G-aenial Universal Flo

Homogeneous spherical particles

Good wear resistance

High flexural strength (167 MPa)

Filled 50% by volume

Good polishability

Blends in well

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

Beautifil Flow 00

Unique glass ionomer filler particles

Releases fluoride and other ions

Neutralizes pH-Antibacterial

Good polishability

Visibly blends in well

S-PRG (Surface pre-treated Glass Ionomer)

Intra-oral plaque formation（24 hours W/O Brushing）

Less plaque Full-grown plaque

BEAUTIFIL Ⅱ（Containing S-PRG filler）

Conventional Restorative Material

（Not containing S-PRG filler）

plaque

S PRG Fillers

Reduced Plaque Accumulation

Dispenser Gun

Tray

Compule Tray

Warmer

CALSETThermal Assisted Light Polymerization

WARMER

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Improved flowability of composites

Improved marginal adaptation

Improved rate of polymer conversion

Improved surface hardness/durability/polishing.

Decreased curing time and increased depth of cure

Increased sculptability and ease in shaping anatomy

ADVANTAGESADVANTAGESThermal Assisted Light PolymerizationThermal Assisted Light Polymerization

Stansbury JW. Use of near-IR to monitor the influence of external heating on dental composite photopolymerization. Dent Mat 2004; 20(8).

Dispenser Gun TrayComax Dispenser

CALSETCALSETThermal Assisted Light PolymerizationThermal Assisted Light Polymerization

Low Viscosity Flowable Composite & Warmed Composite

Completed Tooth Restorations Minimally Invasive Dentistry?

“Dentistry begets Dentistry”

Minimally Invasive Dentistry?

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

Treatment performed at age 18

•Black Triangles

•Opaque Crowns

•Dark Roots visible

•Recurrent decay

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Smile Evaluation

•Long Central Incisors

•Inadequate buccal corridor display

•Steep Curve of Spee

•ColorSmile Template

Provisionalization

•Teeth Prepared-unprepared 2nd molars

•Fabricate desired shape in provisionals

•Allow patient to wear, evaluate and accept

Final Impressions & Lab Communication

•Once approved take final impressions-send model of provisionals

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

Final Impressions & Lab Communication

•Tryin and seat crowns

•Notice lower anterior teeth

15 Year Old


15 Year Old


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

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

Add special effects to simulate imperfections within tooth structure

Add translucent incisal hybrid or microfill

Multiple Step Layering Techniques Add dentin shade

•Aura Dentin 6

•Miris

Add General Purpose Shade

•Aura MC 3

•TPH Spectra

Add Characterization

Important-Junction must be invisible

Add Facial Surface

•Aura Enamel

•G-aenial GT

•Beautifil II

•Esthelite Sigma QuickOptrasculpt

Finish and polish restoration

Restore adjacent tooth

Shape, finish and polish restorations

Restore opposite teeth

Pre-Operative

Finished Restorations

Direct Contouring Techniques

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Technique by Dr Paul Belevedere

and Dr. Doug Lambert

Mold Margin Perfect Matrix

Margin Perfect Matrix

Pre-Shaped matrix

Place and cut excess ends of matrix

Use Heliobond to adhere to gingiva

MPM in place sealed against gingival

margin

Etch

Thoroughly wash and dry

Apply composite and adapt to sides

Use brush to push composite into

corners

Apply composite and adapt to sides

Trim with diamonds then finishing carbide burs

Finish and polish restoration

Shape, finish and polish restoration

Restore opposite tooth

Technique by Dr Paul Belevedere

Treatment by Dr. Doug Lambert

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Marginal Integrity


Expose ends of enamel rods

EnamelEnamel

Enamel Bonding

96% inorganic carbonate hydroxyapatite 96% inorganic carbonate hydroxyapatite calcium phosphatecalcium phosphate

4% organic (tyrosine rich amelogenin 4% organic (tyrosine rich amelogenin protein) and waterprotein) and water

Enamel rods 4Enamel rods 4--8 microns in diameter8 microns in diameter Bonding occurs within enamel rodsBonding occurs within enamel rods HydrophobicHydrophobic

Sheared enamel Sheared enamel rodsrods

White Lines

Unprepared Margins

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Expose fresh ends of the enamel rods with a very fine diamond

Koase K, Inoue S, Noda M, Tanaka T et al. Effect of burKoase K, Inoue S, Noda M, Tanaka T et al. Effect of bur--cut dentin on bond strength cut dentin on bond strength using two allusing two all--inin--one and one twoone and one two--step adhesive systems. step adhesive systems. J Adhes DentJ Adhes Dent. 2004;6:97. 2004;6:97--104.104.

