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2016 Greater New York Dental Meeting

PERFECTING Esthetic Posterior Restorations

Daniel H Ward DDS

Daniel H Ward DDS

Graduated 1979 OSU

Private Practice‐Columbus, Ohio

Assistant Clinical Professor The Ohio State University‐13 years

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

Composite

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Decay Removal

Composite Direct Placement Challenges

Thoroughly remove decay only

Lifetime of tooth often determined by first dentist intervention

Minimally Invasive Dentistry

Fissurotomy bur

201.3VF

Conservative Tooth Preparation

169L330

Low Viscosity Flowable Composite

How do you restore?

G-aenial Universal Flo

Homogeneous spherical particles

High Viscosity (Low Flow) Flowable Composite

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

G-aenial U Flo Conventional Nano-hybrid

G-aenial Universal Flo

Homogeneous spherical particles

Good wear resistance

High flexural strength (167 MPa)

Filled 50% by volume

Good polishability

Blends in well


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Beautifil Flow 00

Unique glass ionomer filler particles

Releases fluoride and other ions

Neutralizes pH-Antibacterial

Good polishability

Visibly blends in well

S-PRG (Surface pre-treated Glass Ionomer)

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

Less plaque Full-grown plaque

BEAUTIFIL Ⅱ（Containing S-PRG filler）

Conventional Restorative Material

（Not containing S-PRG filler）

plaque

S PRG Fillers

Reduced Plaque Accumulation

Dispenser Gun

Tray

Compule Tray

Warmer

CALSETThermal Assisted Light Polymerization

WARMER

Improved flowability of composites

Improved marginal adaptation

Improved rate of polymer conversion

Improved surface hardness/durability/polishing.

Decreased curing time and increased depth of cure

Increased sculptability and ease in shaping anatomy

ADVANTAGESADVANTAGESThermal Assisted Light PolymerizationThermal Assisted Light Polymerization

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

Dispenser Gun TrayComax Dispenser

CALSETCALSETThermal Assisted Light PolymerizationThermal Assisted Light Polymerization

Low Viscosity Flowable Composite & Warmed Composite

Completed Tooth Restorations

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Post-Operative Sensitivity

Composite Direct Placement Challenges

Hydrodynamic Theory

Hydrodynamic Theory

Fluid flow within dentinal tubules causes PAINBrannstrom M. The Cause of post restorative sensitivity and its prevention. J Endod 1986;12:475-481.

Hydrodynamic Theory

Opened, unsealed dentinal tubules causes PAIN

DentinDentin

Dentin Bonding

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

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

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

Most Bonding occurs between dentinal tubulesMost Bonding occurs between dentinal tubules

HydrophilicHydrophilic

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

Etched Dentin

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•Total Etch Technique Fill and Occlude open dentinal tubules

Bonding agent should not leave the dentinal tubules open

Method #1-Reducing Post-Op Sensitivity

Placement of Etchant

Total Etch Technique

“Moist” Dentin”

Rinsing of Etchant Placement of Resin Primer

Apply multiple coats

Moist Moist

Placement of Resin Primer

“Overwet” Phenomenon

Tay FR, Gwinnett AJ, Wei Sh. The overwet phenomenon: a scanning electron microscopic study of surface moisture in the acid-conditioned, resin-dentin interface. Am J Dent. 1996;9(3):109-114.

Overdrying

Gwinnett AJ. Dentin bond strength after air drying and rewetting. Am J Dent. 1994;7(3):144-148.

Collapsed collagen fibrils

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Overdrying

SEM Perdigao

Un-collapsed collagen fibrils Collapsed collagen fibrils

Proper Moisture

Moisture Variability

Acetone

Alcohol

Water

Bonding Agent Solvents

Air only syringe Warm air dryer

Air/water syringe Air/water syringe

Evaporating the solvent with dry air

Bond StrengthSensitivity

Variability

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

17.6(+/-5.9)

18.4(+/-4.8)

14.2(+/-7.0)

Deep

Dentin

21.0(+/-7.4)

18.9(+/-4.1)

22.1(+/-2.8)

