contemporary esthetics for everyday practice - crd 2016...

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Paresh Shah, DMD, MS (Physiology), Cert. Esthetic DentistryParesh Shah, DMD, MS, Cert. Esthetic Dentistry

March 17, 2017Voorhees, NJ

Pinnacle Dental Study Club

Contemporary Esthetics for Everyday Practice Thank you!

• Dr. Ben Calem• Pinnacle Dental Study Club

Disclosure

• All photography taken on our patients has been left unaltered except for cropping to fit slides

• Photography by other providers is acknowledged on appropriate slides

• I serve as a consultant for a variety of manufacturers -product development & evaluations

Dr. Paresh Shah

204-837-4517 work204-295-2233 direct

[email protected]

drpareshshah.com

Catapult Education is the only dental

CE provider that integrates clinical expertise, management effectiveness, and growth strategies to support thriving practices.

• Many of Dentistry’s Most Trusted Educators• Practical, Actionable CE That Helps Practices Grow• Reviews & Leading Edge Topics• Simple Online Education Format & Live Events

Learning Objectives

•Learn to evaluate various direct and provisional restorative materials so as to select the most appropriate for each situation

•Learn practical restorative techniques to simplify the restoration of your cases and implement them immediately

•Learn practical layering techniques to make your anterior restorations more natural looking

•Learn techniques to improve the outcome and esthetics of your indirect restorations on natural teeth or implants

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Let’s start from the beginning with the basics of Bonding &

Adhesion..............

Paresh Shah, DMD, MS, Cert. Esthetic Dentistry

Adhesion



Adhesion

Adhesion to tooth structure involves the removal of the mineral portion of hydroxyapatite (calcium phosphate) and the subsequent replacement of this lost mineral with acrylic monomers.


Enamel Histology

Consists of 90% hydroxyapatite (inorganic mineral) prisms.10% proteins & water.

Enamel may be desiccated to create a hydrophobic surface to bond since there is no direct circulation to replenish this water

The outer layer typically lacks prisms which creates a challenge bonding with self-etch systems.

Exposing the enamel prisms with a bur makes the the enamel better suited to bonding.


Dentin Histology

Comprised of 60% hydroxyapatite (inorganic) mineral, 30% collagen (organic) and 10% water.

Collagen is not found in enamel and typically takes the shape of a helical strand-like network in dentin.

Most of the water comes from the dentinal tubules due to pulpal pressures which are influenced by the proximity to the pulp. A small amount of water is bound in the hydroxyapatite crystals.

Dentin is hydrophilic in nature and the extent is influenced by the proximity to the pulp and subsequent pulpal pressures.


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Role of an Adhesive System?1.Sealthetooth 2.Retainrestorative

• Hydrophilic• GoodenamelEtch• Primerpenetrationintodentintubules

• Lowhydrolyticdegradation• Efficientcuring

• Hydrophobic• Resincompatibility• Strength• Efficientcuring

Combating Sensitivity•By achieving a great bond••


All Adhesives and Composites are Hydrophobic in nature

They do not like moisture and will not stick to hydrophilic structures without the aid of a Primer


Primers and SolventsPrimers are bipolar monomers with a

hydrophobic component on one end and a hydrophilic on the other

The hydrophilic component allows coupling with moist surfaces such as dentin while the hydrophobic end facilitates bonding to the adhesive/composite over top


Primers and solventsPrimers are typically suspended in a

volatile solvent such as acetone, alcohol or water.

The solvents allow the penetration of primers into the dentin and tubules, but must be evaporated off


Smear LayerComposed of hydroxyapatite, collagen

and tooth debrisLoosely attached lining over the floor of

pulp after dentin has been freshly cut

Believed to serve as a barrier to bacterial invasion into dentinal tubules


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Smear LayerAdhesives tend to be classified by the way they interact

with the smear layer:

early generations: attempted to modify or attach to smear layer

4th & 5th generations (total etch): advised removing the smear layer

current generations (self-etch): incorporate the smear layer into the bond


Adhesion - Enamel (total etch)

Enamel:

Mechanism of adhesion to enamel is different to that of dentin

Micromechanical retention to the ends of etched enamel rod prisms

Removes Calcium phosphate from the hydroxyapatiteExposes enamel prism rod to create a rough surface for micromechanical

retention

(BUONOCORE MG. J Dent Res. 1955 Dec;34(6):849-53.)Paresh Shah, DMD, MS, Cert. Esthetic Dentistry

Enamel Bondingn Isolate teeth (moisture control)n Preparationn Etch cut/prepared enamel 15- 20 seconds - phosphoric acid (34-37%) & uncut

enamel 30 - 60 secondsn Rinse etch for 5 secondsn light air dryn Apply bonding agent to entire prep by scrubbing with a stiff, dry microbrush for

2-3 applicationsn lightly air dry to remove solventn light cure at least 10 seconds n place composite

de Meneszes, FC et.al. Quintessence Int. 2013;44(1):9-15


Adhesion - DentinDentin:Adhesion to dentin involves encapsulation of exposed collagen fibers.Inorganic phase removed from dentin surface by acid etching.Dentin bonding agent penetrates the vacancies and fills the tubules and

peritubular dentin.This is called the hybridization zone & is dependent on control of moistureCombination of collagen and bonding agent form a barrier to microbial invasion

and eliminates post-op sensitivity


Removes smear layer allowing for micromechanical adhesion similar to enamel

Demineralizes hydroxyapatite in the intertubular and peritubular dentinOpens dentinal tubules & exposes collagen matrix in the dentin to facilitate

adhesionOpening dentinal tubules makes the technique sensitive to operator

technique if they are not suitably “sealed”Moisture control is key to collagen fiber exposure - avoid over-wetting or

over-drying

(Brännström M, Noredenvall KJ.J Dent Res. 1977 Aug;56(8):917-23.)

