daniel h ward dds
TRANSCRIPT
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Daniel H Ward DDS
May 19, 2017
Incorporating Minimally Invasive Techniques into your Office
Treatment Protocols
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Health and appearance conscious
The Public has concerns about:
Appearance
Metals
Patients are more knowledgeable than ever
We must listen more to our patients
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We must provide alternatives for our patients
…but the rightalternatives
Minimally Invasive DentistryMinimally Invasive Dentistry
Conservative approach
Ideal treatment is no treatment necessary
Remove only diseased portion of tooth
Preserve healthy tooth structure for future restorative needs
CACARIES RIES MMANAGEMENT ANAGEMENT BBY Y RRISK ISK AASSESSMENTSSESSMENT
CAMBRA
stands forstands for……
Tooth decay is the destruction of tooth enamel. It Tooth decay is the destruction of tooth enamel. It occurs when foods containing carbohydrates (sugars occurs when foods containing carbohydrates (sugars and starches) such as milk, pop, raisins, cakes or and starches) such as milk, pop, raisins, cakes or candy are frequently left on the teeth. Bacteria that candy are frequently left on the teeth. Bacteria that live in the mouth thrive on these foods, producing live in the mouth thrive on these foods, producing acids as a result. Over a period of time, these acids acids as a result. Over a period of time, these acids destroy tooth enamel, resulting in tooth decay.destroy tooth enamel, resulting in tooth decay.
ADA Website
Tooth DecayTooth Decay CariesCaries
Caries is a point in a persons life at which the process of demineralization of tooth structure by acid from bacteria in the tooth biofilm overwhelms the patient’s ability to remineralize tooth structure.
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CariesCaries--Important PointsImportant Points
Caries is a bacterial infection caused by specific acidogenic bacteria in tooth biofilm. These bacteria are indigenous to humans. There are 30-40 known cariogenic bacteria present in saliva. Most commonly cited are Strep mutans, Strep sobrinus, Lactobacillus, and Actinomyces. These bacteria are acidogenic (acid producing) and aciduric (survive in an acidic environment). They produce lactic, acetic, formic and propionic acids.
Featherstone J. The Caries Balance. Featherstone J. The Caries Balance. Dimensions Dent Dimensions Dent HygHyg.. 2004;2(2):142004;2(2):14--18. 18.
CariesCaries--Important PointsImportant Points
Caries is a transmissible infection. Studies have shown that certain strains of Strep mutans are transmitted from mother to child. Early colonization, even before the teeth erupt, can occur in infants by transmission from mothers and caregivers. Transmission from child to child and adult to adult of Strep mutans have been reported. Children who have been colonized earlier have been shown to have more decay later.
Berkowitz RJ. Acquisition and transmission of Berkowitz RJ. Acquisition and transmission of mutansmutans streptococci. J streptococci. J CalifCalif Dent Assoc. Dent Assoc. 2003;3:1352003;3:135--137.137.
CariesCaries--Important PointsImportant Points
Caries is a multifactorial process of tooth demineralization and remineralization which, until cavitation, is reversible. This progression is determined by the balance between pathological factors and protective factors. Pathological factors include acid-producing bacteria, fermentable carbohydrates, and reduced salivary function. Protective factors include salivary components, fluoride together with calcium and phosphate to remineralize the lesion, and antibacterial therapy.
Featherstone JDB. The caries balance: contributing factors and eFeatherstone JDB. The caries balance: contributing factors and early detection. J arly detection. J CalifCalif DentaDentaAssoc. 2003;31:129Assoc. 2003;31:129--133. 133.
Demin/ReminDemin/Remin
Components of Saliva– Phosphate
– Calcium
Oral pH
Equilibrium
TOOTH
Acid
Calcium
phosphate
Demineralization Remineralization
DemineralizationDemineralization
Calcium
Phosphate
Demineralization Remineralization
TOOTH
Detection identifies signs (cavitations) and symptoms
Diagnosis identifies the disease (bacterial infection, biofilm disease)
Caries Detection Caries Detection vsvs DiagnosisDiagnosis
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Caries ActivityCaries Activity Caries RiskCaries Risk
Traditional Surgical ModelTraditional Surgical Model Medical ModelMedical Model
Surgical Model-Wait until cavitation occurs and surgically remove
Medical Model-Attempt to influence patient to change oral environment to prevent caries
Paradigm shiftParadigm shift 2002 FDI POLICY STATEMENT2002 FDI POLICY STATEMENT
The FDI World Dental Federation supports the principles of minimal intervention dentistry in the management of dental caries. The Principles are:
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1. Modification of the Oral 1. Modification of the Oral Flora to Favor HealthFlora to Favor Health
Dental caries is an infectious disease, and the primary focus should therefore be on control of the infection, plaque control and reduced carbohydrate intake.