Superficial

Dentin

Clearfil

Liner

Bond

Optibond

Solo

Single Bond

Adhesive

System

Mean shear bond strength in MPa

Effect of Dentin Depth on Bond Strengths

•Occludes tubules

•Anti-bacterial

GLUMA

•Occlusions


Summary

Most technique sensitiveRequires proper attention to detailUse in ideal sized preparations


Materials-4th

Generation

Acetone solvent Alcohol solvent


Materials-5th

Generation

Acetone solvent Alcohol solvent

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•Self Etch Technique Never leave the dentinal tubules open



Acid-groupsHydrophilic end

etches tooth structure (self

limiting)

Spacer-chainlink between

functional groups

Methacrylate-groupHydrophobic end

connects to polymer-network

COOH

COOH

CH 2

CH 2

O

OO

O

Self-Etching Primer

“Self Etching” PrimerAcidifying Primer accompanies etch

Acid reaction is self-limiting Lohbauer U, Nikolaenko SA, Petschelt A, Frankenberger R.. Resin Tags do not contribute to dentin adhesion in self-etching adhesives. J Adhes Dent. 2008;10(2):97-103 .

Resin Tags do not Contribute to Dentin Adhesion in SE Adhesion

Self-Etch Technique

Challenges

Decreased bond strength to un-etched enamel

Marginal gap formation with un-etched enamel

Bond incompatibility to self-cure and dual-cure resins

More susceptible to hydrolytic degradation resulting in significantly diminished bond strengths over time

Self etching Primer

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37% H3PO4 etched Unprepared enamel surface for 15s. Popular SE primer etched Unprepared enamel surface

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

Substrate All-Bond UniversalSelf-Etch

All-Bond UniversalTotal-Etch

Uncut Enamel 18.7±6.7 31.4±7.1

Cut Enamel 29.0±5.5 35.6±3.6

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

55% improvement

Effect of Enamel Etching-Bond Strength

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



Uncut Enamel 18.7±6.7 31.4±7.1

Cut Enamel 29.0±5.5 35.6±3.6


67% improvement




Uncut Enamel 18.7±6.7 31.4±7.1

Cut Enamel 29.0±5.5 35.6±3.6


22% improvement


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

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

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

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

Effect of Enamel Etching-Marginal Gaps

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

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

Effect of Enamel Etching-Marginal Gaps

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

Bond Incompatibility with Self and Dual Cured Resins

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

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

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


pH=3.2

Solution: Use a dual-cure activator


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

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

Hydrolytic Degradation

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

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

Hydrolytic Degradation

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

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

Hydrolytic DegradationSelf Etch Technique

OptiBond XTR

6th generation DBA that effectively etches enamel

Unprepared enamel surface

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

Popular 6th Generation DBA Popular 7th Generation DBA

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

Self Etch Technique

OptiBond XTR

Self Etch Technique

OptiBond XTR

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

enhanced etching capabilitiesHydrophobic adhesive to maximize

material compatibility, increase strength and promote bond durability

Self Etch Technique

OptiBond XTR

Primer contain acetone, alcohol and water solvents

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

zirconia, porcelain Direct and indirect restorative procedures

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Self Etch Technique

Materials 6th & 7th

Generation

Sixth Generation Seventh Generation

All-Bond SE Clearfil SE Protect

BeautiBond G-BondOptibondXTR

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

involved in dentin formation and trapped during odontogenesis

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

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

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

Long Term Dentin Bond StabilityCysteine Proteases (Cathepsins)

Lysosomal enzymes that become activated in lysosomes by a low pH

Secreted by osteoclasts in bone resorption

Regulated by chondroitin

Collagenase activity breaks down collagen and hydrolyzes collagen into small peptides

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

MMP-Matrix Metalloproteases

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

In-vivo 12 m w/PBNT (Acetone)

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

w/CHX in 12 m

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

Potential MMP Inhibitors

Long Term Dentin Bond Stability

Chlorhexidine (CHX)

Benzalkonium Chloride

MDPB ((12-methacryloxydodecalpyridinium bromide)

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

Epigallocatechin-3-gallate (green tea polyphenol)

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

Disinfect to prevent MMPs

Use Etchant containing 1% Benzalkonium Chloride

TE-Apply 2% Chlorhexidine after acid etching for 30 sec

SE-Apply 2 coats 2% Chlorhexidine prior to application of primer

OR


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Disinfect to prevent MMPs

MDPB (12-methacryloxydodecalpyridinium bromide)


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

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

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.

