CDA-Anaheim. Daniel H Ward DDS. I get by with a little help from my friends. Plain Talk about Perfecting Esthetic Posterior Restorations

Transcription

1 Let s Be Direct: Plain Talk about Perfecting Esthetic Posterior Restorations CDA-Anaheim Daniel H Ward DDS Graduated 1979 OSU Private Practice Columbus, Ohio Assistant Clinical Professor The Ohio State University 13 years Daniel H Ward DDS May 14, 2016 Daniel H Ward DDS Fellow Academy of General Dentistry Fellow American College of Dentists Fellow International College of Dentists Fellow American Society for Dental Aesthetics Associate Member American Academy of Esthetic Dentistry Daniel H Ward DDS Reviewer Journal of Prosthetic Dentistry Reviewer Journal of Esthetic and Restorative Dentistry Member and Evaluator for Catapult Lecturer and Chief Examiner University of Minnesota Post Graduate Program in Esthetic Dentistry 20 years I get by with a little help from my friends I get by with a little help from my friends Dr Harry Albers Dr Paul Belvedere Dr John Burgess Dr Mark Canon Dr Gordon Christensen Dr George Freedman Dr Galip Gürel Dr Geoff Knight Dr Doug Lambert Dr Karl Leinfelder Dr Graeme Milicich Dr Buddy Mopper Dr Jeff Morley Dr Brian Novy Dr Jorge Perdagão Dr Steve Rosenstiel Dr Robert Seghi Dr Irwin Smigel Dr Byong Suh Dr Ed Swift AdDent BISCO Caulk/Dentsply Centrix Clinicians Choice Coltene/Whaledent GC America Heraeus Kulzer Ivoclar Kerr Pulpdent Shofu SDI SSWhite Tokuyama Triodent 3 M VOCO 1

2 Some Images May be: Cropped Rotated Levels adjusted No Images were: Site adjusted Enhance to produce a better result Composite The most USED and ABUSED Material in Dentistry Composite Direct Placement Challenges Marginal Integrity Expose ends of enamel rods Enamel Enamel Bonding 96% inorganic carbonate hydroxyapatite calcium phosphate 4% organic (tyrosine rich amelogenin protein) and water Enamel rods microns in diameter Bonding occurs within enamel rods Hydrophobic 2

3 White Lines Sheared enamel rods Unprepared Margins Expose fresh ends of the enamel rods with a very fine diamond Use a fine 25 micron diamond when using self-etching primers Class II Interproximal Margin Preparation Koase K, Inoue S, Noda M, Tanaka T et al. Effect of bur-cut dentin on bond strength using two all-in in-one and one two-step adhesive systems. J Adhes Dent ;6: Hosoya Y, Shinkawa H, Suefiji C, Nozaka Ket al. Effects of diamond bur particle size on dentin bond strength. Am J Dent ;17: Exposing Greater Better bonding angle ends of than and enamel direction less rods shearing of resulting enamel of in enamel rods rods 3

4 Class II Interproximal Margin Preparation Class II Interproximal Margin Preparation Composite Preparation Amalgam Preparation Expose the ends of the enamel rods to avoid tooth fracture at margins Bevel Interproximal Enamel for better bonding and less shearing of enamel rods Importance of flaring Class II Interproximals Importance of flaring Class II Interproximals Fractured tooth structure Parallel preparation Importance of flaring Class II Interproximals Composite Direct Placement Challenges Post-Operative Sensitivity Hydrodynamic Theory Result 4

5 Hydrodynamic Theory Hydrodynamic Theory Fluid flow within dentinal tubules causes PAIN Brannstrom M. The Cause of post restorative sensitivity and its prevention. J Endod 1986;12: Opened, unsealed dentinal tubules causes PAIN Dentin Placement of Resin Primer Apply multiple coats Dentin Bonding Etched Dentin 70% inorganic carbonate hydroxyapatite calcium phosphate 30% organic (collagen) and water Dentinal tubules microns in diameter Most Bonding occurs between dentinal tubules Hydrophilic Demineralize surface Expose collagen fibers Remove smear layer Increase porosity of intertubular dentin Open up dentinal tubules Increase surface area 5