BacteriaBacteria
•Poor Oral Hygiene
Older adults may have a difficult time
•Dexterity
•Flossing
•Frustration
BacteriaBacteria--RemovalRemoval•Removes biofilm
BacteriaBacteria--RemovalRemoval•Compensates for poor technique
Sonicare
DietDiet
•Loss of Taste results in increased sugar intake
2. Patient Education and 2. Patient Education and Informed ParticipationInformed Participation
The etiology of dental caries should be explained to the patient, together with the means of prevention through dietary and oral hygiene measures.
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AcidityAcidity
•Critical pH
Enamel exposed to a pH less that 5.5 will begin to demineralize
‐ 216 liters per capita
‐ 42.8 liters per capita
‐ 155 liters per capita
Soft Drink :Soft Drink :
Fruit Juice:Fruit Juice:
Bottled Water:Bottled Water:
Source: Global Market Information Database, published by Euromonitor 2002
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Acidity of Common DrinksAcidity of Common Drinks
Determining the Determining the CariogenicCariogenic Bacteria Bacteria LoadLoad
• Caries Susceptibility Testing Meter
• Rub swab over tooth surface
• Bioluminescencememeasures ATP levels which are elevated by cariogenicbacteria
•CariScreen
1-866-928-4445 www.carifree.com
•Associated Diseases
•Cancer•Diabetes•Sjögren’s Syndrone
XerostomiaXerostomia
“In a published study of 3,313 patients, 21.3% of men & 27.3% of women exhibited dry mouth”
NedersforsNedersfors T, T, IsakssonIsaksson R, R, MornstadMornstad H et al. H et al. PrevelancePrevelance of perceived symptoms of dry of perceived symptoms of dry mouth in an adult Swedish populationmouth in an adult Swedish population--relation to age, sex and pharmacotherapy. relation to age, sex and pharmacotherapy.
Community Dent Oral Community Dent Oral EpidemiolEpidemiol.. 1997;25:2111997;25:211--216.216.
Prevalence of XerostomiaPrevalence of Xerostomia
“In another study approximately 1 in 4 adult patients complained of dry mouth symptoms”
OrellanaOrellana MF, MF, LagravereLagravere MO, MO, BoychukBoychuk DG et al. DG et al. PrevelancePrevelance of xerostomia in of xerostomia in populationpopulation--based samples: A Systematic Review. based samples: A Systematic Review. J Public Health Dent.J Public Health Dent. 2006;1522006;152--158.158.
Prevalence of XerostomiaPrevalence of Xerostomia
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“Another study states that dry mouth impacts 30% of the elderly.”
Ship JA, Ship JA, PillemerPillemer SR, Baum BJ. Xerostomia and the geriatric patient. SR, Baum BJ. Xerostomia and the geriatric patient. J Am J Am GeriatrGeriatrSoc.Soc.2002;50:5352002;50:535--543.543.
Prevalence of XerostomiaPrevalence of Xerostomia
Do you have any difficulty swallowing?
Does your mouth feel dry when eating a meal?
Do you sip liquids to help in swallowing dry food?
Does the amount of saliva in your mouth seem to be little, too much, or do you notice?
XerostomiaXerostomia--Questions to AskQuestions to Ask
XerostomiaXerostomia--Clinical AppearanceClinical Appearance
Rampant Decay
Tooth Loss
Periodontal Disease
Difficulty Speaking
Candidiasis
XerostomiaXerostomia--EffectsEffects
Quantify S. Quantify S. mutansmutans & Lactobacilli & Lactobacilli levelslevels--measure buffering capacitymeasure buffering capacity
CRT Bacteria and CRT Buffer-Ivoclar
Determining Saliva Volume, pH, and Determining Saliva Volume, pH, and Buffering CapacityBuffering Capacity
Saliva Check-GC
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1.1. Roll back bottom lipRoll back bottom lip
2.2. Dab dry with gauzeDab dry with gauze
3.3. Timer startsTimer starts
4.4. Look for bubbles of Look for bubbles of saliva forming at saliva forming at outlets from the minor outlets from the minor saliva glandssaliva glands
5.5. At 60 seconds check At 60 seconds check with a tissuewith a tissue
Test OneTest One--HydrationHydration
Measures unstimulated saliva from minor salivary glands
1.1. Observe the Observe the consistency of consistency of saliva (watery, saliva (watery, bubbly, frothy, bubbly, frothy, stringy??)stringy??)
