Restoring Deep Cavity Preparations Townies share techniques and discuss restoring posterior teeth with composites Dentaltown.com > Message Boards > Cosmetic Dentistry > Restoring Deep Cavity Preparations Post: 1 of 63 Introduction I have been restoring posterior teeth with composite for more than 30 years and thought I d demonstrate some things that work for me. I have done hundreds of deep restorations and found that composite bonded to dentin works well in deep preparations if done with good isolation and technique. Tooth #1 Deep cavity. Related Message Boards Anterior Cantilever Tips? Anterior Cantilever Premier cure through contoured matrix held in place by the rubber dam and gingival margin. How to Restore #4 Restore 4 Millimeter ruler showing depth of decay to be about 7mm interproximally. I etch, prime and bond separately with All-Bond 2 and place 2mm at the gingival and cure. Then I can wedge the tooth without having the matrix collapse into the box. Depth outside prep to be 6mm. Finished Continued on p. 28 26 DECEMBER 2015 // dentaltown.com
Continued from p. 26 Finished This is the matrix section I used. The gingival part is tapered and the matrix is wider toward the occlusal. If the matrix is too wide it will not slide down to the sulcus and also gets hung up on the clamp. This restoration had decay deeper than the buccal bone crest, so you need a technique to reach down deep interproximally. Occlusal views. X-ray of decay. Nice overlap. Better angle shows depth of Tooth 2. Tooth on opposite arch of same patient done in April 2013. Deep Another view. Tooth 3. Deep restorations everywhere. Tooth 4. Serious decay. Partially prepped. Continued on p. 30 28 DECEMBER 2015 // dentaltown.com
Continued from p. 28 Matrix. Finished. Final X-ray. Conclusion I have many old composite restorations bonded to dentin that are functioning well after many years. Another technique to use to restore deep decay. n agonzalez1 Member Since: 08/18/11 Post: 2 of 63 mxlplx Member Since: 01/19/06 Post: 3 of 63 Dr Boot Knocka Member Since: 03/25/02 Post: 4 of 63 alanrw Member Since: 05/16/11 Post: 5 of 63 DoctorEd Member Since: 09/21/02 Post: 9 of 63 My problem would be bleeding control that deep if I didn t get a wedge in first. What do you do to keep that from bleeding up in the box? n I don t see any separating ring, i.e., bitine, V-ring. Are you achieving these nice-looking contacts with just a wedge and a contoured matrix? n Those all look like endodontic time bombs! But, nice job nonetheless. n I keep seeing more and more of this in patients who have been decay stable for years previous. The bulk of them complain about dry mouth since the MD started prescribing some new anti-depressant or other new wonder drug. n Nice job on these cases, Terry! With all due respect, the last one does not look like a winner. There is either caries remaining or the composite contracted leaving a radiographic open margin. Which do you think? n Turbulent Member Since: 01/07/10 Post: 15 of 63 Posts: 16 & 17 of 63 Love your posts, Terry! Do you cut one matrix for each tooth or could you cut one into, say, six pieces for six teeth? These cure through bands look like regular metal bands but clear? n Ed, I agree and wondered that myself. I do my final drilling with a 4 or 6 round on these types of cases. Usually I have shredded the dam by this time and place a new dam when I restore the tooth. I position my bur shaft against the marginal ridge of the adjacent tooth when I do my final drilling this far down. Continued on p. 32 30 DECEMBER 2015 // dentaltown.com
Continued from p. 30 This helps prevent the bur from jumping or bouncing around and going down the front of the gingival box and removing too much good tooth. I usually take my explorer or small spoon and check to see how hard the bottom of the box is. If not hard I keep going, but many times you have to stop and blow water and dry due to the blood in the prep. I have seen this before on some of the deep ones and sometimes I think it is not so much decay as dentin that is not as hard we would like. I see these on perio patients a lot and sometimes will restore if it is soft. Sometimes it is not as I can feel any softness. One has to be careful not to drill a tooth with burnout on an X-ray. I have been fooled before as I am sure we all have with burnout especially on older patients with bone loss around the tooth. Bottom line is, we will keep an eye on this tooth. We all have placed temporaries and gone back in a month or two later and been amazed how hard some of the affected (was soft at the initial appointment) dentin is. I can get three or four matrices by cutting up one whole matrix band. These bands are contoured and the best matrix bands I have found in 39 years of dental practice. The contour results