6 Bonding agent should not leave the dentinal tubules open Method #1-Reducing Post-Op Sensitivity Total Etch Technique Placement of Etchant Total Etch Technique Fill and Occlude open dentinal tubules Rinsing of Etchant Moist Dentin Overwet Phenomenon Placement of Resin Primer Moist Moist 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): Overdrying Overdrying Collapsed collagen fibrils Un-collapsed collagen fibrils Collapsed collagen fibrils Gwinnett AJ. Dentin bond strength after air drying and rewetting. Am J Dent. 1994;7(3): SEM Perdigao 6

7 Proper Moisture Moisture Variability Evaporating the solvent with dry air Air only syringe Warm air dryer Variability Air/water syringe Air/water syringe Sensitivity Bond Strength Effect of Dentin Depth on Bond Strengths Adhesive System Superficial Dentin Deep Dentin Single Bond 22.1 (+/-2.8) 14.2 (+/-7.0) Optibond Solo 18.9 (+/-4.1) 18.4 (+/-4.8) Mean shear bond strength in MPa Clearfil Liner Bond 21.0 (+/-7.4) 17.6 (+/-5.9) Lopez CL, Perdigao J, Lopes M et al. Dentin Bond Strengths of Simplified Adhesives:Effect of Dentin Depth. Compendium. 2006;27(6): GLUMA Occludes tubules Anti-bacterial 7

8 Total Etch Technique Summary Most technique sensitive Requires proper attention to detail Use in ideal sized preparations Occlusions Total Etch Technique Materials-4 th Generation Total Etch Technique Materials-5 th Generation Acetone solvent Alcohol solvent Acetone solvent Alcohol solvent Bonding agent should not leave the dentinal tubules open Self-Etching Primer Method #2-Reducing Post-Op Sensitivity Self Etch Technique Never leave the dentinal tubules open O O Methacrylate-group Hydrophobic end connects to polymer-network CH 2 CH 2 O Spacer-chain link between functional groups O COOH COOH Acid-groups Hydrophilic end etches tooth structure (self limiting) 8

9 Self Etching Primer Acidifying Primer accompanies etch Resin Tags do not Contribute to Dentin Adhesion in SE Adhesion 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): 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% H 3 PO 4 etched Unprepared enamel surface for 15s. Popular SE primer etched Unprepared enamel surface 9

10 Effect of Enamel Etching-Bond Strength Tests confirm that preparing the enamel margin improves bond strength especially with self-etch dentin bonding agents 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 Substrate All-Bond Universal Self-Etch All-Bond Universal Total-Etch Substrate All-Bond Universal Self-Etch All-Bond Universal Total-Etch Uncut Enamel 18.7± ±7.1 Cut Enamel 29.0± ±3.6 55% improvement Uncut Enamel 18.7± ±7.1 Cut Enamel 29.0± ±3.6 67% improvement 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: 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: Effect of Enamel Etching-Bond Strength Tests show that etching cut enamel with phosphoric acid increases bond strength to enamel with 1- bottle dentin bonding agents Effect of Enamel Etching-Marginal Gaps Solution: Etching prepared enamel w phosphoric acid promoted better marginal integrity with self-etching bonding agents. Substrate All-Bond Universal Self-Etch All-Bond Universal Total-Etch Uncut Enamel 18.7± ±7.1 Cut Enamel 29.0± ±3.6 22% improvement 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: 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: Bond Incompatibility with Self and Dual Cured Resins 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 Solution: Use of a higher ph (>3.0)self-etching dentin bonding agent does not inactivate the tertiary amines and allows for polymerization. ph=3.2 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: 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:

11 Bond Incompatibility with Self and Dual Cured Resins Solution: Use a dual-cure activator Hydrolytic Degradation 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: Hydrolytic Degradation Hydrolytic Degradation Solution: Use 2 layers-a hydrophilic layer covered with a hydrophobic layer Solution: Use MDP containing bonding agents which become hydrophobic upon polymerization due to high amount of crosslinkage. MDP-containing adhesives form nano-layering at the adhesive interface. Stable MDP-Ca salt deposition along with nanolayering 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: 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: Self Etch Technique Unprepared enamel surface 6 th generation DBA that effectively etches enamel Etched with 37% Phosphoric Acid OptiBond XTR 6 th Generation DBA OptiBond XTR Popular 6th Generation DBA Popular 7th Generation DBA Swift E, et al. J Esthet Restor Dent. 2011;23(6):

12 Self Etch Technique OptiBond XTR Self Etch Technique OptiBond XTR 2 component self-etch 15% filled by volume Hydrophilic acidic self-etching primer with enhanced etching capabilities Hydrophobic 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 Beautibond Dual acidic monomers Low film thickness (5 micron) Radiopaque Easy to use-single application 10 sec Self Etch Technique Materials 6 th & 7 th Generation Selective Etch Technique Apply etch to enamel only for 15 seconds Wash thoroughly Place self-etching primer Sixth Generation Seventh Generation All-Bond SE Clearfil SE Protect Optibond XTR BeautiBond G-Bond 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:

13 Selective Etch Technique High Viscosity allows precise placement Contains BAC Selective Etch Technique Allows total etch or self etch of enamel and/or dentin G-aenial Bond Selective Etch Technique Precursor to Universal Bonding agents Bond strength same to total vs self etch Dentin Bond Strength Total, Self or Selective Etch Universal Bonding Materials Self etch Selective etch Total etch Self-Etch Total Etch Moist Total Etch Wet Total, Self or Selective Etch Universal Bonding Materials Total, Self or Selective Etch MDP Universal Bonding Materials 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. 13

14 Total, Self or Selective Etch Universal Bonding Materials Composite Direct Placement Challenges Decay Removal Thoroughly remove decay only Amalgam Preparation Composite Preparation Minimally Invasive Dentistry Convenience Form MID Lifetime of tooth often determined by first dentist intervention Conservative Tooth Preparation How do you restore? 169L VF Fissurotomy bur Low Viscosity Flowable Composite 14

15 G-aenial Universal Flo Homogeneous spherical particles G-aenial Universal Flo Homogeneous spherical particles Good wear resistance High flexural strength (167 MPa) Filled 50% by volume G-aenial U Flo Mean particle size 200 nm Conventional Nano-hybrid Particle size range nm 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 S PRG Fillers Reduced Plaque Accumulation Releases fluoride and other ions Neutralizes ph-antibacterial Good polishability BEAUTIFIL Containing S-PRG filler plaque Conventional Restorative Material Not containing S-PRG filler Visibly blends in well S-PRG (Surface pre-treated Glass Ionomer) High Viscosity (Low Flow) Flowable Composite Less plaque Full-grown plaque Intra-oral plaque formation 24 hours W/O Brushing CALSET Thermal Assisted Light Polymerization Compule Tray Warmer W A R M E R Dispenser Gun Tray Improved flowability of composites Improved marginal adaptation ADVANTAGES Thermal Assisted Light Polymerization 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 Stansbury JW. Use of near-ir to monitor the influence of external heating on dental composite photopolymerization. Dent Mat 2004; 20(8). 15

16 CALSET Thermal Assisted Light Polymerization Completed Tooth Restorations Comax Dispenser Dispenser Gun Tray Low Viscosity Flowable Composite & Warmed Composite Composite Direct Placement Challenges Oral Environment Challenges- Xerostomia Recurrent Decay Composite Alternatives 40% of all prescription drugs have dry mouth listed in the PDR as a possible side effect Chalmers J. Personal Communication Oral Environment Challenges- Xerostomia Oral Environment Challenges- Carbohydrates Incidence increases with # of drugs taken 50% of patients taking 4 or more medications had Dry Mouth Nutrition Facts:16 fl oz; calories 140; total fat 0g; sodium 220mg; potassium 60mg; total carbs 28g; sugars 28g Nutrition Facts: Serving Size: 8.3 fl. oz Calories: 140 Total Fat: 0g Sodium: 200mg Protein: 0g Total Carbohydrates: 28g Sugars: 28g 16