Test TwoTest Two--ViscosityViscosity
Measures quality of saliva-serous vs mucous(poor buffer)
1. Expectorate some resting saliva into the plastic cup.
2. Test the pH using the pH strips
Test ThreeTest Three--pHpH
Measures pH of stimulated saliva
normalnormal>5.0 >5.0 mLmL
lowlow3.53.5--5.0 5.0 mLmL
very lowvery low<3.5 <3.5 mLmL
ValueValueVolume Volume of Salivaof Saliva
1. Chew the unflavouredgum for 5 minutes, collecting the stimulated saliva in the measuring cup
2. Discard the gum once finished
3. Record amount of saliva collected
Test FourTest Four--QuantityQuantity
Measures stimulated saliva from major salivary glands
Green = 4 points
Blue = 2 points
Red = 0 points Normal/hiNormal/hi
ghgh1010--1212
lowlow66--99
very lowvery low00--55
Buffering Buffering abilityability
Combined Combined totaltotal
1. Using the pipette dispense 1 drop of saliva on each of the 3 squares ensuring the entire surface is covered by saliva
2. Invert buffer strip so excess saliva is absorbed into the underlying tissue
3. Read results after 5 mins.
Test FiveTest Five--BufferingBuffering
Measures bicarbonate level of stimulated saliva
Record and analyze results
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Determining Presence of Strep Determining Presence of Strep MutansMutans
Saliva Check Mutans
XerostomiaXerostomia--Aid ProductsAid Products
Biotene
XerostomiaXerostomia--Aid ProductsAid Products
Salese lozenges
•Long Lasting, Slow Release
•Cellulose based
•Contains ACP, Essential Oils, Xylitol
•Bicarbonate neutralizes pH
•Dissolves biofilm
• Freshens Breathe
1-877-419-2646 www.nuvorainc.com
EnvironmentEnvironment
•Chemotherapeutics
3. Remineralization of Non3. Remineralization of Non--CavitatedCavitatedLesions of Enamel & DentinLesions of Enamel & Dentin
Saliva plays a critical role in the demineralization/remineralization cycle, and its quantity and quality should therefore be assessed. There is strong evidence that ‘white spot’ lesions of enamel and non-cavitated lesions of dentin can be arrested or reversed. Such lesions should therefore be managed initially by remineralization techniques. The extent of the lesion should be objectively recorded such that any progression can be identified at recall.
ACPACP--CPP CPP RemineralizationRemineralization
TOOTH
Demineralization Remineralization
(hydroxyapatite)
Acid
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•Amorphous calcium phosphates stabilized by
casein phosphopeptides
•Molecule serves as a delivery vehicle for
Calcium and Phosphate at the tooth surface in
a slow release amorphous form
ACPACP--CPPCPP(amorphous calcium phosphate- casein phosphopeptides)
ACPACP--CPPCPP
•Increases phosphate and calcium in plaque
•Derived from milk products-highly
concentrated
•Lactose Intolerance OK
•If allergic to milk NO
CPP coating allows attachment to biofilmand stabilizes ACP
In presence of acid Calcium and Phosphate ions are released
CPP EffectsCPP Effects
CPP-ACPACP
•Prevents enamel demineralization
•Promotes remineralization of non-caviated
enamel subsurface lesions
•Seals off dentinal tubules reducing sensitivity
Action of ACPAction of ACP--CPPCPP(amorphous calcium phosphate- casein phosphopeptides)
MI PasteMI Paste
Provides bio-available calcium and phosphate to the oral cavity
Aides remineralization Reduces localized
hypersensitivity when used after scaling or tooth whitening
Remains on tooth surface 3 hours
After tooth whitening
For pregnant mothers
For children 6 & under
During or after ortho
Desensitization
Poor Oral Hygiene
Extra protection for teeth
MI Paste MI Paste vsvs MI Paste PlusMI Paste Plus
Use MI Paste
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MI Paste PlusMI Paste Plus
Addition of 0.2% NaF
900 ppm NaF (toothpaste =1100 ppm)
If F- concentration too high-CaF deposited on surface preventing absorption
150 micron penetration
White spot lesions
Desensitization
During or after ortho
Medical compromised pts
Xerostomia
High Acid Environment
High Caries Risk pts
Extra Protection
MI Paste MI Paste vsvs MI Paste PlusMI Paste Plus
Use MI Paste Plus
MI Paste Application
Apply after toothbrushing
No food or drink for 30 minutes
May apply with trays for 3-5 minutes
MI Paste Uses
Temperature sensitivity
Dentinal hypersensitivity
After tooth-whitening
During or after ortho
Xerostomia
Excess soft drink consumption
During pregnancy
Saliva substitute
Open dentinal tubules
Occluded dentinal tubules
Apply MI Paste:
After toothpaste and fluoride application
Before bleaching/scaling and days after
Ongoing throughout day and night
MI Paste works well in SGH (salivary gland hypofunction)pts-use all day/night
