dynamics 17 web version.pdf

7/29/2019 Dynamics 17 Web Version.pdf

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Issue 17

Visit our website www.dentsplymea.com

In a class II of its own


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waveoneTM reciprocating motion as well as continuous rotation

File selection at a single glance due to the ISO colour coded file library

On / Off button on the motor handpiece

Excellent visibility & access due to the miniature contra-angle head

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Dynamics

Dynamics 3

pages

10-11DENTSPLY Product News

pages

12-16New Techniques and Tools for Back-to-Back

Class II Restorations: A Clinical Case with Palodent

Plus and SDR

pages

18-19Clinical Application of the DENTSPLY

Endo-Resto System

page

20Nupro Sensodyne Case Study

DynamicsContentspages

4-5Clinical Case with Palodent Plus, Sectional Matrix

System

pages

6-7Matching the Natural Central, A Ceramists View onAesthetic Implant Restorations

page

8 Ceramco PFZ, Porcelain for Zirconia


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Dynamics

Dynamics4

During the initial visit of a 26-year

old patient, defective composite

restorations were found on the 26

and 27.

After consultation these old

restorations were replaced by new

composite restorations. For an

optimal functional and aesthetic

result we decided to create a

restoration with SDRSmart Dentin

Replacement as a base and

CeramX mono+, Nano-Ceramic

Restorative, as the occlusal layer.

Replacement of Class I and II restorations

The new Palodent Plus system is a

further development of these possibilities

and user-friendliness, with an anatomically

correct contour, which enables thesystematic and reliable restoration of the

lost interdental dimensions. The matrices

are thinner and the wedge and ring system

easier to use. The new protective

WedgeGuards were added to the

Palodent Plus system for protection ofadjacent teeth during preparation.

Case

The patient was administered an

anesthesia, colour was determined. Colourmatched Vita shade tab A2, which

corresponds to the shade tab M2 ofCeramX mono+. A rubber dam was used

for ideal absolute isolation (Figure 2A).

To protect elements 26 and 27, PalodentPlus WedgeGuards were inserted

before the MO and DO preparations

of element 26 (Figure 2B). After

preparation, the shields (or guards) of

the WedgeGuards were removed,

which converted the WedgeGuards intoregular wedges (Figures 2C - 2E).

Matrices were inserted and tucked into

the interproximal areas and secured

by the rings to enable creation ofanatomical and optimal contact points

(Figure 2F).

Initial Situation

Figure 2BFigure 2A Figure 2C

Figure 2D Figure 2E Figure 2F

A good composite restoration is one of the

most challenging treatments. This has to

do with the number of steps required and

the technique sensitivity to achieve a goodresult. But what can be seen as a good

result? In my opinion a good result is a

restoration with a good internal adaptation

of the composite to the cavity wall, a good

marginal integrity, optimal contact points

and an anatomically correct shape. Alsothe lack of post-operative sensitivity and

long durability in function are fundamental

for a successful restoration.

Any technique or material that simplifies

the procedure is very welcome to theclinician. SDR has been on the market for

a number of years now, in which time it hasproven to be very successful. As a result

of the low polymerization stress and the

flowable characteristic SDR guarantees an

optimal adaptation to the cavity walls,which decreases the chance of post-

operative pain. Besides that, SDR can be

applied in 4mm layers, which simplifies

and speeds up the procedure

considerably. However, for a good

marginal integrity and optimal contactpoints just a good composite alone is not

enough. The development of sectional

matrix systems has made the restoration

of the interdental anatomy and contactpoint much easier and more predictable in

the past years.

Clinical Case with Palodent

Plus, Sectional Matrix

Systemby Dr. Annemie Grobbink (NL)


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Dynamics

Dynamics 5

Figure 5

Figure 3A Figure 3B Figure 3C Figure 3D

Figure 4A Figure 4B Figure 4C Figure 4D

Figure 4E Figure 4F

Figure 3E

Figure 3F

Next step was etching with 35%

phosphoric acid; enamel during 20

seconds and dentine during 15 seconds.

After rinsing thoroughly with a mild jet,

primer and bonding were applied (Figures

3A - 3D). SDR and CeramX mono+ are

compatible with every conventional

methacrylate-based dentine/enamel

adhesive system.