17 Oral Environment Challenges- Bottled Water Oral Environment Challenges- Illegal Drugs Fluoride-less water Fluoridated water Meth mouth or chronic marijuana use Need Therapeutic Restorations Composite Challenges Glass Ionomer Xerostomia patients High carbohydrate users Non-fluoridated water users Drug abusers Post-operative sensitivity Low post-op sensitivity Recurrent decay Fluoride Release Achieving proper moisture Moisture variability Polymerization shrinkage No shrinkage Increased time-layering Bulk placement Technique sensitivity Simple-more forgiving Glass Ionomer Family Glass Ionomers (Self-Cured) Resin-Modified Glass Ionomers (Dual Cured) Glass Ionomer Characteristics More highly filled-reduced wear Self-curing in minutes No polymerization (setting) shrinkage stress Expansion/contraction similar to tooth High fluoride release Bioactive 17

18 Glass Ionomer Uses Multiple cervical carious lesions Pediatric Patients Sealants Class V restorations Sandwich Technique Crown buildups Long term interim restorations Cements Glass Ionomer Bases Fuji IX RIVA SC FX-II Stop if you feel you will expose pulp Rinse thoroughly Use slow speed and then spoon excavator Gain access to decay using a high speed Closed Sandwich Technique Condition enamel only with phosphoric acid Condition dentin with poly-acrylic acid for 10 seconds and wash SEM of dentin treated with PCA Closed Sandwich Technique CARDOSO et al. J Dent 2010 Place Glass Ionomer base Zhang Y, Burrow MF, Palamara JEA, Thomas CDL. Bonding to Glass Ionomer Cements using Resin-based Adhesives. Op Dent 2011;36: Place Composite & Cure Wait 2:30 Re-prep if necessary after set Apply Seventh Generation Bonding Agent Closed Sandwich Technique Finish and polish (Sonic Fill) Closed Sandwich Technique 18

19 Glass Ionomer Restorations Glass Ionomer Restorations Long term interim restoration Long term interim restoration Glass Ionomer Restorations Glass Ionomer Restorations Long term interim restoration Long term interim restoration But How long do they last? Single Surface Restorations* (*based on placement of older GI formulations) Placement 2 years 10 years But How long do they last? Multiple Surface Restorations* (*based on placement of older GI formulations) Placement 2 years 10 years Survival Rate 92.7% success 65.2% success Survival Rate (n=62) 86.8% success 30.6% success 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): 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):

20 But How long do they last? 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 Long term interim restoration Then what? Re-prepare surface and place posterior composite restoration Prepare tooth for a crown Glass Ionomer/Filled Resin Sealant Easy, Quick, Universal Designed as a system that included surface sealant Becomes stronger in time Long term interim restoration Equia Surface Sealant 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 20

21 Restoration w large crack Restoration w large crack Dentist-Multiple Radiographic Caries Before and After Posterior Glass Ionomer Posterior Glass Ionomer Equia Forte 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 21

22 Posterior Glass Ionomer Posterior Glass Ionomer Equia Forte RIVA Self Cure HV Sudden Onset Caries Posterior Glass Ionomer Posterior Glass Ionomer Sudden Onset Caries Posterior GI Restorations Resin-Modified Glass Ionomers Acid/base and polymerization reaction Ionic and micromechanical bonding Dual-curing-faster Lower fluoride release More esthetic & translucent Resin-Modified Glass Ionomer Uses Liner or Base Class V Restorations Restoration Under Crown Temporary prior to crown Sandwich technique Cements Bonding Agent 22

23 Resin-Modified Glass Ionomer Liner Resin-Modified Glass Ionomer Base Capsule Vitrabond Fuji Lining LC Fuji II LC RIVA LC RMGI Base RMGI Liner Reprepare No dentin conditioner needed due to self-etch primer component Dentin conditioner preferred to achieve optional dentin bond Quick Temporary prior to Crown Temporary placed 5 years ago 23