Home use in trays at night
Recaldent gum all day long
For longest time possible
MI Protocols for Adults
Jane Chalmers BDSc MS PhD
University of Iowa
5% Na F (22,600 ppm)
2% ACP-CPP
Releases Ca, PO4 ,F
Excellent retention
Desensitization
Does not clump
Extra protection for teeth
MI VarnishMI Varnish
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MI Varnish Application
Place after prophy but not mandatory
Dry teeth before applying Do not brush or floss for 4
hours Avoid hard, hot, sticky
foods and alcohol containing products for 4 hours
Do not use fluoride for 24 hours
MI Varnish Mechanisms
No water so it does not precipitate Ca allowing for longer retention
Greater amount of fluoride in saliva
Highest amount of fluoride uptake is in demineralized areas
Fluoride effects are present 1-7 days
4. Minimal operative intervention 4. Minimal operative intervention of cavitated lesionsof cavitated lesions
An operative (‘surgical’) approach should only be used when specifically indicated, e.g., when cavitation is such that the lesion cannot be arrested, or when there are aesthetic or functional requirements. Operative intervention should focus on the preservation of natural tooth structure and be limited to the removal of friable enamel and infected dentin. This can be done with hand, rotary, sonic, ultrasonic, air abrasive or laser instruments, depending on the circumstances. Each prepared cavity is therefore unique, and is primarily dependent on the extent of infected dentin rather than on a predetermined cavity design. Preparation of minimal cavities enables their restoration with adhesive materials such as glass-ionomer cement and/or resin composite. Some studies suggest that glass-ionomer cement may aid in the remineralization of demineralized, firm, non-infected dentin; however, further clinical studies are needed.
Composite
The most USED
and ABUSED
Material in Dentistry
Composite
Amalgam Preparation
Composite Preparation
“Convenience”Form MID
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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
High Viscosity (Low Flow) Flowable Composite High Viscosity (Low Flow) Flowable Composite
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)
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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 5. Repair of Defective 5. Repair of Defective RestorationsRestorations
Removal of restorations results in an inevitable increase in cavity size as a consequence of removal of sound tooth structure. Depending on the clinical judgment of the dentist, repair could be considered as an alternative to replacement in some circumstances.
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Minimally Invasive Dentistry?
“Dentistry begets Dentistry”
Minimally Invasive Dentistry?
“The more dentistry you do for a patient, the more dentistry they will eventually need.”
Treatment performed at age 18
•Black Triangles
•Opaque Crowns
•Dark Roots visible
•Recurrent decay
Smile Evaluation
•Long Central Incisors
•Inadequate buccal corridor display
•Steep Curve of Spee
•ColorSmile Template
Provisionalization
•Teeth Prepared-unprepared 2nd molars
•Fabricate desired shape in provisionals
•Allow patient to wear, evaluate and accept
Final Impressions & Lab Communication
•Once approved take final impressions-send model of provisionals
•Send photos of desired color shade tab, stump shades and provisionals
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Final Impressions & Lab Communication
•Tryin and seat crowns
•Notice lower anterior teeth
15 Year Old
Minimally Invasive Dentistry
70% RED Proportion
Minimally Invasive Dentistry
Buildup dentin replacement with opaque darker hybrid –typically A3-A3.5
Buildup remaining form with shade similar to desired final color with hybrid (typically A1-A2)
Add special effects to simulate imperfections within tooth structure
Add translucent incisal hybrid or microfill
Multiple Step Layering Techniques
Add dentin shade
•Aura Dentin 6
•Miris
Add General Purpose Shade
•Aura MC 3
•TPH Spectra
Add Characterization
Important-Junction must be invisible
Add Facial Surface
•Aura Enamel
•G-aenial GT
•Beautifil II
•Esthelite Sigma QuickOptrasculpt
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Finish and polish restoration
Restore adjacent tooth
Shape, finish and polish restorations
Restore opposite teeth
Pre-Operative
Finished Restorations
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
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Oh NO, not another bonding lecture!
