PERFECTING Esthetic Posterior Restorations Daniel H Ward DDS Graduated 1979 OSU Private Practice Columbus, Ohio Assistant Clinical Professor The Ohio State University 13 years 2016 Greater New York Dental Meeting Daniel H Ward DDS 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 Composite The most USED and ABUSED Material in Dentistry 1
Composite Direct Placement Challenges Minimally Invasive Dentistry Decay Removal Thoroughly remove decay only Lifetime of tooth often determined by first dentist intervention Conservative Tooth Preparation How do you restore? 169L 330 201.3VF Fissurotomy bur Low Viscosity Flowable Composite 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 40-5000 nm Good polishability Blends in well High Viscosity (Low Flow) Flowable Composite High Viscosity (Low Flow) Flowable Composite 2
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). CALSET Thermal Assisted Light Polymerization Completed Tooth Restorations Comax Dispenser Dispenser Gun Tray Low Viscosity Flowable Composite & Warmed Composite 3
Composite Direct Placement Challenges Hydrodynamic Theory Post-Operative Sensitivity Hydrodynamic Theory Fluid flow within dentinal tubules causes PAIN Brannstrom M. The Cause of post restorative sensitivity and its prevention. J Endod 1986;12:475-481. Hydrodynamic Theory Dentin Opened, unsealed dentinal tubules causes PAIN Dentin Bonding Etched Dentin 70% inorganic carbonate hydroxyapatite calcium phosphate 30% organic (collagen) and water Dentinal tubules 0.06-3 3 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 4
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 Placement of Resin Primer Apply multiple coats Overwet Phenomenon Placement of Resin Primer Overdrying Collapsed collagen fibrils 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):109-114. Gwinnett AJ. Dentin bond strength after air drying and rewetting. Am J Dent. 1994;7(3):144-148. 5
Overdrying Proper Moisture Un-collapsed collagen fibrils Collapsed collagen fibrils SEM Perdigao Moisture Variability Bonding Agent Solvents Acetone Alcohol Water Evaporating the solvent with dry air Air only syringe Warm air dryer Variability Air/water syringe Air/water syringe Sensitivity Bond Strength 6
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):340-345. GLUMA Occludes tubules Anti-bacterial 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 7
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) 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):97-103. 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 8
37% H 3 PO 4 etched Unprepared enamel surface for 15s. Popular SE primer etched Unprepared enamel surface 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±6.7 31.4±7.1 Cut Enamel 29.0±5.5 35.6±3.6 55% improvement Uncut Enamel 18.7±6.7 31.4±7.1 Cut Enamel 29.0±5.5 35.6±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;5:467-484. 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. 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 Substrate All-Bond Universal Self-Etch All-Bond Universal Total-Etch Uncut Enamel 18.7±6.7 31.4±7.1 Cut Enamel 29.0±5.5 35.6±3.6 Effect of Enamel Etching-Marginal Gaps SEM analysis found no marginal gap formation of enamel etched w phosphoric acid prior to application of a self-etching 6 th generation bonding agent (Clearfill SE) following thermocycling SEM analysis reported marginal gap formation of enamel not etched w phosphoric acid prior to application of a self-etching 6th generation bonding agent (Clearfill SE) following thermocycling 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;5:467-484. 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. 9
Effect of Enamel Etching-Marginal Gaps Solution: Etching prepared enamel w phosphoric acid promoted better marginal integrity with self-etching bonding agents. 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. 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. 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. 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. Bond Incompatibility with Self and Dual Cured Resins Solution: Use a dual-cure activator 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;5:267-282. Hydrolytic Degradation Hydrolytic Degradation The cured layer of 1-step self-etching adhesives is hydrophilic and a permeable membrane. Solution: Use 2 layers-a hydrophilic layer covered with a hydrophobic layer Tay F, Suh B, Pahsley D, Carvalho R. Single Layer Adhesives are Permeable membranes. J Dent 2002;30:371-382. 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. 10
Hydrolytic Degradation 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. Self Etch Technique 6 th generation DBA that effectively etches enamel 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. OptiBond XTR Unprepared enamel surface Self Etch Technique OptiBond XTR Etched with 37% Phosphoric Acid OptiBond XTR 6 th 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 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 11
Sixth Generation All-Bond SE Clearfil SE Protect Self Etch Technique Materials 6 th & 7 th Generation Optibond XTR Seventh Generation BeautiBond G-Bond Long Term Dentin Bond Stability MMP-Matrix Metalloproteases MMPs 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 metalloproteinasemediated collagen degradation. Eur J Oral Sci 2011;119:79-85. Long Term Dentin Bond Stability Cysteine 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 In-vivo 12 m w/pbnt (Acetone) w/chx in 12 m Immediate (MPa) 14 mo (MPa) Control 29.3 (9.2) Control 19.0 (5.2) CHX 32.7 (7.6) CHX 32.2 (7.2) Carrilho et al., JDR 2007; 86; 529 Brackett et al.,operative Dentistry; 2009;34(4):381-385 Long Term Dentin Bond Stability Potential MMP Inhibitors 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. Long Term Dentin Bond Stability Disinfect to prevent MMPs Use Etchant containing 1% Benzalkonium Chloride OR TE-Apply SE-Apply 2% 2 Chlorhexidine coats 2% after Chlorhexidine acid etching prior for 30 to sec application of primer 12