Hosoya Y, Shinkawa H, Suefiji C, Nozaka Ket al. Effects of diamHosoya Y, Shinkawa H, Suefiji C, Nozaka Ket al. Effects of diamond bur particle ond bur particle size on dentin bond strength. size on dentin bond strength. Am J DentAm J Dent. 2004;17:359. 2004;17:359--364.364.

Use a fine 25 micron diamond when using self-etching primers

Exposing ends of enamel rods resulting inGreater angle than direction of enamel rods

Better bonding and less shearing of enamel rods

Class II Interproximal Margin Preparation

Expose the ends of the enamel rods to avoid tooth fracture at margins


Composite Composite PreparationPreparation

Amalgam Amalgam PreparationPreparation

Bevel Interproximal Enamel for better bonding and less shearing of enamel rods


Importance of flaring Class II Interproximals

Fractured tooth structure

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Parallel preparation


Result

Post-Operative Sensitivity


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

DentinDentin

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Dentin Bonding

70% inorganic carbonate hydroxyapatite 70% inorganic carbonate hydroxyapatite calcium phosphatecalcium phosphate

30% organic (collagen) and water30% organic (collagen) and water

Dentinal tubules 0.06Dentinal tubules 0.06--3 microns in diameter3 microns in diameter

Most Bonding occurs between dentinal tubulesMost Bonding occurs between dentinal tubules

HydrophilicHydrophilic

Oh NO, not another bonding lecture!

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

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

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

Oh NO, not another bonding lecture!

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

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

•What are Universal Dentin Bonding Agents?

Etched Dentin

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

Etched Dentin

•Total Etch Technique Fill and Occlude open dentinal tubules

Bonding agent should not leave the dentinal tubules open

Method #1-Reducing Post-Op Sensitivity

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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 fibrils

Overdrying

SEM Perdigao

Un-collapsed collagen fibrils Collapsed collagen fibrils

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Proper Moisture Moisture Variability

Acetone

Alcohol

Water

Bonding Agent SolventsAir only syringe Warm air dryer

Air/water syringe Air/water syringe

Evaporating the solvent with dry air

Bond StrengthSensitivity

Variability

Lopez CL, Perdigao J, Lopes M et al. Dentin Bond Strengths of Simplified Adhesives:Effect of Dentin Depth. Compendium. 2006;27(6):340-345.

17.6(+/-5.9)

18.4(+/-4.8)

14.2(+/-7.0)

Deep

Dentin

21.0(+/-7.4)

18.9(+/-4.1)

22.1(+/-2.8)

Superficial

Dentin

Clearfil

Liner

Bond

Optibond

Solo

Single Bond

Adhesive

System

Mean shear bond strength in MPa

Effect of Dentin Depth on Bond Strengths

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•Occludes tubules

•Anti-bacterial

GLUMA

•Occlusions


Summary

Most technique sensitiveRequires proper attention to detailUse in ideal sized preparations


Materials-4th

Generation

Acetone solvent Alcohol solvent


Materials-5th

Generation

Acetone solvent Alcohol solvent

•Self Etch Technique Never leave the dentinal tubules open



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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

Self etching Primer

37% H3PO4 etched Unprepared enamel surface for 15s.

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Popular SE primer etched Unprepared enamel surface

•Tests confirm that preparing the enamel margin improves bond strength especially with self-etch dentin bonding agents

Substrate All-Bond UniversalSelf-Etch

All-Bond UniversalTotal-Etch

Uncut Enamel 18.7±6.7 31.4±7.1

Cut Enamel 29.0±5.5 35.6±3.6

Bisco in-house data.. Lee IS, Son SA, Hur B, Kwon YH, Park JK. The effect of additional etching and curing mechanism of composite resin on the dentin bond strength. J Adv Prosthodont. 2013;5:467-484.

55% improvement

Effect of Enamel Etching-Bond Strength

•Tests show that etching uncut enamel with phosphoric acid increases bond strength to enamel with 1- bottle dentin bonding agents



Uncut Enamel 18.7±6.7 31.4±7.1

Cut Enamel 29.0±5.5 35.6±3.6


67% improvement




Uncut Enamel 18.7±6.7 31.4±7.1

Cut Enamel 29.0±5.5 35.6±3.6


22% improvement


•Tests show that etching cut enamel with phosphoric acid increases bond strength to enamel with 1- bottle dentin bonding agents

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

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

Souza-Junior EJ, Prieto LT, Araújo CT, Paulillo LA. Selective enamel etching: effect on marginal adaptation of self-etch LED-cured bond systems in aged Class I composite restorations. Oper Dent. 2012;37:195-204.