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 reportedin the overwhelming majority of studies. In other words, a simplification of clinical application procedures is done to thedetriment 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 factorsthat reduce the longevity of the bonded interface.

Dentin Bonding Challenges

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.

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 of the collagens fibrils within the hybrid layer inhibiting the intrinsic collagenolytic activity of human dentin.

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 self-cured composites.

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

Dentin Bonding Solutions

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

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

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

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Selective Etch TechniqueHigh Viscosity allows precise placementContains BAC

Total, Self or Selective Etch Universal Bonding

Materials

Self‐etch Selective‐etch Total‐etch

Total-etch, self-etch or selective-etch technique

Can be used for direct and indirect restorations

Bond to all indirect substrates-metal, ceramics, zirconia, porcelain and lithium disilicate.

Compatible with light-cured, self-cured and dual-cured composite and luting cements.

Universal Bonding Materials

Total, Self or Selective Etch All-Bond UniversalTotal-etch, self-etch or selective-etch

Single bottle for direct and indirectrestorations

High bond strengths to metal, ceramics, zirconia, porcelain & lithium disilicate.

Compatible with light-cured, self-cured and dual-cured composite and luting cements since pH is 3.2

Becomes hydrophobic upon setting

Total, Self or Selective Etch

MDP Universal Bonding Materials

Total, Self or Selective Etch

•GI Sandwich Technique-Never open the dentinal tubules



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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 Liner

No dentin conditionerneeded due to self-etch

primer component

RMGI BaseReprepare

Dentin conditionerpreferred to achieve optional dentin bond

10. It’s not necessary

9. It takes more time

8. It costs more money

7. I don’t understand which product to use

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

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

5. I don’t know how to use

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

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

2. Fluoride release is transient

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

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

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

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

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

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

Clinical Class I Restoration

••Completed PreparationsCompleted Preparations

Ivoclar P-1

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

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

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

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

•If large use incremental layers

•Cure thoroughly

Posterior Finishing Burs

Occlusal Anatomy OcclusalSecondary Anatomy

Buccal/ lingual gingival-IP

12 fluted carbide burs

ProcedureProcedure Trim and shape composite

Adjust occlusion

Blend margin between tooth and composite

Define secondary anatomy

Restore occlusal fissures

Restore buccal/ lingual contour

Reduce and smooth composite surface

Interproximal shaping at gingiva and above contact

Popular InstrumentsPopular Instruments Football or egg-shaped

7406

H379

15106-5

Flame-shape

H-274

5379-5

Needle shape

Safe-end SE6

7901

15121-5

Ivoclar

Astropol

SS White

Jazz

Caulk Enhance/POGO

••Blend margins with finishing carbidesBlend margins with finishing carbides

••Adjust occlusionAdjust occlusion

••Finish and polishFinish and polish

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

Best reduction of post-operative sensitivity

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

Total Etch with RMGI Liner/Base

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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 CompositesBulk Fill Composites

Allow many posterior restorations to be built up in 1 segment

Descriptions– “Stick the stuff in the hole and cure”– Evolutionary– Monolithic

Physical Advantages– Deeper depth of cure– Less Polymerization Shrinkage– Less Polymerization Shrinkage Stress– Reduced likelihood of air voids between layers

Bulk Fill CompositesBulk Fill Composites

Modes of Action– Improved initiators– Greater translucency allows better light transmission– Delayed gel state formation– Increased elasticity

Materials– Flowable– Conventional

Advantages– Quicker, easier– Less chance of enamel and cusp fractures– Increased likelihood of adequate resin polymerization

Bulk Fill Flowable CompositesBulk Fill Flowable CompositesLow Shrinkage StressStress

•Surefill SDR• Voco Xtra•Beautifil Bulk Flowable•Venus Bulk Fill

Surefill SDRSurefill SDR

•Reduced polymerization shrinkage stress• Bulk fill to 4mm•Increased sensitivity to lightGreat placement with metal tips•Self-leveling•A1, A2, A3 Universal shades

Roggendorf MJ1, Krämer N, Appelt A, Naumann M, Frankenberger R. Marginal quality of flowable 4-mm base vs. conventionally layered resin composite. J Dent. 2011;39:643-647.