Long Term Dentin Bond Stability 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. Dentin Bonding Challenges Most simplified one-step adhesives were shown to be the least durable, while three-step etch-and-rinse and two-step self-etch adhesives continue to show the highest performances, as reported in the overwhelming majority of studies. In other words, a simplification of clinical application procedures is done to the detriment of bonding efficacy. Among the different aging phenomena occurring at the dentin bonded interfaces, some are considered pivotal in degrading the hybrid layer, particularly if simplified adhesives are used. Insufficient resin impregnation of dentin, high permeability of the bonded interface, sub-optimal polymerization, phase separation and activation of endogenous collagenolytic enzymes are some of the recently reported factors that reduce the longevity of the bonded interface. Dentin Bonding Solutions In order to overcome these problems, recent studies indicated that (1) resin impregnation techniques should be improved, particularly for two-step etch-and-rinse adhesives; (2) the use of conventional multi-step adhesives is recommended, since they involve the use of a hydrophobic coating of nonsolvated resin; (3) extended curing time should be considered to reduce permeability and allow a better polymerization of the adhesive film; (4) proteases inhibitors as additional primer should be used to increase the stability ofthe collagens fibrils within the hybrid layer inhibiting the intrinsic collagenolytic activity of human dentin. Breschi L, Mazzoni A, Ruggeri A, Cadenaro M, Di Lenarda R, De Stefano Dorigo E. Dental adhesion review: aging and stability of the bonded interface. Dent Mater. 2008 Jan;24(1):90-101. Breschi L, Mazzoni A, Ruggeri A, Cadenaro M, Di Lenarda R, De Stefano Dorigo E. Dental adhesion review: aging and stability of the bonded interface. Dent Mater. 2008 Jan;24(1):90-101. Dentin Bonding Solutions 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 selfcured composites. 3-step, etch-and-rinse adhesives remain the gold standard in terms of adhesive durability. Selective Etch Technique Apply etch to enamel only for 15 seconds Wash thoroughly Place self-etching primer 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. 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. 13
Selective Etch Technique High Viscosity allows precise placement Contains BAC Total, Self or Selective Etch Universal Bonding Materials Self etch Selective etch Total etch Total, Self or Selective Etch 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. Total, Self or Selective Etch All-Bond Universal Total-etch, self-etch or selective-etch Single bottle for direct and indirect restorations 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 MDP Universal Bonding Materials Bonding agent should not leave the dentinal tubules open Method #3-Reducing Post-Op Sensitivity GI Sandwich Technique- Never open the dentinal tubules 14
Resin-Modified Glass Ionomer Resin-Modified Glass Ionomer Never open dentinal tubules Less post-operative sensitivity Fluoride release Long-term consistent bond to dentin RMGI Base RMGI Liner Reprepare No dentin conditioner needed due to self-etch primer component Dentin conditioner preferred to achieve optional dentin bond TOP TEN REASONS: GI isn t used under every restoration 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 15
Make initial access opening w small bur Use slow speed to remove decay Clinical Class I Restoration Use high speed to refine preparation Smooth margins with Completed a football Preparations diamond. Place glass ionomer base/liner Etch enamel then dentin, wash and dry Place Ivoclar & scrub P-1multiple coats bonding agent, wait, evaporate solvent and cure Place composite and adapt to sides If large use incremental layers Cure thoroughly Posterior Finishing Burs 12 fluted carbide burs Occlusal Anatomy Occlusal Secondary Anatomy Buccal/ lingual gingival-ip 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 SS White Jazz Ivoclar Astropol Blend margins with finishing carbides Adjust occlusion Caulk Enhance/POGO Popular Instruments Football or egg-shaped 7406 H379 15106-5 Flame-shape H-274 5379-5 Needle shape Safe-end SE6 7901 15121-5 Finish and polish Etch, wash/dry and apply surface sealant Total Etch with RMGI Liner/Base Summary Best reduction of post-operative sensitivity Insurance of fluoride release Best bond to enamel Long term stable bond to dentin Use in majority of posterior preparations 16
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! 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 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) 17
Bulk Fill Posterior Composites Low Shrinkage Stress Sonic Energy Assisted Light Polymerization Voco Xtra Fill Beautifil Bulk Flow Aura Bulk Fill Tetric Evo-Ceram Bulk Fill Sonic Fill Sonic Fill 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;60:104-108. 18
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 Interproximal Contact Solution Interproximal Contact Solution Contact Perfect Contact Perfect 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 19