Effect of Enamel Etching-Marginal Gaps

Solution: “Etching prepared enamel w phosphoric acid promoted better marginal integrity with self-etching bonding agents.”

Souza-Junior EJ, Prieto LT, Araújo CT, Paulillo LA. Selective enamel etching: effect on marginal adaptation of self-etch LED-cured bond systems in aged Class I composite restorations. Oper Dent. 2012;37:195-204.

Effect of Enamel Etching-Marginal Gaps

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When the pH of a dentin bonding agent is too low (more acidic), tertiary amines (necessary for the polymerization reaction) are deactivated resulting in bond incompatibility with self and dual cured resins.

Bond Incompatibility with Self and Dual Cured Resins

Suh BI, Feng L, Pashley DH, Tay FR. Factors contributing to the incompatibility between simplified-step adhesives and chemically-cured or dual -cured composites. Part III. Effect of acidic resin monomers. J Adhes Dent 2003;5:267-282.

Solution: Use of a higher pH (>3.0)self-etching dentin bonding agent does not inactivate the tertiary amines and allows for polymerization.

Suh BI, Feng L, Pashley DH, Tay FR. Factors contributing to the incompatibility between simplified-step adhesives and chemically-cured or dual -cured composites. Part III. Effect of acidic resin monomers. J Adhes Dent 2003;5:267-282.


pH=3.2

Solution: Use a dual-cure activator


“The cured layer of 1-step self-etching adhesives is hydrophilic and a permeable membrane.”

Tay F, Suh B, Pahsley D, Carvalho R. Single Layer Adhesives are Permeable membranes. J Dent 2002;30:371-382.

Hydrolytic Degradation

Solution: Use 2 layers-a hydrophilic layer covered with a hydrophobic layer

Yoshida Y, Yoshihara K, Nagaoka N, Hayakawa S, Tori Y, Ogawa T, Osaka A, Van Meerbeek B. Self-assembled nano-kayering at the adhesive interface. J Dent Res 2012;9:376-381.


Solution: Use MDP containing bonding agents which become hydrophobic upon polymerization due to high amount of cross-linkage.“MDP-containing adhesives form nano-layering at the adhesive interface. Stable MDP-Ca salt deposition along with nano-layering may explain the high stability of MDP-based bonding.”

Yoshida Y, Yoshihara K, Nagaoka N, Hayakawa S, Tori Y, Ogawa T, Osaka A, Van Meerbeek B. Self-assembled nano-kayering at the adhesive interface. J Dent Res 2012;9:376-381.


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Self Etch Technique

OptiBond XTR

6th generation DBA that effectively etches enamel

Unprepared enamel surface

Etched with 37% Phosphoric Acid OptiBond XTR 6th Generation DBA

Popular 6th Generation DBA Popular 7th Generation DBA

Swift E, et al. J Esthet Restor Dent. 2011;23(6):390-398.

Self Etch Technique

OptiBond XTR

Self Etch Technique

OptiBond XTR

2 component self-etch 15% filled by volumeHydrophilic acidic self-etching primer with

enhanced etching capabilitiesHydrophobic adhesive to maximize

material compatibility, increase strength and promote bond durability

Self Etch Technique

OptiBond XTR

Primer contain acetone, alcohol and water solvents

Low film thickness (5 micron)Bonds to gold, non-precious metal,

zirconia, porcelain Direct and indirect restorative procedures

Seventh Generation DBA

BeautibondDual acidic monomersLow film thickness (5 micron)RadiopaqueEasy to use-single application 10 sec

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Self Etch Technique

Materials 6th & 7th

Generation

Sixth Generation Seventh Generation

All-Bond SE Clearfil SE Protect

BeautiBond G-BondOptibondXTR

Long Term Dentin Bond StabilityMMP-Matrix MetalloproteasesMMPs are naturally occurring proteases

involved in dentin formation and trapped during odontogenesis

Not bacteria but proteolytic enzymes found within dentin capable of degrading collagen within newly created adhesive hybrid layers

Low pH causes dentin to release these inherent MMPs which attack exposed collagen fibrils

Osorio R, Yamauti M. Osorio E., et al. Effect of dentin etching on metalloproteinase-mediated collagen degradation. Eur J Oral Sci 2011;119:79-85.