•What are MMP’s and what agents can affect their effects?
•What is the effect of the width of the hybrid layer and dentin bond strengths?
•What new Self-Etching Primer Dentin Bonding Agent has bond strengths to un-etched enamel greater than 40 MPa ?
Oh NO, not another bonding lecture!
•Is there a relationship between post-operative sensitivity and dentin bond strengths?
•What are the characteristics of alcohol, acetone and water based solvents of dentin bonding agents?
•What are Universal Dentin Bonding Agents?
Etched Dentin
Demineralize surfaceExpose collagen fibersRemove smear layer Increase porosity of intertubular dentinOpen up dentinal tubules Increase surface area
Etched Dentin
•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
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“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
Overdrying
SEM Perdigao
Un-collapsed collagen fibrils Collapsed collagen fibrils
Proper Moisture
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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
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
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•Occlusions
Total Etch Technique
Summary
Most technique sensitiveRequires proper attention to detailUse in ideal sized preparations
Total Etch Technique
Materials-4th
Generation
Acetone solvent Alcohol solvent
Total Etch Technique
Materials-5th
Generation
Acetone solvent Alcohol solvent
•Self Etch Technique Never leave the dentinal tubules open
Bonding agent should not leave the dentinal tubules open
Method #2-Reducing Post-Op Sensitivity
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
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“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
37% H3PO4 etched Unprepared enamel surface for 15s. Popular SE primer etched Unprepared enamel surface
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•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
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.
Bond Incompatibility with Self and Dual Cured Resins
pH=3.2
Solution: Use a dual-cure activator
Bond Incompatibility with Self and Dual Cured Resins
“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
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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
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 Degradation
Self 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
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Self Etch Technique
OptiBond XTR
Primer contain acetone, alcohol and water solvents
Low film thickness (5 micron)Bonds to gold, non-precious metal,
zirconia, porcelain Direct and indirect restorative procedures
Seventh Generation DBA
BeautibondDual acidic monomersLow film thickness (5 micron)RadiopaqueEasy to use-single application 10 sec
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.
27
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
Long Term Dentin Bond Stability
Disinfect to prevent MMPs
MDPB (12-methacryloxydodecalpyridinium bromide)
Long Term Dentin Bond Stability
Pashley DH, Tay FR, Imazato S. Hot to Increase the durability of Resin-Dentin Bonds. Compend. 2010;32(7):60-64.
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.
Dentin Bonding Challenges
• 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.
Selective Etch TechniqueHigh Viscosity allows precise placementContains BAC
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Universal Dentin Bonding
Bond strength same to total vs self etch
Dentin Bond Strength
Self-Etch Total Etch Moist
Total Etch Wet
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
Total Etch vs. Self EtchShear bond strength of Universal Adhesives on Tooth Structures MPa*
*Manufacturer supplied data
MDP Universal Bonding Materials
Total, Self or Selective Etch
29
Universal Bonding Materials
Total, Self or Selective Etch
•GI Sandwich Technique-Never open the dentinal tubules
Bonding agent should not leave the dentinal tubules open
Method #3-Reducing Post-Op Sensitivity
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
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Pre-Operative
Completed Preparation
Fuji II LC Resin Modified Glass Ionomer Base
Kalore
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
Social Media Communication Cell Phone Text MessagingCell Phone Text Messaging Appt Reminder/Late Cancel
31
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 Custom Email MessagingCustom Email Messaging Birthday Wishes
32
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 Online DashboardOnline DashboardSummary
33
Management ResearchManagement Research--MapsMapsResearch Locale Demographics New Mobile Apps
Mobile DevicesMobile Devices
Distribute Testimonials OnlineIncrease internet marketing
HealthgradesHealthgrades
March 1, 2016
Increase internet marketing
HealthgradesHealthgrades
December 1, 2016
If you cannot see it you cannot treat it!