Adhesion - Dentin (total etch) Dentin Bondingn Isolate teeth (moisture control)n Preparationn Etch dentin for 10 seconds - phosphoric acid (34-37%)n Etch enamel for 15-20 secondsn Rinse etch and lightly air dry over dentin (moist dentin bonding) - should see a

shiny consistencyn Apply bonding agent to entire prep by scrubbing with a stiff, dry microbrush for

2-3 applicationsn lightly air dryn light cure a minimum of 10 secondsn place composite in increments

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Dentin Bonding

Smear Layer Removed/EtchedSmear Layer Present/Unetched

Unetched vs. Etched Dentin

Challenges with Dentin Bonding - total etch Moistvs.DryDentin– overdryingcanresultin1.Nowatertosupportthecollagenfibers2.Poorhybridlayer3.Sensitivity

Moist Dentin Dry Dentin

Collagenfiberscollapsedandspacebetweencollagenfibersclosed

Openspacebetweencollagenfibersmaintainedbywater

Hybridlayer NoHybridlayer

Combating Sensitivity - By Achieving a Great Bond

§Isolate area to prevent contamination§Do not over-etch§Do not pre-dispense adhesive§Evaporation degrades adhesion§Lowers bond strength

§Blot excess water§Leave surface moist§Saturate tooth w/ adhesive & scrub§Lightly air dry adhesive layer§Thoroughly light cure adhesive§Check your curing light regularly

Combating Sensitivity••By using a universal adhesive•

Selective Etch & Universal Adhesive Bonding Agents - Universal Adhesive

ex: Peak Universal bondn Key Benefits:

- Total-etch technique- Self-etch technique- Selective-etch technique

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3 methods of use

Total-Etch

Self-Etch

Selective-Etch

Dentin Bonding - Selective-Etch

n Isolate teeth (moisture control)n Preparation of tooth and placement of dentin liner (if desired)n Selective etch of enamel only for 15 seconds (agitate)nRinse etch for 5 seconds & lightly dryn Dispense universal bonding agent according to manufacturers

instructions (dish, stiff micro-brush)n Apply universal bonding agent by scrubbing onto entire prep for at

least 10 seconds (apply 2-3 coats without drying in between)n light air dry and acheive a shiny finishn Light cure 10 seconds (manufacturers instructions)n place composite in increments

Bonding Monomers - what you sould knowGPDM – 20 years of use

• Twomethacrylatefunctionalgroupsmeans:

– Moreeffectivecuring– Improvedmechanicalrigidity/more

bondingstrength– Morebonddurability

• Morehydrophilic– Worksbetterwithtoothstructure

MDP - 20 years of use

• Onemethacrylatefunctionalgroupmeans:

– Lesseffectivecuring– Lessmechanicalrigidity,– lowermechanicalstrength– Lessbonddurability

• Lesshydrophilic– Doesnotworkaswellwithtooth

structure

KeepinginmindGPDMandMDPbothworkwithsolvents&othermonomersforanoverallmoreeffectivebondingsystem.

Thinkofitlikethis– whichofthesetwohooksdoyouthinkismoreeffective?

Matrix Metalloproteases (MMP’s)

• MMPs are not bacteria but are inactive proforms of proteolytic enzymes found within dentin collagen fibrils capable of degrading collagen within newly created adhesive hybrid layers as well as extracellular matrix proteins

• MMPs play a major role in autodegradation of collagen fibrils within the hybrid layer at adhesive tooth restoration interfaces

• MMPs are well studied. These proteolytic enzymes have been linked to Periodontal Disease/tissue destruction for years. However, degradation is an important feature of development, tissue repair, and remodeling.

Matrix Metalloproteases (MMP’s)

• With new research, they have just recently been linked to collagen breakdown within dentin, leading to adhesive failure.

• Benzylkonium Chloride (BAC) and Chlorhexidine (CHX) are two of the only disinfectants which in addition, inhibit MMP activity on dentin surfaces. Other studied compounds include: galardin, flavonols, EGCG, tetracyclines, QAMS

MMP inhibitors

CHX = ChlorhexidineBAC = Benzalkonium Chloride

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Adhesion Basics - Summaryn No ideal adhesive system exists when it comes to total-etch or self-etch

n Vigorous scrubbing of adhesive during application increased bond strength for both types of adhesives

n Prolonged light curing beyond recommended manufacturers instructions increased bond strengths

n warm air drying of adhesive helped remove solvents better than air

Reis, Carrilho, Breschi, LoguercioOperative Dent. 2013;38(4):1-15

Adhesion Basics - Summaryn Difficult to get an absolute best adhesive result with just one type of adhesive

n Total-etch and self-etch both have a place n Bond strengths depend on type of substrate (enamel or dentin)

n When using a self-etch system, it is best to etch enamel (keep off dentin) to achieve high bond strengths

n Vigorous application with a stiff brushn Always overcure

John Kois - Symposium update July 2013

Combating Sensitivity•••By using a liner/base

Combating Sensitivity - Glass Ionomer Liner/Base

§ Deep restorations w/ near pulp exposures§ Bonds to dentin and enamel w/o surface pre-treatment§ No need to etch§ Reduces sensitivity§ Fluoride Release§ Once cured can be etched and bonded with any type of adhesive

Glass & Resin Ionomers

• ACT as a dentin substitute• REPLACE composites as a dentin

substitute• Still REQUIRE composites as an

enamel substitute in posterior occlusal load areas and in cosmetic anterior issues

• Are Bioactive, no other restorative material is!• They can re-mineralize tooth structure so

remove the soft stuff but leave the dentin that can remineralize

• Inhibits Plaque by fluoride release, great for lesions in furcas, deep dentin and cementum

• Glass ionomers have greater ion release than resin ionomers

Why a Dentin Replacment?