Long Term Dentin Bond StabilityCysteine Proteases (Cathepsins)

Lysosomal enzymes that become activated in lysosomes by a low pH

Secreted by osteoclasts in bone resorption

Regulated by chondroitin

Collagenase activity breaks down collagen and hydrolyzes collagen into small peptides

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

MMP-Matrix Metalloproteases

Carrilho et al., JDR 2007; 86; 529Brackett et al.,Operative Dentistry; 2009;34(4):381-385

In-vivo 12 m w/PBNT (Acetone)

Immediate (MPa)Control 29.3 (9.2)CHX 32.7 (7.6)

w/CHX in 12 m

14 mo (MPa)Control 19.0 (5.2)CHX 32.2 (7.2)

Potential MMP Inhibitors

Long Term Dentin Bond Stability

Chlorhexidine (CHX)

Benzalkonium Chloride

MDPB ((12-methacryloxydodecalpyridinium bromide)

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

Epigallocatechin-3-gallate (green tea polyphenol)

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

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


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Disinfect to prevent MMPs

MDPB (12-methacryloxydodecalpyridinium bromide)


Pashley DH, Tay FR, Imazato S. Hot to Increase the durability of Resin-Dentin Bonds. Compend. 2010;32(7):60-64.

Pashley DH, Tay FR, Imazato S. Hot to Increase the durability of Resin-Dentin Bonds. Compend. 2010;32(7):60-64.

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

Dentin Bonding Challenges

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

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

• Acidic components cause incompatibility with self-cured composites.

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

Dentin Bonding Solutions

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

Selective Etch TechniqueApply etch to enamel only for 15 secondsWash thoroughlyPlace self-etching primer

Frankerger R, Lohbauer U, Roggendorf MJ, Naumann M, Taschner M. Selective enamel etching reconsidered:better than etch-and-rinse and self etch? J. Adhes Dent. 2008;10:339-344.

Selective Etch TechniqueHigh Viscosity allows precise placementContains BAC

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Selective Etch TechniqueAllows total etch or self etch of enamel

and/or dentin

G-aenial Bond

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

*Manufacturer supplied data

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MDP Universal Bonding Materials

Total, Self or Selective Etch Universal Bonding

Materials

Total, Self or Selective Etch

•GI Sandwich Technique-Never open the dentinal tubules



Resin-Modified Glass Ionomer


Never open dentinal tubules

Less post-operative sensitivity

Fluoride release

Long-term consistent bond to dentin

RMGI Liner

No dentin conditionerneeded due to self-etch

primer component

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RMGI BaseReprepare

Dentin conditionerpreferred to achieve optional dentin bond

Pre-Operative

Completed Preparation

Fuji II LC Resin Modified Glass Ionomer Base

Kalore

10. It’s not necessary

9. It takes more time

8. It costs more money

7. I don’t understand which product to use

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

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

5. I don’t know how to use

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

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

2. Fluoride release is transient

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

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

••Make initial access opening w small burMake initial access opening w small bur

••Use slow speed to remove decayUse slow speed to remove decay

••Use high speed to refine preparationUse high speed to refine preparation

••Smooth margins with a football diamond.Smooth margins with a football diamond.

Clinical Class I Restoration

••Completed PreparationsCompleted Preparations

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Ivoclar P-1

••Place glass ionomer base/linerPlace glass ionomer base/liner

••Etch enamel then dentin, wash and dryEtch enamel then dentin, wash and dry

••Place & scrub multiple coats bonding Place & scrub multiple coats bonding agent, wait, evaporate solvent and cureagent, wait, evaporate solvent and cure

••Place composite and adapt to sidesPlace composite and adapt to sides

•If large use incremental layers

•Cure thoroughly

Posterior Finishing Burs

Occlusal Anatomy OcclusalSecondary Anatomy

Buccal/ lingual gingival-IP

12 fluted carbide burs

ProcedureProcedure Trim and shape composite

Adjust occlusion

Blend margin between tooth and composite

Define secondary anatomy

Restore occlusal fissures

Restore buccal/ lingual contour

Reduce and smooth composite surface

Interproximal shaping at gingiva and above contact

Popular InstrumentsPopular Instruments Football or egg-shaped

7406

H379

15106-5

Flame-shape

H-274

5379-5

Needle shape

Safe-end SE6

7901

15121-5

Ivoclar

Astropol

SS White

Jazz

Caulk Enhance/POGO

••Blend margins with finishing carbidesBlend margins with finishing carbides

••Adjust occlusionAdjust occlusion

••Finish and polishFinish and polish

Etch, wash/dry and apply surface sealantEtch, wash/dry and apply surface sealant

Summary

Best reduction of post-operative sensitivity

Insurance of fluoride releaseBest bond to enamelLong term stable bond to dentinUse in majority of posterior preparations

Total Etch with RMGI Liner/Base So, Now do you Understand?Cna yuo raed tihs? The phaonmneal pweor of the hmuan mnid, aoccdrnig to a rscheearch at Cmabrigde Uinervtisy, it dseno't mtaetr in waht oerdr the ltteres in a wrod are, the olny iproamtnt tihng is taht the frsit and lsat ltteer be in the rghit pclae. The rset can be a taotl mses and you can sitll raed it whotuit a pboerlm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. Azanmig hu h? yaeh and I awlyas tghuhot slpeling was ipmorantt!