Orascoptic Designs for Vision
Surgitel
34
If you cannot see it you cannot treat it!
Ultra-Light Optics
Nano Freedom DentLight
If you cannot see it you cannot treat it!
Flecta Mirror
A Day at the OfficeA Day at the Office
Digital Dental Photography
• Xerostomia
• Difficulty maintaining oral hygiene
• Root exposures
• Some unable to tolerate long appointments
• Difficulty coming to office
• Fixed Income
US Population is Aging
US Population is Aging
DonDon’’t miss appointmentst miss appointments
AppreciativeAppreciative
Pay billPay bill
Often need more treatmentOften need more treatment
Refer new patientsRefer new patients
Say Thank You!Say Thank You!
60+ Patients are Wonderful
OneOne--Visit TechniqueVisit Technique
Immediate placement natural tooth Immediate placement natural tooth fiberfiber--reinforced bonded reinforced bonded ponticpontic
35
•Perio abcess
•Sub-gingival distal decay
•Carefully extract tooth
•Suture
•Scale and root plane adjacent teeth
•Cut off root of extracted tooth
•Remove decay and restore with glass ionomer
•Tryin and prepare slots
•Shape root area to support tissue
•Cut lingual slot when trying in
•Place groove inline with 2 adjacent teeth
•Prepare Ever Stick fibers
•Place tooth
•Etch and bond
•3 months later •3 months later
36
Before
Happy patient says that I just “straightened” his crooked tooth
Multiple Medications
Oral Environment Challenges-Xerostomia
Oral Environment Challenges-Xerostomia
“40% of all prescription drugs have dry mouth listed in the PDR as a possible side effect”
Chalmers J. Personal Communication. 2006.Chalmers J. Personal Communication. 2006.
Oral Environment Challenges-Xerostomia
In a published study of 131 different prescribed medications the most common side effect cited was xerostomia.
Smith RG, Smith RG, BurtnerBurtner AP. Oral sideAP. Oral side--effects of the most frequently prescribed drugs. effects of the most frequently prescribed drugs. Spec Spec Care Dent.Care Dent. 1994;14:961994;14:96--102. 102.
Oral Environment Challenges-Xerostomia
• Incidence increases with # of drugs taken
• 50% of patients taking 4 or more medications had Dry Mouth
Oral Environment Challenges-Carbohydrates
Nutrition Facts: Serving Size: 8.3 fl. oz Calories: 140 Total Fat: 0g Sodium: 200mg Protein: 0g Total Carbohydrates: 28g Sugars: 28g
Nutrition Facts:16 fl oz; calories 140; total fat 0g; sodium 220mg; potassium 60mg; total carbs 28g; sugars 28g
37
Oral Environment Challenges-Antacids
Ingredients:Calcium carbonate, adipic acid, corn starch, crospovidone, dextrose, flavors, malodextrin, sucrose, talc, colors.
Oral Environment Challenges-Bottled Water
Fluoride-less water Fluoridated water
Oral Environment Challenges-Illegal Drugs
“Meth mouth” or chronic marijuana use
Xerostomia patients
High carbohydrate users
Non-fluoridated water users
Drug abusers
Need TherapeuticRestorations
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
Look, we all know that Glass Ionomers are weak!
•Which wears more resin modified glass ionomers or pure glass ionomers?
•According to research what is the average 10 year survival rate of posterior single surface glass ionomers?
38
Look, we all know that Glass Ionomers are weak!
•Which form(s) of glass ionomer can be used as an RUC under bonded crowns? Under conventionally cemented crowns?
•Will placement of large glass ionomers always result in less total tooth and restored surface than placement of composites?