24 Riva Bond LC Resin-modified Bonding Agent Triturated Reduces polymerization shrinkage stress Sandwich Technique Novel concept Co-Cure Sandwich Technique* Co-Cure Sandwich Technique *recommended by Dr Graeme Milicich Acid etch enamel Condition dentin w PCA -wash Wash thoroughly Mix GI Place Glass Ionomer Spread w/ instrument Co-Cure Sandwich Technique Co-Cure Sandwich Technique Puncture seal and dip brush into RMGI Use wet brush to spread out-up sides Light Cure 24

25 Co-Cure Sandwich Technique Co-Cure Sandwich Technique Insert Sonic-Fill tip Express composite Compress-push against margins Place anatomy Light Cure Adjust occlusion Finish and Polish Class I Composite Co-Cure Cure Sandwich Technique Cut a large deep round divot into Class I Tooth Prep Mix Glass Ionomer and RIVA bond Place GI into divot and spread out Place brush into RIVA Bond capsule Paint over GI and spread out Light Cure Place Composite and Light Cure Glass Ionomer Exposed to occlusion Able to control moisture Not acid etching No shrinkage stress Highest fluoride release Resin-Modified Glass Ionomer Out of occlusion Need quickness Need to acid etch Need to bond translucence/esthetic Glass Ionomers The missing link of esthetic restorative materials Clinical Class I Restoration Make initial access opening w small bur Use slow speed to remove decay Use high speed to refine preparation Smooth margins with Completed a football Preparations diamond. 25

26 Bur Block Setup Er:YAG Laser #1 rd #4 rd Jazz Flame Jazz Cup Gw C 201.3VF (Pirhana) L Lite-Touch Often use no anesthesia Restoration blends well into tooth Er:YAG Laser Er:YAG Laser Lite-Touch Laser inside handpiece More efficient and easier to use Less Expensive Use for limited bone re-sculpting Biological Width Place glass ionomer base/liner Etch enamel then dentin, wash and dry Posterior Finishing Burs 12 fluted carbide burs Occlusal Anatomy Occlusal Secondary Anatomy Buccal/ lingual gingival-ip Place Ivoclar & scrub P-1multiple coats bonding agent, wait, evaporate solvent and cure Place composite and adapt to sides If large use incremental layers Procedure 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 Cure thoroughly Popular Instruments Football or egg-shaped 7406 H Flame-shape H Needle shape Safe-end SE

27 Etch, wash/dry and apply surface sealant SS White Jazz Ivoclar Astropol Caulk Enhance/POGO Blend margins with finishing carbides Adjust occlusion Finish and polish Endodontic Root Canal Therapy? Perhaps not IF: OOPS! Asymptomatic Single small exposure Able to achieve hemostasis Traditional Pulpal Protection Indirect 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 Protection Indirect/Direct Pulp Capping What are we trying to accomplish? Mechanical Sealing of the Pulp Stimulate hydroxyapatite formation Dentin bridge formation 27

28 Traditional Pulpal Protection Indirect/Direct Pulp Capping How does this happen? Material sets hard and adheres to dentin Alkaline ph Release of Ca ++ ions Ca +2 H2O Ca +2 OH - OH - Traditional Pulpal Protection Indirect/Direct Pulp Capping Ca(OH) 2 Paste DyCal Dentsply/Caulk (paste/paste) Multi-Cal Pulpdent (non-setting) Ca(OH) 2 in VLC resin Prisma VLC DyCal (light cured) Life Kerr (light cured) Unproven Pulpal Protection Indirect/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. Unproven Pulpal Protection Indirect/Direct Pulp Capping Glass Ionomer/RMGI? Poly Acrylic Acid (PAA) inhibits apatite formation in the body environment. PAA released from the glassionomer cements inhibits the apatite formation on tooth surfaces. It might be considered difficult to obtain bioactive glass-ionomer cements 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: 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: Improved Pulpal Protection Indirect/Direct Pulp Capping Ca(OH) 2 Paste Ultra-Blend Plus Ultradent 28