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•What’s new in composite technology?

•What’s all the buzz about bulk fill composites?

•To achieve good Class II interproximal contacts with composite, you just use the same armementarium as amalgam?

““Fill meFill me”” in on the latest in Direct in on the latest in Direct Restoratives!Restoratives!

New Filler TechnologyNew Filler TechnologyGiomer FillersGiomer Fillers

Unique Filler particles made of set glass ionomer with special surface coating

Set Glass Ionomer Material Surface Modified Pre-Reactive Glass Ionomer Filler

Surface modified layer

Glass Ionomer phase

Glass Core

New Filler TechnologyNew Filler TechnologyGiomer FillersGiomer Fillers

BeautiSealant BeautiBond

Beautifil IIBeautifil Flow Plus

16 of 26 Class I, and 25 of 35 Class II restorations were observed.No failures

No secondary caries

Alpha or Bravo aesthetics

No post-op sensitivity noted

Gordan VV, Mondragon E, Watson RE, Garvan C, Mjör IA. A clinical evaluation of a self-etching primer and a giomer restorative material: results at eight years. J Am Dent Assoc. 2007;138(5):621-7

GiomerGiomer TechnologyTechnology8 Year Results8 Year Results

19 of 26 Class I, and 22 of 35 restorations were observed.Retention rate 66% (27 of 41)

– 52% of retained noted as excellent – 41% of retained noted minor changes

Secondary caries rate 3.27% (2 of 61) Overall positive results and low secondary caries attributable to Giomer technology

Gordan VV, Blaser PK, Mjor IA, Sensi L, Watson R, McEdward DL, Riley III J. Clinical Evaluation of a Giomer Restorative System: Thirteen-Year Recall 2013 IADR #3104:University of Florida

GiomerGiomer TechnologyTechnology13 Year Results13 Year Results

Agl MicrofillAgl MicrofillHeliomolarHeliomolar

MicroMicro--HybridHybridMiris, Point4, Miris, Point4, EsthetX, Venus EsthetX, Venus

NanoclusterNanoclusterFiltek SupremeFiltek Supreme

NanoNano--HybridHybridVenus Diamond, Venus Diamond, Tetric EvoTetric Evo--Ceram, Ceram, Kalore, Esthelite QKalore, Esthelite Q

New Filler TechnologyNew Filler Technology

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Low Shrinkage CompositesLow Shrinkage Composites

Nano/Hybrids in green

Open Margin Cracked Enamel

(white line)

Effects of polymerization shrinkage STRESS

Fractured Cusp

New Filler TechnologyNew Filler TechnologySpheroidal FillersSpheroidal Fillers

Easy polishing and retention

Blends well into tooth structure

Nano‐hybrid Spherical

Filtek Supreme Ultra•Silica filler: 20nm•Zirconia filler: 4 ‐ 11nm•Zirconia/silica cluster: 0.6 –10nm

Clearfil Majesty ES‐2•Organic filler: 700nm•Organic‐inorganic filler

Estelite Sigma Quick•Spherical filler: 200nm•Organic‐inorganic filler

G‐aenial Sculpt•Barium glass filler: 300nm•Organic‐inorganic filler

G‐aenial Universal Flo Strontium glass filler:

200nm

G‐aenial Flo• Strontium glass filler:

400nm

New Filler TechnologyNew Filler TechnologySpheroidal FillersSpheroidal Fillers

DX-511

MW 895

BIS-GMA

MW 512

UDMA

MW 470

TEGMA

MW 286MW=Molecular Weight

New Resin TechnologyNew Resin TechnologyNanofill/HybridNanofill/Hybrid

Concern about bis-GMA

Shrinkage of bis-GMA,TEGMA

Higher molecular weight-less shrinkage

New advances possible through resin technology

DX-511


30

Increasing the size and molecular weight of monomers reduces overall shrinkage

Low Molecular weight

Shrinkage

High Molecular weight

Polymerization

Less Shrinkage


GC Products-G-aenial Sculpt

Kerr products

Venus Pearl

New Resin TechnologyNew Resin TechnologyNon Non bisbis--GMA CompositesGMA Composites

New Resin TechnologyNew Resin TechnologyNon Non bisbis--GMA CompositesGMA Composites

G-aenial Sculpt

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

•Beautifil Bulk Flowable

•Venus Bulk Fill

31

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.