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
High caries rate individuals
Glass Ionomer RestorationsGlass Ionomer Restorations
Remove decay and place matrices
Glass Ionomer RestorationsGlass Ionomer Restorations
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Treat dentin with PAA
Glass Ionomer RestorationsGlass Ionomer Restorations
Place, shape and wait 2:30
Glass Ionomer RestorationsGlass Ionomer Restorations
Shape with diamonds w/ water
Glass Ionomer RestorationsGlass Ionomer Restorations
Dry and place Surface Sealant
No phosphoric acid
Glass Ionomer RestorationsGlass Ionomer Restorations
High caries rate individuals
Glass Ionomer RestorationsGlass Ionomer Restorations
Spoon out decay and refine prep
Glass Ionomer RestorationsGlass Ionomer Restorations
40
Place and rinse Poly-acrylic acid
Glass Ionomer RestorationsGlass Ionomer Restorations
Mix Gi and quickly place and push out
Glass Ionomer RestorationsGlass Ionomer Restorations
Allow to set 2:30
Glass Ionomer RestorationsGlass Ionomer Restorations
Hold down gingiva and shape
Glass Ionomer RestorationsGlass Ionomer Restorations
Dry and place surface sealant
Glass Ionomer RestorationsGlass Ionomer Restorations
High caries rate individuals
Glass Ionomer RestorationsGlass Ionomer Restorations
41
Pediatric Patients
Glass Ionomer RestorationsGlass Ionomer Restorations
Pediatric Patients
Glass Ionomer RestorationsGlass Ionomer Restorations
Class V root caries
Glass Ionomer RestorationsGlass Ionomer Restorations
Class V root caries
Glass Ionomer RestorationsGlass Ionomer Restorations
Repair around crown margins
Glass Ionomer RestorationsGlass Ionomer Restorations
Repair around crown margins
Glass Ionomer RestorationsGlass Ionomer Restorations
42
Long term interim restoration
Glass Ionomer RestorationsGlass Ionomer Restorations
Long term interim restoration
Glass Ionomer RestorationsGlass Ionomer Restorations
Long term interim restoration
Glass Ionomer RestorationsGlass Ionomer Restorations
Long term interim restoration
Glass Ionomer RestorationsGlass Ionomer Restorations
Decalcified areas in partially erupted tooth
Treat with phosphoric acid
Glass Ionomer SealantsGlass Ionomer Sealants
Activate, mix and place glass ionomer
Place Surface Sealant over glass ionomer and light
cure
Glass Ionomer SealantsGlass Ionomer Sealants
43
Glass Ionomer Sealants
5 Year Recall
Glass Ionomer SealantsGlass Ionomer Sealants
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
Closed Sandwich Technique
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
Closed Sandwich Technique
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.
Closed Sandwich Technique
Finish and polish
Place Composite & Cure
(Sonic Fill)
Preparation w cervical margin in
dentin
Open Sandwich Technique
Acid etch enamel
Condition dentin w PCA
44
Place glass ionomer base
Open Sandwich Technique
Place RMGI bonding agent and cure
*recommended by Dr Graeme Milicich
Build up tooth with composite
Open Sandwich Technique
Shape with diamonds and fine carbides
Finished occlusal view
Open Sandwich Technique
Mesial View
Glass Ionomer
Composite
RMGI
Restoration Under Crown
Internal Cracks
Restoration Under Crown
Deep decay w affected dentin
Restoration Under Crown
Deep decay w affected dentin
45
Restoration Under Crown
Deep decay w affected dentin
Restoration Under Crown
Deep decay w affected dentin
Restoration Under Crown
Do Not Use in Anterior Teeth to replace Large Defects
RUC with crack
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)
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
86.8% success
30.6% success
Survival Rate
Multiple Surface Restorations*
(n=62)
(*based on placement of older GI formulations)
46
But… How long do they last?
Five Year Restorations
Long term interim restoration
How long do they last?• 8-12 years- single surface• 5-8 years- multiple surface• The larger the restoration, the
shorter its lifetime
Long term interim restoration
Then what?• Re-prepare surface and place posterior
composite restoration• Prepare tooth for a crown
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
47
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
RIVA Self Cure HV
48
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
Posterior Glass Ionomer
Preparations
Posterior Glass Ionomer
Posterior GI Restorations
Posterior Glass Ionomer
•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
49
•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
Class V Restoration 294
Gingival recession & root caries
• 1st molar and bicuspid
• Remove decay‐place retention
Resin-Modified Glass Ionomer
50
295
Gingival recession & root caries
• 1st molar and bicuspids
• Remove decay‐place retention
Condition with PA
• Pre‐treatwith dentin conditioner (Poly‐
acrylic acid)
Resin-Modified Glass Ionomer
296
Material Placed and Light Cured
• Place excess material
• Light Cure
Resin-Modified Glass Ionomer
297
Final Restorations
• Shape restorations
• Hold back gingiva and shape with fine
diamond
• Etch with phosphoric acid, wash and dry
• Place surface sealant and light cure
Material Placed and Light Cured
• Place excess material
• Light Cure
Resin-Modified Glass Ionomer
Restoration Under Crown
Quick Temporary prior to Crown Temporary placed 5 years ago
51
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 Bioactive
Having an effect upon a living organism, tissue, or cell. Biologically
active.