in a nice emergence profile for anterior bonding or posterior composites. They have memory and the contours you get are really nice. Premier Cure-Thru Contoured Matrix is what this is called. n nminotti Member Since: 04/26/07 Post: 19 of 63 Posts: 25 & 26 of 63 nminotti Member Since: 04/26/07 Post: 28 of 63 Can you please give us an average follow up of those with deep decay? Vitality testing and apical X-ray in two-year interval? After 7-8 years I supposed some have been through RCT? Any idea on the average? And if so, how were the symptoms in their appearance chronology? Acute or low increase of discomfort? I would only say that RX follow up seems to be a gambling game, as no clear interface can be detected. Do you see tertiary dentin? n Left molar had a pulp exposure and TheraCal pulp cap. No problems so far after two years. I don t worry about the teeth needing root canals as many smaller restorations will cause pulp problems many times. In the last 30 years of just composite dentistry I have done many deep restorations. Some went to RCT but many haven t. You can t worry about it. Correct me if I am wrong but cementum is dentin and we have been bonding to dentin for 25 years and I have done hundreds if not thousands of posterior restorations with only dentin margins and they work hands down. All this talk about deep restorations not working because you are dealing with just dentin is bull. The pictures below are a bulimia case I did in 2006 with composite and the bottom picture is nine years later. Right central has been repaired and the rest are nine years and counting. All-Bond 2 and Z250 A2. Don t tell me you can t bond to dentin! n I agree completely with the first statement and it reflects exactly what I wrote: Kind of gambling game! Therefore, I m sick and tired, and yes I do worry, to see how poor pulps are Continued on p. 34 32 DECEMBER 2015 // dentaltown.com
Continued from p. 32 considered while the outmost still focus mainly on appearance, emergence profile and adequate contact point. n docrob98 Member Since: 04/12/07 Post: 30 of 63 Post: 32 of 63 John Kanca Member Since: 06/21/03 Post: 33 of 63 Post: 48 of 63 John Kanca Member Since: 06/21/03 Post: 49 of 63 I have found great results on the roots, deep subgingival boxes, direct and indirect pulp caps using Vitrebond after Consepsis and filling the area in greatest risk of recurrent decay, i.e., at or below the gingiva with Fuji II LC, then placing Filtek Supreme to finish. The Fuji II is great for Class V and crown margin repairs. I rarely see recurrent decay. n Whatever works in your hands is what you should use. I have never liked the GI for permanent restorations due to wear and lack of polishability. I have never seen too many at 10 years that could compare to my composite restorations. I also have never had any problems bonding to dentin for the past 25 years. On Class V restorations I run composite over the enamel and finish to a featheredge and very few fail. I just like composite way more than any other restorative material. It is faster than layering over GIs and works better for me. Not that it won t work for others, because it will. I have done posterior composite for over 30 years and have seen the deep restorations at recall and recurrent decay rates are higher than amalgam but not a problem overall. Most problems are due to inadequate home care. I use Equia (a GI) for really deep, borderline hopeless teeth that I have trouble isolating well. I quickly syringe Equia into the prep use it this way. It will buy you time but it is no way as nice as I can do with composite. n Hate to be picky, Terry but cementum is not dentin. Nice case! n John, thanks for the update on cementum. Googled it and learned a little more about the cementum. Still bond to it and have for years. Wondering if the reason I have had success bonding to cementum is the fact that I have been sandblasting the root surface for more than 20 plus years, and since the cementum is 30 microns to 200 microns I might have been removing the cementum layer and etching dentin? Does this make sense? Also what year did All-Bond 2 become available? Was it 1991? Like Ed, I have been using it forever or since I heard you in Moncton or Bermuda in the early 1990s. Any difference between Simplicity and All-Bond 2? Looking forward to Moncton Nov 28 when you will be presenting. Way overdue for an update. Hope you can comment on the above. We realistically don t bond to cementum, except possibly for the tiny sliver that may remain next to the deep gingival cavosurface of the prep. Anything done mechanically to a root surface removes cementum. n JUN 26 2015 JUN 27 2015 JUN 27 2015 JUN 28 2015 JUN 28 2015 Join the discussion online at: www.dentaltown.com Cavity Preparations 34 DECEMBER 2015 // dentaltown.com