• - They have thermal expansion properties similar to DENTIN• - They require a chemical bond with only mild etching… even less than self

etch, no over etching, NO OPENING TUBULES, you want the ions there!• - They have 1/9th the shrinkage of a composite and thus less stress. • - They release fluoride and other ions as they are exposed to water and

reactivate when exposed to fluoride• - They are easy to place!

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Linings• Linings are ResinIonomers with finer

grained contents and are meant to be placed in thin increments. No greater than 1.5mm

• Examples areFuji Lining Cement Paste Pak

Ionoseal Vitrebond Plus Clicker system: studies show can reduce an effect of polymerization shrinkage by more than 50 per cent of bonding aloneIn any class they can line the dentin walls and floors

Deep Caries

Bases - Techniques• Bases: Applied in thicker amounts• Glass Ionomers such as–Fuji 9 Equia–KetacNano by 3M–Hi-Fi by Shofu–Riva Self Cure Fast Set

Resin Ionomersq Fuji 2 LCq Riva Light cure

Either can be placed as bases in open or closed sandwich

Bases - Techniques• Open Sandwich would be a class 2 in which the

cavosurface margin would be in dentin or cementum and the margins of the restoration cervically are exposed to the oral environment and thus restored with a GIC

• Closed Sandwich would be in a class 1 where the pulpal floor and dentin are lined or built up by the GIC or in a Class 2 in which the proximal box is in enamel and the GIC is fully enclosed by the composite

Flowables

G-aenial Flo

Selective Etch

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G-aenial Flo

Universal Adhesive

G-aenial Flo

Polishing

Final Restorations Class V - NCCL

Adhesive & application of composite

Easy placement and manipulation

Final Restorations

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Posterior Restorations

Class II restorations -foundational to everyday practice

Success?10 years post-tx Success?10 Years post-tx

Contacts Embrasures

Final Contour

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Challenges with posterior composites

• Technique sensitive - moisture control- depth of cure- contours & contacts• Time consuming - compared to traditional amalgam

restorations • Harder to do quadrant dentistry

• The #1 reason for composite failure is recurrent decay – and the floor of the proximal box of a Class II is the most vulnerable area

Posterior composites

Traditionally have been more time consuming that alloy restorations

Technique sensitivity has created a negative reputation for direct composite restorations

Isolation is key!!

Challenges with Toffelmire Matrices

TofflemireSystemFailstorestoreproximalanatomyThincontactatthemarginalridgeLargefoodtrapbelowIncreasedlikelihoodoffracture,occlusalinterference,recurrentcariesandperiodontaldisease

Wedging & contact forming instruments

• Traditionally to create tight contact areas we need to use wedges to separate teeth.

• We also need to use contact forming instruments to assure tight contacts

• The combination allows us to create natural contact areas

• With amalgam we can do multiple restorations at one time faster

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Active wedging required to create contact areas

There has to be a better way!

Posterior composites - Just got easier and more predictable

1. Sectional matrices & ring systems2. Universal bonding agents3. Bulk fill materials4. Can do multiple compositee restorations

simultaneously

Ring & Matrix Systems

Sectional Matrix Sectional Matrix

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Solutions using Sectional Matrices

TofflemireSystemFailstorestoreproximalanatomyThincontactatthemarginalridgeLargefoodtrapbelowIncreasedlikelihoodoffracture,occlusalinterference,recurrentcariesandperiodontaldisease

SectionalMatrices✓Operator-friendlyretainingsystem✓Naturallycontouredbands✓Anatomicallycorrectcontacts✓Contactsattheheightofcontour✓Contactssotightyou’llneedahemostattogetthebandout!

NiTi only spring

V-Shaped glass reinforced autoclavable plastic tines(leaves room for the wedge)

Built in lip for increased stability in forceps.

Anatomically shaped tines

6.5mm Matrix with sub-gingival extension

Tab can be bent 90˚forcontra-angleplacement

Side holes for easyremoval

Holes designed to fit with positive grip Pin-Tweezers

The only matrix band with marginal ridge contour

Developer: Dr Simon McDonald BDS MSc DDPH

Clinical case - Narrow V3 Ring

Final Restorations

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Bulk Fill Materials

Requirements of a Bulk Fill Composite

Simultaneous

Adaptationthroughoutcavity

FullyCured

Lowshrinkagestress

StrengthDurability

GoodAesthetics

Posterior restorative optionsTraditional BulkFill

Mostpopular LeastPopular

Single-FillTM Lowviscosity Highviscosity

*Source:SDMdata

What does the literature say?…

Conclusions: Bothrestorativeresinsperformedequallywellclinicallyduring18-monthevaluation.

EvaluationofBulkfilledandNanofilledCompositeinClass-IIRestorations:18-MonthResults

R.Yazici1;S.Antonson2;Z.B.Kutuk1;E.Ergin1

1SchoolofDentistry,DepartmentofConservativeDentistry,HacettepeUniversity,Ankara,Turkey;2RestorativeDentistry,UniversityatBuffalo,SUNY,SchoolofDentalMedicine,Buffalo,NewYork,UnitedStates

Objectives: Tocomparethe18-monthclinicalperformanceofabulk-filledandananofilledresincompositeinClassIIrestorations.

Methods:• Fiftypatients• 104ClassIIrestorations:50%eachwithFiltekSupremeUltra,50%withTetricEvoCeramBulkFill• FiltekUltimatewasusedwithits’respectiveadhesive,AdperSingleBond2• TetricEvoCeramBulkFillwasusedwithits’adhesive,ExciTE-F• Therestorationswereevaluatedatbaselineandafter6,12and18months

Conclusions: ClassIIrestorationsfilledinbulkwithacorrespondinghigh-viscositycompositewereequivalentlyorevenbetteradaptedcomparedtoanincrementallyplacedfilling.