Exchange ions to and from biological structure
Regenerative/remineralization
Promote healing
Release Calcium, Fluoride, Phosphate
Maintains alkaline pH
Antimicrobial
52
GI Initial setting and early strength Fluoride release
Calcium Aluminate Long term-increased strength and retentionApatite formation Sealing at marginal interface Sustained long term properties w/o degradingHigher pH (not acidic)-virtually no sensitivity
Ceramir Ceramir
Forms apatite crystals(a group of phosphate minerals, usually referring to hydroxyapatite, fluorapatite and chlorapatite, named for high concentrations of OH−, F−, Cl− or ions, respectively, in the crystal. The formula of the admixture of the four most common end members is written as Ca10(PO4)6(OH,F,Cl)2, and the crystal unit cell formulae of the individual minerals are written as Ca10(PO4)6(OH)2, Ca10(PO4)6(F)2 and Ca10(PO4)6(Cl)2.)
Ceramir
Forms apatite crystals Powder and water are mixed Dissolution results in nano-crystal formation Gibbsite and Katoite forms
Gibbsite
Tooth apatite
Mixed zoneChemically formed apatiteGibbsite(Calcite)
Katoite
Ceramir
Forms apatite crystals Powder and water are mixed Dissolution results in nano-crystal formation Gibbsite and Katoite forms Crystals form on tooth and restoration Long-term stable bond Ceramir Dentin
Physical Properties– Creates Apatite when in contact with phosphates– No shrinkage– Hydrophilic system with Alkaline pH– Thermal properties similar to tooth structure– Low film thickness -15 microns– 160 Mpa compressive strength– Anti-bacterial-inhibits caries– Gets stronger over time– Acid resistant– Bonds well to metal, porcelain, ceramics, zirconium
Ceramir Ceramir
Jeffries SR, Fuller AE, Boston DE. Preliminary Evidence that Bioactive Cements Occlude Artificial Marginal Gaps. J Esthet Restor Dent. 2015.
Self Adhesive Resin Cement
Resin-Modified Glass Ionomer
Glass Ionomer
Calcium AluminateRMGI
Calcium Silicate
53
0:00
Ceramir
2:00
Ceramir
4:00
Ceramir Ceramir
Bioactive
TheraCem
Releases fluoride and calcium
Bioactive
Activa
Liner/Base
Releases fluoride and calcium
Restorative Material
54
ppm
Releases Calcium as pH lowers
Activa
Releases Phosphates as pH lowers
Activa
Versatile Material
Activa
Liner/Base
LinerIndirect Pulp Cap
Versatile Material
Activa
Direct restorativeCrown RepairCore Buildup
Restorative Material
Advanced Engineering for People
Biomimetic
• Replacing damaged structure with material
that will mimic the function of the original
Biomimetics is the term used to describe the substances, equipment,
mechanisms and systems which humans imitate natural systems and
designs.
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
55
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)
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
56
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
Sonic Energy Assisted Light Sonic Energy Assisted Light PolymerizationPolymerization
Sonic FillSonic Fill
Sonic Energy Assisted Light Sonic Energy Assisted Light PolymerizationPolymerization
Sonic FillSonic Fill
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.
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
57
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
Interproximal ContactInterproximal Contact
RetainersRetainers
TrioDent/Palodent
Universal V3 Ring Narrow V3 Ring
Interproximal ContactInterproximal Contact
Also Available as:Also Available as:
Palodent Plus
Universal Ring Narrow Ring
Interproximal ContactInterproximal Contact
BandsBands
TrioDent/Palodent Plus
Bendable tab
Side holes for easy removal
Holes allow grip with Pin-Tweezers
Marginal Ridge Contour
Pin Tweezers
Interproximal ContactInterproximal Contact
BandsBands
TrioDent/Palodent Plus
Bicuspid
Molar
Sub-gingival Molar
58
Interproximal ContactInterproximal Contact
Anatomical WedgesAnatomical Wedges
Wave Wedges
Pin Tweezers
TrioDent/Palodent Plus
Challenge:
Adjacent Class II Composite Restorations
Prepare enamel margins
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
59
Peel back band
Cure from both sides at
gingiva
Place Composite as before
Light Cure Finish and polish
Adjust occlusion
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•Stay current on the latest technologies•Communicate effectively with patients•Offer choices
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