Polymerization Shrinkage Polymerization Shrinkage StressStress(MPa)(MPa)

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Bulk Fill Posterior CompositesBulk Fill Posterior CompositesLow Shrinkage StressStress

• Voco Xtra Fill•Beautifil Bulk Flow•Aura Bulk Fill•Tetric Evo-Ceram Bulk Fill•Sonic Fill

Sonic Energy Assisted Light Sonic Energy Assisted Light PolymerizationPolymerization

Sonic FillSonic Fill

Improved flowability of composites

Improved marginal adaptation

5mm depth of cure

Increased sculptability and ease in shaping anatomy

Composite designed specifically for use

ADVANTAGESADVANTAGESSonic Energy Assisted Light Sonic Energy Assisted Light

PolymerizationPolymerization





Interproximal Contacts

Composite Direct Placement Composite Direct Placement ChallengesChallenges

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

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Microband Focu-tip Trimax

Interproximal ContactsInterproximal ContactsOriginal Attempted SolutionsOriginal Attempted Solutions

Not enough pressure to separate teeth

Fly off

Wedge in the way

Interproximal ContactsInterproximal ContactsSectional Matrix ChallengesSectional Matrix Challenges

Interproximal ContactInterproximal Contact

SolutionSolution

Contact Perfect


SolutionSolution

Contact Perfect

TofflemireTofflemire vs. Sectional vs. Sectional MatricesMatrices

Tofflemire System

Thin contact at the marginal ridge

Non‐anatomical Foodtrapbelowcontact

Increasedlikelihoodof:fracture,recurrentcariesandperiodontaldisease.

SectionalMatrices

Broad contacts at the proper height of contour

Anatomicallyshapedcontacts

TightContactsPropercontactsthatflossproperlyandpromotegingivalhealth

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RetainersRetainers

TrioDent/Palodent

Universal V3 Ring Narrow V3 Ring


Also Available as:Also Available as:

Palodent Plus

Universal Ring Narrow Ring


BandsBands

TrioDent/Palodent Plus

Bendable tab

Side holes for easy removal

Holes allow grip with Pin-Tweezers

Marginal Ridge Contour

Pin Tweezers


BandsBands


Bicuspid

Molar

Sub-gingival Molar


Anatomical WedgesAnatomical Wedges

Wave Wedges

Pin Tweezers


Challenge:

Adjacent Class II Composite Restorations

Prepare enamel margins

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Place contoured

band, wedge & V-Ring

Selective etching

Wash thoroughly

Apply bonding agent

Fill box 2/3’s full

Compress w 1P

Cure

Finish buildup

Cure

Sonicfill

Remove wedge peel band back

Cure IP

Remove band & cure

ContacEZ

Re-contour diamond/finishing

carbides

Finishing strips

Place V-Ring on adjacent tooth

Burnish desired contact area

Selective etching

Place Universal bonding agent

Light Cure

Peel back band

Cure from both sides at

gingiva

Place Composite as before

Light Cure Finish and polish

Adjust occlusion

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OOPS!

Endodontic Root Canal Endodontic Root Canal Therapy?Therapy?

Asymptomatic

Single small exposure

Able to achieve hemostasis

Perhaps not IF:

Traditional Pulpal ProtectionIndirect 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 ProtectionIndirect/Direct Pulp Capping

What are we trying to accomplish?

• Mechanical Sealing of the Pulp• Stimulate hydroxyapatite formation• Dentin bridge formation


How does this happen?

• Material sets hard and adheres to dentin• Alkaline pH• Release of Ca++ ions Ca+2

OH-

H2O

Ca+2

OH-


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)

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Unproven Pulpal ProtectionIndirect/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.”

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.