SDR was applied with the canula placed

mesial in the cavity, so that SDR could flow

into the cavity under the influence of

gravity. The self leveling character of SDR

ensures an optimal adaptation to the cavity

walls. As soon as SDR forms a smooth

surface, the material was light cured

(Figures 3E - 3F).

Then marginal edges were placed in

element 26 with CeramX mono+, matrices

and rings were removed carefully (Figures

4A - 4B). This resulted in remaining class

I restorations in elements 27 and 26.

These were built up per cusp, first to

minimize the effects of shrinkage.

Secondly this is the way to realize a perfect

anatomical result relatively easy (Figures

4C - 4F). After application of CeramX

mono+ the composite was shaped with a

modified ASH and then fissures were

created with a Suter and a probe. The

surface was smoothened with a brush.

To finish the interdental excess of the

restorations, a scaler, a scalpel and an

interdental abrasive strip were used.

Finally the restorations were polished with

a finishing disc impregnated with

aluminum oxide (Enhance Finishing

System) and a polishing point-brush

impregnated with diamond particles. Final

restoration is shown in Figure 5.


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A complete set of impressions were taken

and forwarded to the laboratory.

Laboratory Procedures

To reproduce aesthetic results for thecorrect emergence profile, models needed

to be prepared

and temporary

abutments needed

to be customized to

give the correct

finish line andvolume of material

in the neck and

crown area (Figure 3). This was

accomplished by reshaping a temporary

abutment with light-cured resin. Theoptimized situation afforded input that will

result in a custom-milled abutment and a

sintered zirconia coping. Having similar

materials enhanced both the structural and

the aesthetic integrity of the case.

The ceramic veneering process began

after the fit of the coping was confirmed

over the custom abutment. A layer ofCeramco PFZ margin porcelain with

modifier ceramics was added to increase

chroma and fluorescence in some areas of

the tooth and to provide the right surface

for the subsequent layers of ceramic.

The connection was created by mixing theCeramco PFZ margin material with glaze

liquid. The viscosity of the glaze liquid

dispersed the ceramic particles, creating a

very porous surface after baking up to

1,000C under the vacuum with a 1-minute

hold. This bisque layer provided physical

retention for the layers of ceramics to beapplied on top of it. Especially in this case,

it was very important to have a high

chroma in the internal layer leaving the

external layer to give the translucency

necessary of a typical older tooth(Figures 4 and 5).

Dynamics6

Matching the Natural CentralA ceramists view on aesthetic

implant restorationsby Carlos Montaner, Clinical Dental Technician

Case Clinical Background

The patient presented to Dr. Kurt

McKissick, the restoring dentist, with a left

central (No. 8) that was not salvageable.

However, the patient wanted the

restoration to match his remaining vitalteeth (Figure 1). Impressions and

photographs were taken before extraction.

After extraction and temporization, a

photograph was taken with a shade guide

in place to provide

the lab withaesthetic guidance

(Figure 2). The

natural teeth were

chromatic and

characterized, in

the A3 to A3.5shade range.

After discussion

with the restoring

team, including the

periodontist, azirconia abutment was chosen for

aesthetic enhancement. Resin was addedto the temporary abutment to shape the

tissue with the correct emergence profile.

Careful treatment planning, collaboration between the dental team, and using metal-free material options are

all key to enhancing anterior aesthetics. In the case presented, a left central was replaced with a state-of-the

art implant using a zirconia abutment and the CeramcoPFZ system, creating a functionally and artistically

restored smile.

Aesthetics are subjective. However, the requirement to match natural dentition with a prosthesis gives

the dental team a fixed target to apply their collective skills and enhance patient satisfaction. In the

authors opinion, the most challenging restoration to create is a mirror image of a natural single central

incisor. The authors laboratory has come across many non-conservative or less natural techniques,

including preparing otherwise vital teeth for aesthetic matching. However, with skilled operators,

consistent dentistlaboratory communication, and aesthetic materials available today, this is a

challenge that can be met with a less invasive technique.