AdaptationofHigh-ViscosityBulk-fillCompositesinClass-IICavities

R.Haak1;T.Naeke1;M.Pfeffer1;F.Krause1;H.Schneider11Dept.ofCariology,EndodontologyandPeriodontology,UniversityofLeipzig,Leipzig,Germany

Objectives: Todeterminetheinternaladaptationofbulk-fillcompositestoenamelanddentinbeforeandafterwaterstorageandthermalloading.

Methods:• StandardizedclassIIpreparations• 128caries-freehumanmolars(16groups,n=8each)andfilledusingthebulk-fill

compositesSonicFill(SF,Kerr),TetricEvoCeramBulkFill(TEC,Ivoclar)andx-trafil(XF,Voco)aswellastheadhesivesOptiBondFL(OFL,Kerr)andXenoV+(X,Dentsply).

• CavitiesofthecontrolgroupwererestoredinincrementsusingtheconventionalhybridcompositePremise(P,Kerr)

• Halfofthesampleswerestoredinwater(180d,37°C)andthermocycled(5-55°C,2500x)

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Conclusions: Allbulk-fillcompositeresinshadlowershrinkagestress,comparedwithconventionalcompositesplacedincrementally.

EffectofCompositeTypeandPlacementTechniqueonShrinkageStress

V.G.Olafsson1;A.Ritter1;E.J.Swift1;L.W.Boushell1;C.Ko2;T.E.Donovan11OperativeDentistry,UNCSchoolofDentistry,ChapelHill,NorthCarolina,UnitedStates;2Orthodontics,UNCSchoolofDentistry,ChapelHill,NorthCarolina,UnitedStates

Objectives: Comparethepolymerizationshrinkagestressexertedontoothstructurebybulk-fillandconventionalcompositeresins.

Methods:• Thirty-fiveextractedmaxillarypremolars• Straingaugeswerebondedtothebuccalandlingualcusps• SpecimensreceivedstandardizedMODcavitypreparations• Straingaugeswereconnectedtoadataacquisitionunit• Positivecontrol(n=7):FiltekSupremeUltrain2mmobliqueincrements• Experimentalgroups:1(n=6):SonicFillinbulk;2(n=8):SurefilSDRinbulk,coveredwitha

2mmocclusallayerofFiltekSupremeUltra;3(n=7):TetricEvoCeramBulkFillinbulk

Conclusions: Theclinically-relevantmethodmetorexceededthemanufacturers’claimedDOCofallcompositestested.

Clinically-relevantMeasurementsofDepthofCureofBulk-fillComposites

A.Tiba1;R.Vinh1;C.Estrich11DivisionofScience,AmericanDentalAssociation,Chicago,Illinois,UnitedStates

Objectives: Todetermineandcomparethedepthofcure(DOC)ofbulk-fillcompositeresinsmeasuredbyamoreclinically-relevantprocedureversusthestandardISO4049measurementandbottom/tophardnessratio(H).Humanteethwereusedinsteadofthetraditionalsteelmold

Methods:PreservedhumanthirdmolarteethCylindricalspecimens(n=5)Soft,unpolymerizedcompositematerialwasscrapedawayLengthoftheapparentlycuredcompositewasdividedbytwo(ISO4049methodology)

SureFil SDR flow�First posterior bulk fill resin base�Low stress allows for bulk placement (4mm)�Self leveling handling and excellent adaptation to

cavity walls�Reduces procedural time�Allows the use of any methacrylate based composite

on top as a capping agent�68% filled by weight- 44% by volume�Low volumetric shrinkage (3.6%) and low shrinkage

stress (1.4Mpa)

Tetric EvoCeram - Bulk Fill Composite

Tetric EvoCeram®

…has the same long working time, superior esthetics and excellent balance of physical properties as

3 new patented technologies were added which enables it to be the only material on the market that can be placed in bulk

Patented Polymerization Booster for deeper depth of cure.Patented Light-Sensitivity Filter for extended working time.Patented Shrinkage Stress Relievers ensure superior marginal integrity.

No additional viscosities.No additional layers.No additional equipment.

Bulk, Sculpt & Curewith Tetric EvoCeram® Bulk Fill

Tetric EvoCeram Bulk FillOne Material:

The material’s smooth consistency provides excellent adaptation to cavity walls without the need for a flowable liner.

One Filling: Cavities can be “Bulk” filled and contoured immediately without the need for a final layer or additional equipment. Bulk & Sculpt!

One Increment: The 4-mm bulk increment provides for the faster, easier and more efficient placement of direct posterior restorations.

Unique FeaturesPatented Polymerization “Booster”ensures a complete 4mm depth of cure in

just 10 seconds.

Patented Light Sensitivity Filterprovides over 3 ½ minutes of working time for adequate placement and contouring.

Patented Stress Relieverminimizes shrinkage stress during polymerization preserving superior marginal integrity.

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Universal Shades

A Shade (between A2-A3)

B Shade (between B1-B2)

W Shade (White for bleach shaded or pediatric teeth)

Clinical Case - Tetric evoceram bulkfill

Dr Eduardo Mahn, Chile

Apply adhesive

Final Restorations

Bulk Filling with Tetric EvoCeram Bulk Fill ‒ one layer, one cure cycle

Final situation immediately after treatment

Sonicfill 2Similar to SonicFill

– Adaptation– Depth of Cure– Shrinkage Stress

Improved in these areas:• Polishability• Overall esthetics• Durability• Working Time

Technique: Keep it simpleVoids – Technique Caused

Don’t move the Handpiece back & forth

Importance of managing shrinkage stress

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Consequences of Improper Light CuringInsufficient polymerization adversely affects both physical and chemical properties of the restoration

–Inflammatory response–Lower bond strengths–More water sorption–Weaker properties–Microleakage–Sensitivity–Recurrent decay

*J Esthet Restor Dent 2010;22:86-103.