Unproven Pulpal ProtectionIndirect/Direct Pulp Capping

Glass Ionomer/RMGI?

“Poly Acrylic Acid (PAA) inhibits apatite formation in the body environment. PAA released from the glass-ionomer cements inhibits the apatite formation on tooth surfaces. It might be considered difficult to obtain bioactive glass-ionomer cements”

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 ProtectionIndirect/Direct Pulp Capping

Ca(OH)2 Paste• Ultra-Blend Plus– Ultradent

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Pulpal Protection – Indirect/DirectPulp Capping

MTA (Mineral Trioxide Aggregate)

• ProRoot-Dentsply• Biodentine-Septodont• Thera-Cal LC-Bisco

Bismuth oxide Bi2O3

Gypsum CaSO4 · 2 H2O

Tetracalcium aluminoferrite (CaO)4.Al2O3.Fe2O3

Tricalcium aluminate (CaO)3.Al2O3

Dicalcium silicate (CaO)2.SiO2

Tricalcium silicate (CaO)3.SiO2

Biodentine

Latest Pulpal ProtectionIndirect/Direct Pulp Capping

Resin Modified Calcium Silicate• Theracal

Latest Pulpal ProtectionIndirect/Direct Pulp Capping

Light cured apatite forming MTA in a unique hydrophilic resin (polyethylene glycol methacrylate) that releases calcium

Hilton TJ. Keys to Clinical Success with Pulp Capping: A Review of the Literature. Op Dent 2009;34:615-625.

Social Media Communication

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Cell Phone Text MessagingCell Phone Text Messaging Appt Reminder/Late Cancel Custom Email MessagingCustom Email Messaging Appt Reminder/Confirmation

Custom Email MessagingCustom Email Messaging Appt Reminder/Confirmation Custom Email NewslettersCustom Email Newsletters Holiday Promotions

Custom Email NewslettersCustom Email Newsletters Promotions Custom Email NewslettersCustom Email Newsletters Regular Newsletters

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Custom Email MessagingCustom Email Messaging Birthday Wishes Custom Email Patient SurveysCustom Email Patient Surveys Automated Post-Appointment

Custom Email Patient SurveysCustom Email Patient Surveys Automated Post-Appointment Custom Email Patient SurveysCustom Email Patient Surveys Automated Post-Appointment

Online Patient ReviewsOnline Patient Reviews Monitor Online Reviews Online Patient PortalOnline Patient PortalAutomated Post-Appointment

Pay Bills Online

27

Online DashboardOnline DashboardSummary

Management ResearchManagement Research--MapsMapsResearch Locale Demographics

New Mobile Apps

Mobile DevicesMobile Devices Distribute Testimonials Online

Increase internet marketing

HealthgradesHealthgrades

Xerostomia patients

High carbohydrate users

Non-fluoridated water users

Drug abusers

Need TherapeuticRestorations

28

Composite Challenges

•Post-operative sensitivity

•Recurrent decay

•Achieving proper moisture

•Polymerization shrinkage

•Increased time-layering

•Technique sensitivity

Low post-op sensitivity

Fluoride Release

Moisture variability

No shrinkage

Bulk placement

Simple-more forgiving

Glass Ionomer

Fuji IX Self Cure Glass Ionomer

Glass IonomerBase/Restorative

SDI Self Cure Glass Ionomer

•More highly filled-reduced wear•Self-curing in 2.5-5 minutes•No polymerization (setting) shrinkage stress•Expansion/contraction similar to tooth•High fluoride release•Bioactive

Glass IonomerCharacteristics •Multiple cervical carious lesions

•Pediatric Patients•Sealants•Class V restorations•Sandwich Technique•Crown buildups•Long term interim restorations•Cements

Glass Ionomer Uses

Pediatric Patients

Glass Ionomer RestorationsGlass Ionomer Restorations

Pediatric Patients


29

Class V root caries


Class V root caries


Repair around crown margins


Repair around crown margins


Long term interim restoration




30





Gain access to decay using a high speed

Closed Sandwich Technique

Use slow speed and then spoon excavator

Stop if you feel you will expose pulp

SEM of dentin treated with PCA

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


CARD

OS

O et al. J D

ent 2010

Condition enamel only with phosphoric

acid

Rinse thoroughly

Re-prep if necessary after set

Place Glass Ionomer base


Wait 2:30

Apply Seventh Generation Bonding

Agent

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


Finish and polish

Place Composite & Cure

(Sonic Fill)