29 Pulpal Protection Indirect/Direct Pulp Capping Biodentine MTA (Mineral Trioxide Aggregate) ProRoot-Dentsply Biodentine-Septodont Thera-Cal LC-Bisco Tricalcium silicate (CaO) 3.SiO 2 Dicalcium silicate (CaO) 2.SiO 2 Tricalcium aluminate (CaO) 3.Al 2 O 3 Tetracalcium aluminoferrite (CaO) 4.Al 2 O 3.Fe 2 O 3 Gypsum CaSO 4 2 H 2 O Bismuth oxide Bi 2 O 3 Latest Pulpal Protection Indirect/Direct Pulp Capping Resin Modified Calcium Silicate Theracal Latest Pulpal Protection Indirect/Direct Pulp Capping Light cured apatite forming MTA in a unique hydrophilic resin (polyethylene glycol methacrylate) that releases calcium 29

30 How many of you have problems with Mandibular Nerve Blocks? YES NO.? Hilton TJ. Keys to Clinical Success with Pulp Capping: A Review of the Literature. Op Dent 2009;34: Trustworthy, loyal helpful, friendly, courteous, kind obedient.. Really, Final Answer? How many of you have problems with Mandibular Nerve Blocks? How many of you have problems with Mandibular Nerve Blocks? 10 minutes (60%) 30-Minute Time Course for Pulpal Analgesia - Lidocaine IANBs Data from 30 PRP Studies ( ), n = 1162 Subjects, Lidocaine/Epi IANB Mean 30-Minute Time Course for Pulpal Analgesia - Lidocaine IANBs Data from 30 PRP Studies ( ), n = 1162 Subjects, Lidocaine/Epi IANB How many of you have problems with Mandibular Nerve Blocks? How many of you have problems with Mandibular Nerve Blocks? 10 minutes (60%) 30-Minute Time Course for Pulpal Analgesia - Articaine IANBs Data from 5 PRP Studies Subjects ( ) Mean 30-Minute Time Course for Pulpal Analgesia - Articaine IANBs Data from 5 PRP Studies Subjects ( ) 30

31 Pharmacology of Local Anesthetics Pharmacology of Local Anesthetics Local Anesthetics is an acidic solution with a ph of ~ 3.9 It is an Inactive form to extend shelf life Body must raise ph of the local anesthetic to ~ 7.4 for it to be active Takes up to 6-15 minutes Sodium Bicarbonate neutralizes the anesthetic solution Buffered anesthetic brings ph level close to physiologic ph prior to injection Buffered anesthetic brings ph level close to physiologic ph prior to injection Very quick onset (2-3 minutes)-able to determine proper injection site soon More comfortable injection with less burning More profound anesthesia 6,000 times more active anesthetic at time of injection CO2 microbubbles created during mixing improves ability of anesthetic to cross nerve membrane Buffered and non-buffered anesthetic-time time vs. efficacy of IANB 2 minute Buffered as effective as 10 minute non-buffered anesthetic-efficacy efficacy of IANB 67% Mean 30-Minute Time Course for Pulpal Analgesia Lidocaine, Articaine, Buffered Lidocaine IANBs Data from published and company Studies Mean 30-Minute Time Course for Pulpal Analgesia Lidocaine, Articaine, Buffered Lidocaine IANBs Data from published and company Studies 8 minute Buffered anesthetic gives 90+% efficacy of IANB Onset by Onpharma 67% Cartridge Connector Bicarbonate Solution Mixing Pen Mean 30-Minute Time Course for Pulpal Analgesia Lidocaine, Articaine, Buffered Lidocaine IANBs Data from published and company Studies 31

32 Anutra Buffered Anesthesia Advantages Increased onset of analgesia-feedback Increased efficacy of analgesia More comfortable injection Challenges New routine Cost Buffered Anesthesia If you are interested Onset $50/10 injections Less change to routine Used only on difficult injections Anutra $500/month Commitment to system Used on every patient Once setup easy to use and saves time Onset Anutra New Resin Technology Non bis-gma Composites GC products Kerr products Venus Pearl Bulk 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 32