Light Performance over Distance

2mm

6mm

Light energy delivered lessens as distance of the material from the light tip increases

undercured

CuringLightTip

Effect of Light Angle on Curing

Clinical cases….

Ring System

2 rings in tandem

Universal adhesive

Bulk fill flowable

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Bulk fill and cure-through Contour & finish

Finishing

Multi-fluted carbide bur Diamond finishing strip

Polishing

Diamond or silicone carbide polishing brush

Final restoration Caries

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Sectional ring Adhesive & Sonicfill 2

Shaping and finished restoration Sonicfill 2

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Final Composite warms - Calset

Benefits of heating composites

• Increased flow and adaptability• Decreasing cure time• Increased depth of cure• Increased conversion rate of polymerization

Anterior Composites

Brushes and Brush & Sculpt Black Triangle Syndrome

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Slender Brush Applicator

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Final Restorations Bioclear matrices - Dr. David Clark

Green System (Diastema Closure) clear matrix DC-202

Pink (Anterior) System A-103 Matrix

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Handy InstrumentsCeramist’s brush #3 OptraSculpt Composite Instruments

Why Learn to Layer?

Improvements in resin technology

More shades and opacities

Eliminates lab fees

One visit completion

Preserve natural tooth structure

Value for patients (more affordable)

Considerations When Layering

Handling consistency

Long-term wear

Polymerization shrinkage

Shade selection choices

Curing time

Polish and polish retention

Special needs such as fluoride release

Fluorescence

Opalescence

Mechanical properties

How Versatile is your Composite System?

Translucent

Enamel

Body

Dentin

What are the opacities?

3M ESPE

Multiple Shades

Two ShadesOne Shade

Source: Dr. Newton Fahl

Single Shade

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Two Shades Cosmedent - Renamel

Six Shades!!!

1. WE (White Enamel) to achieve halo effect

3M ESPE

2. Placement of A2D (A2 Dentin) 3. Placement of GT (Grey Translucent)

Six Shades!!!

3M ESPE

4. Placement of A2B (A2 Body) 5. Placement of A2E (A2 Enamel)6. Placement of YT (Yellow

Translucent)

Final Result

Fractured centrals Fractured Centrals

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Silicone Putty Index

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Final Restorations

Single Anterior Dead Soft Matrix

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Final Layers Final Restoration

18 months

Tints & Opaquers Tints & Opaquers

Consistent “stump” shade

Preparation

Consistent “stump” shade

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Final Restorations Fractured Incisor

Shape, contour, occlusion? “lingual shell”nInitial layer is an enamel or

translucent shade (lingual outer layer)

nThe subsequent layer will be an “opaque” shade representing the underlying dentin

n The outer enamel layer will be that of a suitable translucent shade

Final Restoration

Is there a simpler way for those everyday cases?

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Diastema Calipers - spring bow divider

Etch & adhesive Placement and polish

Matrix (mpm)

High viscosity etch - Bisco Dental

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placement

Finishing

Final

Everyday Crown & Bridge

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Types of Indirect Restorations

n Crownsn Bridgesn Conventional and Maryland (adhesive)

n Inlaysn Onlaysn Veneersn Endodontic Posts

Considerations for Material Selection

nEsthetics desirednLocation of the restorationn Location of the marginsn Fit capabilities of the restorationn Ability to properly isolate the arean Costn Strength

Are PFM’s Dying?

Glidewell labs

Glidewell labs - trends

• Full Cast Metal•Gold Alloy• PFM – Porcelain fused to metal

•Many brands, high cost, being replaced by all-ceramics; FPD

• PFT – porcelain fused to titanium•New; mixed success; implant supported restorations

• Polymer

• Leucite reinforced glass ceramic•IPS Empress Esthetic/CAD; Authentic; OPC

•160 MPa• Lithium disilicate/silicate

•IPS e.max Press/CAD; Obsidian•High esthetics and strong•360-400 MPa

• Zirconia (high strength non-etchable)•Monolithic: BruxZir; LAVA Plus; KDZ Bruxer; OccluZir; ZirLux FC•Fastest growing; improved esthetics~1000 MPa

•Zirconia supported: IPS e.max ZirPress; ZirCAD, LAVA DVS,•High esthetics; may be subject to chipping, fractures; slow cooling

•High Translucent Zirconia - improved esthetics•700-800 MPa

ALL-CERAMICMETAL BASED

Crown classification

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What type of ceramic do you use?

• IPS e.max - monolithic• IPS e.max - layered• Monolithic zirconia• Layered zirconia• PFM• Feldspathic• Polymer-ceramic• Full Gold• Resin-based

• Anterior FPD’s, single units - full mouth, implants• Anterior restorations, veneers, premolars, implants?• Posterior FPD’s, single units, full mouth? Implants?• Anterior & posterior FPD’s, single units - full mouth• FPD’s, implants, full mouth• Veneers• Single units - full mouth?• 2nd Molars, non-esthetic/visible areas• Single units - posterior

Material SelectionType Strength MPa Aesthetics Interocclusal Axial Bondable

Full metal >1200 n/a .4mm 4.5mm Cohesive

Porcelain/Metal 120 Good 1-2.0mm 4.5mm Cohesive

Procera 120 Good 1.5-2.0mm >3mm Adhesive/Cohesive

Porcelain (feldspathic) 200 Excellent 1.5-2.0mm >3mm Adhesive

eMax 360 Very good 1-2.0mm >3mm Adhesive/Cohesive

Zirconia >1200 Very good 0.5-1.0mm >4mm Adhesive/Cohesive

Enamel wear - various ceramics

Evaluation: This study examined the wear resistance of human enamel and feldspathic porcelain after simulated mastication against 3 zirconia ceramics, heat-pressed ceramic and conventional feldspathic porcelain

Conclusions: The wear behaviour of human enamel and feldspathic porcelain varies according to the type of substrate materials. On the other hand, 3 zirconia ceramics caused less wear in the abrader than the conventional ceramic.