Polymerization Shrinkage Polymerization Shrinkage StressStress(MPa)(MPa)

Bulk Fill Posterior CompositesBulk Fill Posterior CompositesLow Shrinkage StressStress

• Voco Xtra Fill

•Beautifil Bulk Flow

•Aura Bulk Fill

•Tetric Evo-Ceram Bulk Fill

•Sonic Fill

Sonic Energy Assisted Light Sonic Energy Assisted Light PolymerizationPolymerization

Sonic FillSonic Fill

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



32



Interproximal Contacts

Composite Direct Placement Composite Direct Placement ChallengesChallenges

Christensen JJ. Duplicating the form and function of posterior teeth with Class II resin-based composite. Gen Dent. 2012;60:104-108.

Microband Focu-tip Trimax

Interproximal ContactsInterproximal ContactsOriginal Attempted SolutionsOriginal Attempted Solutions

Not enough pressure to separate teeth

Fly off

Wedge in the way

Interproximal ContactsInterproximal ContactsSectional Matrix ChallengesSectional Matrix Challenges

Interproximal ContactInterproximal Contact

SolutionSolution

Contact Perfect


SolutionSolution

Contact Perfect

33

TofflemireTofflemire vs. Sectional vs. Sectional MatricesMatrices

Tofflemire System

Thin contact at the marginal ridge

Non‐anatomical Foodtrapbelowcontact

Increasedlikelihoodof:fracture,recurrentcariesandperiodontaldisease.

SectionalMatrices

Broad contacts at the proper height of contour

Anatomicallyshapedcontacts

TightContactsPropercontactsthatflossproperlyandpromotegingivalhealth


RetainersRetainers

TrioDent/Palodent

Universal V3 Ring Narrow V3 Ring


Also Available as:Also Available as:

Palodent Plus

Universal Ring Narrow Ring


BandsBands

TrioDent/Palodent Plus

Bendable tab

Side holes for easy removal

Holes allow grip with Pin-Tweezers

Marginal Ridge Contour

Pin Tweezers


BandsBands


Bicuspid

Molar

Sub-gingival Molar


Anatomical WedgesAnatomical Wedges

Wave Wedges

Pin Tweezers


34

Challenge:

Adjacent Class II Composite Restorations

Prepare enamel margins

Place contoured

band, wedge & V-Ring

Selective etching

Wash thoroughly

Apply bonding agent

Fill box 2/3’s full

Compress w 1P

Cure

Finish buildup

Cure

Sonicfill

Remove wedge peel band back

Cure IP

Remove band & cure ContacEZ

Re-contour diamond/finishing

carbides

Finishing strips

Place V-Ring on adjacent tooth

Burnish desired contact area

Selective etching

Place Universal bonding agent

Light Cure

Peel back band

Cure from both sides at

gingiva

Place Composite as before

Light Cure

35

Finish and polish

Adjust occlusion

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

0

20,000,000

40,000,000

60,000,000

80,000,000

100,000,000

120,000,000

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

Num

ber o

f Per

sons

60+

Age60-64

Age65-74

Age75-84

Age85+

Number of people aged 60+

28 M42 M

57 M

92 M

US Population is Aging

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

0

0

0

0

0

0

0

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

Perc

enta

ge 6

0+

Age60-64

Age65-74

Age75-84

Age85+

Percentage of people aged 60+

14%17%

18%

25%

10

5

15

20

25

30


• Xerostomia

• Difficulty maintaining oral hygiene

• Root exposures

• Some unable to tolerate long appointments

• Difficulty coming to office

• Fixed Income



DonDon’’t miss appointmentst miss appointments

AppreciativeAppreciative

Pay billPay bill

Often need more treatmentOften need more treatment

Refer new patientsRefer new patients

Say Thank You!Say Thank You!

60+ Patients are Wonderful

OneOne--Visit TechniqueVisit Technique

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

36

•Perio abcess

•Sub-gingival distal decay

•Carefully extract tooth

•Suture

•Scale and root plane adjacent teeth

•Cut off root of extracted tooth

•Remove decay and restore with glass ionomer

•Tryin and prepare slots

•Shape root area to support tissue

•Cut lingual slot when trying in

•Place groove inline with 2 adjacent teeth

•Prepare Ever Stick fibers

•Place tooth

•Etch and bond

•3 months later •3 months later

37

Before

Happy patient says that I just “straightened” his crooked tooth

Multiple Medications

Oral Environment Challenges-Xerostomia


“40% of all prescription drugs have dry mouth listed in the PDR as a possible side effect”

Chalmers J. Personal Communication. 2006.Chalmers J. Personal Communication. 2006.