33 Bulk 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 Composites Low Shrinkage Stress Surefill SDR Voco Xtra Beautifil Bulk Flowable Venus Bulk Fill Surefill 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 Polymerization Shrinkage Stress (MPa) 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: Bulk Fill Posterior Composites Low Shrinkage Stress Sonic Energy Assisted Light Polymerization Voco Xtra Fill Beautifill Bulk Flow Aura Bulk Fill Tetric Evo-Ceram Bulk Fill Sonic Fill Sonic Fill 33

34 ADVANTAGES Sonic Energy Assisted Light Polymerization Sonic Energy Assisted Light Polymerization Improved flowability of composites Improved marginal adaptation 5mm depth of cure Increased sculptability and ease in shaping anatomy Composite designed specifically for use Sonic Fill Sonic Energy Assisted Light Polymerization Composite Direct Placement Challenges Interproximal Contacts Sonic Fill Christensen JJ. Duplicating the form and function of posterior teeth with Class II resin-based composite. Gen Dent. 2012;60: Interproximal Contacts Original Attempted Solutions Interproximal Contacts Sectional Matrix Challenges Microband Focu-tip Trimax Not enough pressure to separate teeth Fly off Wedge in the way 34

35 Tofflemire vs. Sectional Matrices Tofflemire System Thin contact at the marginal ridge Non anatomical Food trap below contact Increased likelihood of: fracture, recurrent caries and periodontal disease. Sectional Matrices Broad contacts at the proper height of contour Anatomically shaped contacts Tight Contacts Proper contacts that floss properly and promote gingival health Interproximal Contact Retainers Interproximal Contact Also Available as: Universal V3 Ring Narrow V3 Ring Universal Ring Narrow Ring TrioDent/Palodent Palodent Plus Bendable tab Interproximal Contact Bands Holes allow grip with Pin-Tweezers Interproximal Contact Bands Bicuspid Marginal Ridge Contour Side holes for easy removal Molar Pin Tweezers TrioDent/Palodent Plus Sub-gingival Molar TrioDent/Palodent Plus 35

36 Interproximal Contact Anatomical Wedges Wave Wedges Pin Tweezers TrioDent/Palodent Plus Prepare enamel Challenge: Adjacent margins Class II Composite Restorations Place contoured band, wedge & V-Ring Sonicfill Selective etching Wash thoroughly Apply bonding agent Remove wedge peel band back Cure IP Remove band & cure Fill box 2/3 s full Compress w 1P Cure Finish buildup Cure Re-contour diamond/finishing carbides Finishing strips Selective etching Place V-Ring on adjacent tooth Burnish desired contact area ContacEZ Place Universal bonding agent Light Cure 36

37 Adjust occlusion Peel back band Cure from both sides at gingiva Place Composite as before Light Cure Finish and polish Adjacent Class II Preparations Band and Retainer on Mesial of Adjacent Interproximal Tooth Push band in using placement instrument Add first increment-push B & L 37

38 Add second increment to top Add final increment-push against margins Form occlusal anatomy and light cure Disassemble retainer and matrix band-light curing IP each step Remove Interproximal excessshape contact area w dia/carbide Blend and shape IP margins 38

39 Shape Occlusal with Egg Shaped Finishing Carbide-Blend margins Adjust occlusion (if no dam placed) -shape anatomy w 245 bur Finish and polish Place both bands and wedges First place mesial retainer Place distal retainer 39

40 Burnish contacts (Bond in mouth) add f2 increments to mesial-adapt well Repeat process on distal Fill occlusal, shape and light cure Remove retainer-light cure IP Remove wedge-light cure IP 40

41 Remove band-light cure IP Shape Occlusal with Egg Shaped Finishing Carbide-Blend margins Blend and shape IP with Pointed finishing carbide Shape along gingiva w pointed finishing carbide Shape Occlusal IP for EZ flossing Adjust occlusion-shape anatomy w 245 bur 41

42 Polish with cups(in mouth use IP finishing strips Polish with points Post-Cure (Optional etch & surface sealant) Finished Restorations Thank You! 42