J Dent. 2012 Nov;40(11):979-88. Wear evaluation of the human enamel opposing different Y-TZP dental ceramics and other porcelains.

Kim MJ1, Oh SH, Kim JH, Ju SW, Seo DG, Jun SH, Ahn JS, Ryu JJ.

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Enamel wear - Various ceramics

Evaluation: The purpose of this study was to investigate the 3-body wear of enamel opposing 3 types of ceramic (dense sintered yttrium-stabilized zirconia; Crystal Zirconia; lithium disilicate (IPS e-max CAD; Ivoclar Vivadent) (E), and a conventional low-fusing feldspathic porcelain (VitaVMK-Master; Vita Zahnfabrik) (P), treated to impart a rough, smooth, or glazed surface

Conclusions: The degree of enamel wear associated with monolithic zirconia was similar to conventional feldspathic porcelain. Smoothly polished ceramic surfaces resulted in less wear of antagonistic enamel than glazing.

J Prosthet Dent. 2014 May 16. Three-body wear potential of dental yttrium-stabilized zirconia ceramic after grinding, polishing, and glazing treatments.

Amer R1, Kürklü D2, Kateeb E3, Seghi RR4

Enamel wear - Zirconia

Evaluation: The wear of tooth structure opposing anatomically contoured zirconia crowns requires further investigation.

Conclusions: polished zirconia is wear-friendly to the opposing tooth. Glazed zirconia causes more material and antagonist wear than polished zirconia. The surface roughness of the zirconia aided in predicting the wear of the opposing dentition.

J Prosthet Dent. 2013 Jan;109(1):22-9. The wear of polished and glazed zirconia against enamel.

Janyavula S1, Lawson N, Cakir D, Beck P, Ramp LC, Burgess JO.

Enamel wear - Zirconia

Aging of dental zirconia roughens its surface through low temperature degradation. We hypothesized that age-related roughening of zirconia crowns may cause detrimental wear to the enamel of an opposing tooth. To test our hypothesis, we subjected artificially aged zirconia and reference specimens to simulated mastication in a wear device and measured the wear of an opposing enamel cusp.

All zirconia specimens showed less material and opposing enamel wear than the enamel to enamel control or veneering porcelain specimens.

Oper Dent. 2014 Mar-Apr;39(2):189-94. Enamel wear opposing polished and aged zirconia.

Burgess JO, Janyavula S, Lawson NC, Lucas TJ, Cakir D.

CeraMaster - Shofu DentalPorcelain polishers

Key features (Shofu Dental)- CeraMaster is designed to finish, polish, and super-polish

porcelains and enamel. A carefully balanced blend of diamond particles produces the smoothest finish and most glaze-like surface.

• Diamond impregnated silicone polishers• Saves time by providing a simple, two-step system• Use CeraMaster Coarse to polish to a satin finish and CeraMaster to

super-polish• Use CeraMaster for: porcelains and enamel

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Prep design - ceramic thickness?

n “Lithium disilicate significantly improved fracture resistance compared to leucite-reinforced ceramic”

n A 1 mm thick restoration did not show significant reduction of fracture resistance than a 2 mm thick restoration

n“The thickness of ceramic had no significant effect on fracture resistance when the ceramics were bonded to the underlying tooth structure”

(Bakeman, E, Rego, N, Chatyabutre, Y & Kois, J. Operative Dentistry 2013 (in press)

Posterior restorations

n “Fracture resistance and failure risks of posterior partial coverage restorations are significantly influenced by material selection”

n “Lithium disilicate had the highest fracture resistance followed by Leucite ceramic, Feldspathic ceramic and indirect composite”

(Kois, DE, Isvilanonda, V & Chatyabutre, Y. J. Esthet Restor Dent. 2013:25(2): 110-22

Preparation considerations for all-ceramic restorations

n Butt-jointed margins preferred (1mm, 90-110°)

n Avoid tapered, beveled or feathered marginsn Round internal line anglesn Anterior crown preparation minimal reduction = 1.5mm, incisal reduction = 2.0mm n Posterior crown preparation minimal reduction = 1.5mm, cuspal reductions for onlays = 2.0mm (J.F. Shapiro, All-Ceramic Restorations in Everyday Practice, Dentistry Today, April 15, 1998)

Prep Design

Diamonds - Shah Carbide burs - Shah

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Occlusal and Lingual reduction- various ways to “slice” it

Tooth preparation starts with depth reduction

n Breaking contactn Depth cuts- usually done with shoulder or chamfer diamond. correspond desire of depth with the diameter of the abrasive

n Selection of the bur

Margin

Margin

First cord placed

000 cord - passively placed- soaked in hemostatic, and blot dried

Second cord placed - tissue displacement

- optional hemostatic agent over the initial cord- #1 or #2 cord placed dry over the initial cord

Hemostatic Agents• Material is syringed into place and agitated with flocculent

tip• Cord is placed at site after rinsing• Cord can be soaked in liquid hemostatic agent

Good

• Stops bleeding• Some shrink epithelial tissue which provides very slight sulcus expansion

Bad

• Ferric Sulfate: stains proteins (dentin/gingiva) –can ruin esthetic restorations. Also contaminates polyether• Aluminum Chloride: High concentrations (25%) can cause significant harm to cells• Need to be used with retraction cord for Crown and Bridge

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Hemostatic agents Displacement with cordAfter 000 cord, Viscostat clear (aluminum Chloride) 360◦

#2 cord

Removal of Second Cord Sometimes second cord is too small

#1

#2

Retraction pastes• Paste injected at site around circumference of

tooth• Left in place for 2 minutes, then rinsed

• Sometimes addt’l mechanical compression is used (Comprecap)

• Can also be used in place of 2nd cord in two cord technique

Good

• Expasyl stops bleeding/fluid• Shrinks tissue slightly• Atraumatic• Faster/easier application• Sufficient sulcular expansion

Bad

• Higher material expense than cord• Learning curve• Less retraction than cord

Traxodent - Hemodent Paste Retraction System

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What is Traxodent?

nAn absorbent paste that provides hemostasis and/or retraction:n Hemostasis:n 15% Aluminum Chloride (AlCl)n Paste is preloaded into disposable syringesn Material is dispensed through a bendable tip

n Retraction:n Mechanical: Temporary displacement of tissue by the paste.n Bonus: Clay absorbs fluids & expands – helps dry the sulcus, enhances tissue displacement, and has an affinity to blood.