31

Preparation w cervical margin in

dentin

Open Sandwich Technique

Acid etch enamel

Condition dentin w PCA

Place glass ionomer base


Place RMGI bonding agent and cure

*recommended by Dr Graeme Milicich

Build up tooth with composite


Shape with diamonds and fine carbides

Finished occlusal view


Mesial View

Glass Ionomer

Composite

RMGI

But… How long do they last?

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

Placement 2 years 10 years

92.7% success

65.2% success

Survival Rate

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


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

Placement 2 years 10 years

86.8% success

30.6% success

Survival Rate

Multiple Surface Restorations*

(n=62)

(*based on placement of older GI formulations)

32


Five Year Restorations


How long do they last?• 8-12 years- single surface• 5-8 years- multiple surface• The larger the restoration, the

shorter its lifetime


Then what?• Re-prepare surface and place posterior

composite restoration• Prepare tooth for a crown

Equia

Glass Ionomer/Filled Resin Sealant

Easy, Quick, Universal…

Designed as a system that included surface sealant

Becomes stronger in time

Surface Sealant

• Fills in microcracks and porosity

• Provides a high gloss, smooth surface

• Increase wear resistance and allows material to mature

•Light Cured-Do not etch before applying

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

Surface Sealant

33

Restoration w large crack Restoration w large crack

Large restoration with internal fractures Dentist-Multiple Radiographic Caries

Before and After

Equia Forte

Posterior Glass Ionomer

34

Equia Forte


Stronger Glass Ionomer

For use in posterior teeth

Increased compressive strength (219 MPa)

Increased flexural strength

Greater wear resistance

Increased acid resistance

High fluoride release maintained

Stronger surface sealant

Better designed for Class II posterior restorations

Equia Forte


RIVA Self Cure HV

Sudden Onset Caries

Posterior Glass Ionomer47 year old female

Been in the practice over 30 years

Regular re-care appointments

Significant changes in health history

No restorations in 8 years

Radiographs revealed multiple interproimalradiolucencies not present 12 months previous

Required 16 restorations

Need caries resistant restorations

Preparations


Preparations


Posterior GI Restorations


35

•Acid/base and polymerization reaction

•Ionic and micromechanical bonding

•Dual-curing

•Fluoride release

•Bioactive

Resin-Modified Glass Ionomers

•Acid/base and polymerization reactions•Dual cured-faster•Shortens time needed to control moisture•More esthetic and translucent•Fluoride release•Higher tensile, bond strength and wear

Resin-Modified Glass Ionomer Characteristics

•Liner or Base•Class V Restorations•Restoration Under Crown•Temporary prior to crown•Sandwich technique•Cements

Resin-Modified Glass Ionomer Uses

Resin-Modified Glass Ionomers-Advantages

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

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

•Better retention

Resin-Modified Glass Ionomer Base/Restorative

Capsule

Fuji II LC RIVA LCFuji Filling LC

Resin-Modified Glass Ionomer Base/Restorative

Ketac Nano

Paste-Paste

36

Quick Temporary prior to Crown Sandwich Technique

Resin-modified Bonding Agent–Triturated

–Reduces polymerization shrinkage

stress

–Novel concept

Riva Bond LC

•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

Resin-Modified Glass Ionomer

Glass Ionomer

•Core-Cemented posterior crowns

•Entire Class I or II (Long Term Interim)

•Class V-high caries

•All deciduous posteriors

•Sandwich technique-Co Cure

Glass Ionomer Preferred Uses

•Core-all crowns

•Base Class I or II-re-prepared sandwich

•Class V-more esthetic

•Quickly placed short-term interim restorations

Resin-Modified Glass Ionomer

Preferred Uses

37

Glass IonomersThe “missing link” of esthetic

restorative materials

Thank You!

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