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

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


• Incidence increases with # of drugs taken

• 50% of patients taking 4 or more medications had Dry Mouth

Oral Environment Challenges-Carbohydrates

Nutrition Facts: Serving Size: 8.3 fl. oz Calories: 140 Total Fat: 0g Sodium: 200mg Protein: 0g Total Carbohydrates: 28g Sugars: 28g

Nutrition Facts:16 fl oz; calories 140; total fat 0g; sodium 220mg; potassium 60mg; total carbs 28g; sugars 28g

38

Oral Environment Challenges-Antacids

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

Oral Environment Challenges-Bottled Water

Fluoride-less water Fluoridated water

Oral Environment Challenges-Illegal Drugs

“Meth mouth” or chronic marijuana use

Xerostomia patients

High carbohydrate users

Non-fluoridated water users

Drug abusers

Need TherapeuticRestorations

Composite Challenges

•Post-operative sensitivity

•Recurrent decay

•Achieving proper moisture

•Polymerization shrinkage

•Increased time-layering

•Technique sensitivity

Low post-op sensitivity

Fluoride Release

Moisture variability

No shrinkage

Bulk placement

Simple-more forgiving

Glass Ionomer

Look, we all know that Glass Ionomers are weak!

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

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

39

Look, we all know that Glass Ionomers are weak!

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

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

Fuji IX Self Cure Glass Ionomer

Glass IonomerBase/Restorative

SDI Self Cure Glass Ionomer

•More highly filled-reduced wear

•Self-curing in 2.5-5 minutes

•No polymerization (setting) shrinkage stress

•Expansion/contraction similar to tooth

•High fluoride release

•Bioactive

Glass IonomerCharacteristics •Multiple cervical carious lesions

•Pediatric Patients

•Sealants

•Class V restorations

•Sandwich Technique

•Crown buildups

•Long term interim restorations

•Cements

Glass Ionomer Uses

High caries rate individuals

Glass Ionomer RestorationsGlass Ionomer Restorations

Remove decay and place matrices


40

Treat dentin with PAA


Place, shape and wait 2:30


Shape with diamonds w/ water


Dry and place Surface Sealant

No phosphoric acid




Spoon out decay and refine prep


41

Place and rinse Poly-acrylic acid


Mix Gi and quickly place and push out


Allow to set 2:30


Hold down gingiva and shape


Dry and place surface sealant




42

Pediatric Patients


Pediatric Patients


Class V root caries


Class V root caries


Repair around crown margins


Repair around crown margins


43

Long term interim restoration








Decalcified areas in partially erupted tooth

Treat with phosphoric acid

Glass Ionomer SealantsGlass Ionomer Sealants

Activate, mix and place glass ionomer

Place Surface Sealant over glass ionomer and light

cure


44

Glass Ionomer Sealants

5 Year Recall


Gain access to decay using a high speed

Closed Sandwich Technique

Use slow speed and then spoon excavator

Stop if you feel you will expose pulp

SEM of dentin treated with PCA

Condition dentin with poly-acrylic acid for 10 seconds and wash


CARD

OS

O et al. J D

ent 2010

Condition enamel only with phosphoric

acid

Rinse thoroughly

Re-prep if necessary after set

Place Glass Ionomer base


Wait 2:30

Apply Seventh Generation Bonding

Agent

Zhang Y, Burrow MF, Palamara JEA, Thomas CDL. Bonding to Glass Ionomer Cements using Resin-based Adhesives. Op Dent 2011;36:618-625.


Finish and polish

Place Composite & Cure

(Sonic Fill)

Preparation w cervical margin in

dentin

Open Sandwich Technique

Acid etch enamel

Condition dentin w PCA

45

Place glass ionomer base


Place RMGI bonding agent and cure

*recommended by Dr Graeme Milicich

Build up tooth with composite


Shape with diamonds and fine carbides

Finished occlusal view


Mesial View

Glass Ionomer

Composite

RMGI

Restoration Under Crown

Internal Cracks


Deep decay w affected dentin



46






Do Not Use in Anterior Teeth to replace Large Defects

RUC with crack

But… How long do they last?