When do you use Traxodent?

n Hemostasis:n Before any procedure in which a dry field is required.n Blood and crevicular fluids will interfere with bonding agents, impression materials, cements, etc.

n Hemostasis and Retraction:n Before taking an impression or an optical scan.n Blood and crevicular fluids will interfere with impression materials and scans preventing them from capturing preparation margins.

Hemostasis & Retraction- Traxodent only

Traxodent only rinse after 2 minutesImages courtesy of Shalom Mehler DMD, Teaneck, NJ

Cord and Traxodent

Images courtesy of Dean Elledge, D.D.S., M.S.

Traxodent can replace the second cord

Cord, Traxodent & Cap

Images courtesy of Abdi Sameni. DDS

Place cord

Cord, Traxodent & Cap

Adapting the cap so that it contacts the soft tissue is imperative


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Expasyl - gingival retraction system Expasyl - gingival retraction system

• Retraction by displacing tissue for marginal access.• Safe due to minimal pressure required - No danger of rupturing

epithelial attachment.• Comfortable and quick to place.• Hemostatic properties which control bleeding and crevicular

seepage.• Won't dry out - new foil pouch for the capsules.

Cord, Expasyl & Cap

Cap left for 2 minutes

225


Final results

Before After traxodent Final impression

Single cord & expasyl

Cementation

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• Zinc Phosphate• Flecks Mizzy• Polycarboxylate

• Durelon• Glass Ionomer

• Ketac Cem• Resin-Modified Glass Ionomer

• RelyX Luting; FujiCem 2• BioCeramic

• Ceramir

• Total-Etch• Veneers; thin translucent crowns• Examples: Choice 2; RelyX Veneer; Variolink Veneer

• Self-Etch• Self-etching primer applied separately; cement thick,

opaque ceramics• Examples: Duo-Link Universal; MultiLink Automix; RelyX

Ultimate• Self-Adhesive

RESINADHESIVECONVENTIONAL

Cement Classification• Light-Cure

• Photo-initiators• Increased working time, decreased

finishing time, good color stability• Dual-Cure

• Chemicals and photo-initiators• High bond strength, quickly seal

margins, can be esthetic• Chemical-Cure (self-cure)

• Rxn of 2 materials mixed• Use when light curing difficult, metal

restorations, posts• Example: Panavia, C&B Cement

• Total-Etch• PO4 etch, then adhesive is applied• Technique sensitive; highest bond to tooth;

reduced microleakage• Self-Etch

• Self-etching primer applied separately; high bond strength

• Easy to use; some incompatibilities • Self-Adhesive

• One component, all-in-one

Stamatacos C, Simon JF. Cementation of Indirect Restorations: An Overview of Resin Cements. Compend Contin Edu Dent. 2013; 34(1)_:42-46.

BY ADHESIVE SCHEMEBY POLYMERIZATION

Resin Cement Classification

Why Resin Cement?

• High bond strength to tooth structure and porcelain

• High tensile and compressive strength• Lowest solubility• High wear resistance• Highest flexural strength and modulus to

prevent debonding during function• However,

• Can be technique sensitive• May have difficult clean-up• Possible color change during

Simon JF, Darnell LA. Considerations for proper selection of dental cements. Compend Contin Edu Dent. 2012; 33(1):28-36.

Desirable Properties of Cements

• Stable bond to both the remaining tooth structure and the restoration material

• Strength to resist the forces of mastication and parafunctional forces (flexural/modulus)

• Lack of solubility in oral fluids• Low film thickness (5-25 um)• Biocompatible• Color stability• Ease of use and good viscosity• Low water sorption to prevent expansion• Radio-opaque• Possession of anti-cariogenic properties

What about Zirconia?

Zirconia:Silica-free, acid-resistant, polycrystalline ceramic

Since Zirconia does not contain glass, etching is not possible. Hydrofluoric acid usually works by removing a portion of the glassy matrix in a ceramic, thus “etching” the restoration and creating micro-mechanical retention

GC Initial™ Zr: Layered

Zirconia Coping Substructure

Solid Milled Zirconia Crown: No treatment except GC

Initial™ IQ Lustre Paste

GC Initial™ IQ POZ: Pressed

Zirconia Bridge Substructure

Dealing with Zirconia

n Traditionally are cemented by a cohesive process since it has not glass content

n Prep design is important - resistance and retention formn Internal surface can be treated by the lab to faciliate some degree of bonding - silicatized adhesive layer added

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Conventional cements

Ceramir - Doxa Dental

• injectable bioceramic material for dental applications

• initally for orthopedic use

• first approved in Europe and US in 2008

Ceramir technology• Ceramic powder = Calcium oxide + Aluminium-oxide

Key features- Nano structural integration- Permanent seal of the tooth – restoration interface- Bioactivity - Biocompatibility- Creates Apatite when in contact with phosphates- No shrinkage- Hydrophilic system with Alkaline pH- Thermal properties similar to tooth structure- Adjustable handling and setting properties