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 Interproximal Contact Anatomical Wedges Wave Wedges Pin Tweezers TrioDent/Palodent Plus Prepare enamel Challenge: Adjacent margins Class II Composite Restorations 20
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 Adjust occlusion Peel back band Cure from both sides at gingiva Place Composite as before Light Cure Finish and polish 21
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 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) 22
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;31:291-307. 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 Protection Indirect/Direct Pulp Capping Ca(OH) 2 Paste Ultra-Blend Plus Ultradent 23
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 Social Media Communication Hilton TJ. Keys to Clinical Success with Pulp Capping: A Review of the Literature. Op Dent 2009;34:615-625. 24
Cell Phone Text Messaging Appt Reminder/Late Cancel Custom Email Messaging Appt Reminder/Confirmation Custom Email Messaging Appt Reminder/Confirmation Custom Email Newsletters Holiday Promotions Custom Email Newsletters Promotions Custom Email Newsletters Regular Newsletters 25
Custom Email Messaging Birthday Wishes Custom Email Patient Surveys Automated Post-Appointment Custom Email Patient Surveys Automated Post-Appointment Custom Email Patient Surveys Automated Post-Appointment Online Patient Reviews Monitor Online Reviews Online Patient Portal Automated Post-Appointment Pay Bills Online 26
Online Dashboard Summary Management Research-Maps Research Locale Demographics Maps Mobile Devices New Mobile Apps Distribute Testimonials Online Healthgrades Increase internet marketing Need Therapeutic Restorations Xerostomia patients High carbohydrate users Non-fluoridated water users Drug abusers 27
Composite Challenges Glass Ionomer Glass Ionomer Base/Restorative 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 Fuji IX Self Cure Glass Ionomer SDI Self Cure Glass Ionomer Glass Ionomer Characteristics 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 Ionomer Uses Multiple cervical carious lesions Pediatric Patients Sealants Class V restorations Sandwich Technique Crown buildups Long term interim restorations Cements Glass Ionomer Restorations Glass Ionomer Restorations Pediatric Patients Pediatric Patients 28
Glass Ionomer Restorations Glass Ionomer Restorations Class V root caries Class V root caries Glass Ionomer Restorations Glass Ionomer Restorations Repair around crown margins Repair around crown margins Glass Ionomer Restorations Glass Ionomer Restorations Long term interim restoration Long term interim restoration 29
Glass Ionomer Restorations Glass Ionomer Restorations Long term interim restoration Long term interim restoration 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;36:618-625. 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 30
Condition dentin w PCA Acid etch enamel Preparation w cervical margin in dentin Open Sandwich Technique Place glass ionomer base Place RMGI bonding agent and cure *recommended by Dr Graeme Milicich Open Sandwich Technique Glass Ionomer Build up tooth with composite RMGI Finished occlusal view Shape with diamonds and fine carbides Mesial View Composite Open Sandwich Technique Open Sandwich Technique 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):265-71 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 31
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 32
Restoration w large crack Restoration w large crack Large restoration with internal fractures Dentist-Multiple Radiographic Caries Posterior Glass Ionomer Equia Forte Before and After 33
Posterior Glass Ionomer 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 Equia Forte High fluoride release maintained Stronger surface sealant Better designed for Class II posterior restorations Equia Forte RIVA Self Cure HV Posterior Glass Ionomer Posterior Glass Ionomer 47 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 interproimal radiolucencies not present 12 months previous Required 16 restorations Need caries resistant restorations Sudden Onset Caries Preparations Posterior Glass Ionomer Posterior Glass Ionomer Preparations Posterior GI Restorations 34
Resin-Modified Glass Ionomers Acid/base and polymerization reaction Ionic and micromechanical bonding Dual-curing Fluoride release Bioactive Resin-Modified Glass Ionomer Characteristics 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 Uses Liner or Base Class V Restorations Restoration Under Crown Temporary prior to crown Sandwich technique Cements Resin-Modified Glass Ionomers-Advantages Better retention 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. 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 Resin-Modified Glass Ionomer Base/Restorative Capsule Resin-Modified Glass Ionomer Base/Restorative Paste-Paste Fuji II LC RIVA LC Ketac Nano Fuji Filling LC 35
Quick Temporary prior to Crown Sandwich Technique Riva Bond LC Glass Ionomer Resin-Modified Glass Ionomer Resin-modified Bonding Agent Triturated Reduces polymerization shrinkage stress Novel concept 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 Preferred Uses Resin-Modified Glass Ionomer Preferred Uses Core-Cemented posterior crowns Entire Class I or II (Long Term Interim) Class V-high caries All deciduous posteriors Sandwich technique-co Cure Core-all crowns Base Class I or II-re-prepared sandwich Class V-more esthetic Quickly placed short-term interim restorations 36
Glass Ionomers The missing link of esthetic restorative materials Thank You! dward@columbus.rr.com www.drwardhandouts.com 37