Zanata RL, Fagundes TC, Freitas MC, Lauris JR, Navarro MF. Ten-year survival of ART restorations in permanent posterior teeth. Clin Oral Investig. 2011;15(2):265-71

Placement 2 years 10 years

92.7% success

65.2% success

Survival Rate

Single Surface Restorations*(*based on placement of older GI formulations)


Zanata RL, Fagundes TC, Freitas MC, Lauris JR, Navarro MF. Ten-year survival of ART restorations in permanent posterior teeth. Clin Oral Investig. 2011;15(2):265-71

Placement 2 years 10 years

86.8% success

30.6% success

Survival Rate

Multiple Surface Restorations*

(n=62)

(*based on placement of older GI formulations)

47


Five Year Restorations


How long do they last?• 8-12 years- single surface

• 5-8 years- multiple surface

• The larger the restoration, the shorter its lifetime


Then what?• Re-prepare surface and place posterior

composite restoration

• Prepare tooth for a crown

Equia

Glass Ionomer/Filled Resin Sealant

Easy, Quick, Universal…

Designed as a system that included surface sealant

Becomes stronger in time

Surface Sealant

• Fills in microcracks and porosity

• Provides a high gloss, smooth surface

• Increase wear resistance and allows material to mature

•Light Cured-Do not etch before applying

•Sealant retains moisture w/in restoration allowing better maturation and hardness before surface is exposed to forces

Surface Sealant

48

Restoration w large crack Restoration w large crack

Large restoration with internal fractures Dentist-Multiple Radiographic Caries

Before and After

Equia Forte

Posterior Glass Ionomer

49

Equia Forte


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

Equia Forte


RIVA Self Cure HV

Sudden Onset Caries

Posterior Glass Ionomer47 year old female

Been in the practice over 30 years

Regular re-care appointments

Significant changes in health history

No restorations in 8 years

Radiographs revealed multiple interproimalradiolucencies not present 12 months previous

Required 16 restorations

Need caries resistant restorations

Preparations


Preparations


Posterior GI Restorations


50

•Acid/base and polymerization reaction

•Ionic and micromechanical bonding

•Dual-curing

•Fluoride release

•Bioactive

Resin-Modified Glass Ionomers

•Acid/base and polymerization reactions

•Dual cured-faster

•Shortens time needed to control moisture

•More esthetic and translucent

•Fluoride release

•Higher tensile, bond strength and wear

Resin-Modified Glass Ionomer Characteristics

•Liner or Base

•Class V Restorations

•Restoration Under Crown

•Temporary prior to crown

•Sandwich technique

•Cements

Resin-Modified Glass Ionomer Uses

Resin-Modified Glass Ionomers-Advantages

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

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

•Better retention

Resin-Modified Glass Ionomer Base/Restorative

Capsule

Fuji II LC RIVA LCFuji Filling LC

Resin-Modified Glass Ionomer Base/Restorative

Ketac Nano

Paste-Paste

51

Class V Restoration 302

Gingival recession & root caries

• 1st molar and bicuspid

• Remove decay‐place retention


303

Gingival recession & root caries

• 1st molar and bicuspids

• Remove decay‐place retention

Condition with PA

• Pre‐treatwith dentin conditioner (Poly‐

acrylic acid)


304

Material Placed and Light Cured

• Place excess material

• Light Cure


305

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



52

Quick Temporary prior to Crown Temporary placed 5 years ago

Sandwich Technique

•Exposed to occlusion

•Able to control moisture

•Not acid etching

•No shrinkage stress

•Highest fluoride release

•Out of occlusion

•Need quickness

•Need to acid etch

•Need to bond

•↑translucence/esthetic


Glass Ionomer

•Core-Cemented posterior crowns

•Entire Class I or II (Long Term Interim)

•Class V-high caries

•All deciduous posteriors

•Sandwich technique-Co Cure

Glass Ionomer Preferred Uses

•Core-all crowns

•Base Class I or II-re-prepared sandwich

•Class V-more esthetic

•Quickly placed short-term interim restorations


Preferred Uses

53

GI Initial setting and early strength Fluoride release

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

Ceramir Ceramir

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

Ceramir

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

Gibbsite

Tooth apatite

Mixed zoneChemically formed apatiteGibbsite(Calcite)

Katoite

Ceramir

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

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

Ceramir Ceramir

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

Self Adhesive Resin Cement


Glass Ionomer

Calcium AluminateRMGI

Calcium Silicate

54

0:00

Ceramir

2:00

Ceramir

4:00

Ceramir Glass IonomersThe “missing link” of esthetic

restorative materials

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Uncommon Common Sensed1ue90e5sp4tcv.cloudfront.net/2855/images/Asset305718_v1.pdf · Decay Removal Composite Direct Placement Challenges Thoroughly remove decay only Amalgam ... Intra-oral