Benefits

500nm

Ceramir

- Sealed interface – less risk of secondary caries- Basic pH, chemical stability and no shrinkage gives a stable interface

Ceramir Crown & Bridge• Natural: biocompatible and environmentally friendly

• Permanent sealing: so it protects the tooth over time

• Easy to use: self-adhesive, self-curing, easy cleanup, not sensitive to moisture

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Ceramire Crown & Bridge• Incorporates some glass ionomer components which improve

handling and properties

Basic Properties - Ceramir

• Working time: 2 minutes

• Net setting time: 5 minutes

• Film thickness: 15 microns

• Compressive strength: 360 MPa

• Radiopaque

Bioceramic Luting agent1.Natural

- Similartohydroxyapatite- Stateoftheartinbiocompatibility- Biomimeticproperties

Naturalremineralizationprinciple- PermanentSealing- Reliable- Predictable- Cariesprotectedinterface

3.Easeofuse- Quick- Lesstechniquesensitive

Ceramir - easy to use

Ceramir Ceramir

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Ceramir Ceramir

Ceramir

Resin cements

The Next Generation – What’s new?New design NX3 XTR - resin cement

• Dual-cure tertiary hydroperoxide increases stability to provide

• Stable gel-set times • Excellent shelf-life• No refrigeration required.

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Nexus XTR

• Material stability• Easy clean up• Higher color stability - tertiary amine

& BPO-free self cure initiator system

Before Aging

Nexus2 RelyX ARC Calibra Variolink IINX3

After Aging

“gel phase” for easy clean up5 second tack cure

Easy clean up

Clinical application

Clinical case:Dr. Ronny Watzke, DentistFranz Perkon, Dental Technician

Pre-operative situation [previously cemented crowns

on 21 and 23]

Inspection of the selected shade with the Try-in paste


Application of Primer

1. Sufficient quantity of Primer

2. Cover the complete contact surface

3. Scrub in the Primer for 30 seconds, beginning with enamel surface


Application of Multilink Primer

1. Sufficient quantity of Primer2. Cover the complete contact surface3. Scrub in the Primer

for 30 seconds, beginning with enamel surface

4. Disperse excess of Primer with blown air until the mobile liquid film is no longer visible.[The solvent water has to be completely evaporated.]

Importance of scrubbing

n Diffusion of the Primer through the smear layern Dissolved calcium ions will neutralize the Primern Continuously moving the applicator ensures fresh and active Primer at the surface

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Conditioning

Etching of the IPS e.max crown with 5% hydrofluoric acid for 20 seconds Application of Silane

Cementation

Placement of the crown Light activation of excess cement

Clean up & liquid stip Light cure - polymerization

Polymerization of the cement [20 seconds per aspect]

Finishing and polishing

Final Restoration Pre-treatment

Tooth #20 - large composite with previous endodontic treatment.

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Occlusal view of preparation tooth #20

Application of Ceramic Primer II to restoration surface

Adhesive application to prep

Resin cement is dispensed from an automix syringe into the crown.

The crown is seated on the tooth and excess cement is displaced.

Excess cement is removed with a brush prior to light curing.

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The cement is light cured for 20 seconds on each surface.

Excess cement is removed with a suitable instrument.

Excess cement in the interproximal can be easily removed with a separating saw. This is separating strip does not have any abrasive side, but only serations to loosen any cured cement that might be in excess in the interproximal regions.

Final restoration


Application of Primer

1. Sufficient quantity of Primer2. Cover the complete contact surface3. Scrub in the Primer

for 30 seconds, beginning with enamel surface

4. Disperse excess of Primer with blown air until the mobile liquid film is no longer visible.[The solvent water has to be completely evaporated.]


Importance of scrubbing

n Diffusion of the Primer through the smear layern Dissolved calcium ions will neutralize the Primern Continuously moving the applicator ensures fresh and active Primer at the surface

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Conditioning

Etching of the ceramic crown with 5% hydrofluoric acid for 20 seconds Application of Ceramic Primer II

Cementation

Placement of the crownLight activation of cement[20 seconds per aspect]


Clean up cement


Finishing & polishing as required


Final Restoration


Porcelain veneers

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Aesthetic Waxup - Diagnostic

n Purpose: To give the patient some idea what the final result would look like.

n Allow you to make temporaries that will look somewhat like the final result.

n Allow the patient to evaluate temporaries to see if there is anything that they do not like.

Diagnostic Waxup (Aesthetic)

Diagnostic Waxup Be Prepared!

n Make sure you have matrix and or suck downs from lab for your temporaries.

n Make sure you have enough burs and know what you need.n Have everything ready for entire procedure.

Diagnostics Preparation

n Veneers & Crownsn Shoulder or chamfern Evaluate height of smile before preparationn High smile or low smilen This often determines if you need to go sub-gingivally or equi-gingivally

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Veneers

Dr. Ron Kaminer

Reduction guide

Dr. Ron Kaminer

Final Impression - details

Dr. Ron Kaminer

Simple stick bite

Dr. Ron Kaminer

Shade

Dr. Ron Kaminer

Final restorations

Dr. Ron Kaminer

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CY Initial presentation

Diagnostic waxup & depth cuts Stent/guide

Shade tabs for “stump” Veneer Provisionals

BisGMA Provisional Materials

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Remove and trim

Trim & clean Rinse & Bond

Bond & Flowable “shrinkwrap” cure

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Final Provisionals

Failing restorations Shade tabs

Stump shades Cutback - Emax & LiSi ceramic

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Cutback - Emax & LiSi ceramic Final restorations

Final restorations

Wear - nccl Diagnostic wax up

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stump shades

Provisionals Final restorations

Final restorations

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Thank You for your attentionQuestions?

Dr. Paresh Shah

[email protected]

www.drpareshshah.com

contemporary esthetics for everyday practice - crd 2016...

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