Carlos Montaner is a Clinical Dental Technician with thirty years experience. He is an international spokesman

for DENTSPLY Ceramco, and has published many articles in Venezuela, Argentina, Brazil and Spain. He now

owns Montaner Dental Studio in Cary, North Carolina, USA.

Figure 1

Figure 2

Figure 3

Figure 5Figure 4

Dynamics


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Because margin

ceramics are alittle more

opaque, a small

layer of this

material wasadded on the

mesial and distal of the coping to create a

replica of the dentine (Figure 6).

The dentine layer mixed with 15% of

natural enamel clear was applied to thewhole surface of the crown. Opaceous

dentine was added with a mix of 15%

mamelon yellow-orange to create a verysubtle effect to better block the

transition of light.

Following the aesthetic techniques of Ernst

Hegenbarth, the goal was to achieve

improved dynamics between absorption

and refraction of

light (Figure 7).

The stratificationpattern shown

reveals vertical

layers on the

incisal area

enhancing thetranslucency anddeepness of the

crown (Figure 8).

After baking the

ceramic, the

entire surface wascovered with a

material of greater

translucency.

Layer thickness was deliberately controlled

at a low level. This allowed for more controlof ceramic contractions during each bake,

as well as the chromatic effects; forexample, a craze line (Figure 9). Ceramco

PFZ stains were used in small portions and

in internal layers of the ceramic. The

vanilla shade was used to create this effectby simply mixing it with stain liquid and

applying a minimal amount on the ceramic

surface before it was fired. Stains were

used internally to enhance control. Note

that this program can be very fast (120C

per minute from 650C to 840C with nohold), and it will not affect the previous

layers. The ceramic build-up process was

continued with points of contact adjusted

on the model (Figure 10), and the shapeof the crown re-contoured to mimic the

original model (Figure 11). The aesthetic

result of the craze line seen in Figure 9was now visible (Figure 12).

Surface texture was the next challenge to

be addressed. In this case, because of the

patients age, the dental surface was very

smooth due to erosion as well as the

permanent contact with the internal part ofthe lip. Ceramco PFZ glaze and stains

were used to finish the proper colour and

surface of this tooth. Most of the colour

comes from inside, but in aged natural

teeth there is a lot of staining on the

surface. Finally, the surface was polishedwith pumice and the case was done

(Figures 14, 15 and 16). After the case

was cemented, it was difficult to distinguish

the crown on an implant (Figures 17 and

18) versus the patients natural dentition.

These lifelike results were very pleasing for

the patient and rewarding for the entirerestorative team.

Conclusion

The techniciansskills as well as

communicat ion

between the entire

team are keyelements in the

restorative process. It is great to work with

the correct information because this brings

out the best of the dental technician, who

can see the desired finished product

during the whole process, making the workmuch more enjoyable. The development

of aesthetic, wear-friendly ceramicssuch

as the PFZ systemgives the skilleddental lab technician a comprehensive

single set of materials to fabricate all-

ceramic restorations. The immediateadvantages are enhanced reproducibility,

excellent aesthetics, a full spectrum of

shades for prescription, as well as a

reliable shade match in combination cases

involving more than one type of

restoration.

For more information on the Ceramco PFZ

range, please visit www.dentsplymea.com

or for technical support please email

[email protected]

Acknowledgements

This article has been repurposed with

permission by: DENTSPLY Prosthetics;

Carlos Montaner, CDT; Inside DentalTechnology, January 2012, Volume 3,Issue 1, Published by AEGIS

Communications.

The author extends special thanks to

Andreina Montaner for her support and

collaboration on the development on this

article. Clinical insights from Dr. KurtMcKissick (restoring dentist) and Dr. Paul

Kazmer (implant placement) are sincerely

appreciated.

Disclaimer

The preceding material was provided by

the manufacturer. The statements and

opinions contained therein are solely those

of the manufacturer and not of the editors,publisher, or the Editorial Board of Inside

Dental Technology.

Dynamics 7

Figure 6

Figure 8

Figure 7

Figure 14 Figure 15

Figure 17Figure 16

Figure 9 Figure 10

Figure 11 Figure 12

Figure 18

Dynamics


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Following on from Carlos Montaners article on the

application of Ceramco PFZ please find below furtherinformation and FAQs about this product.

What is Ceramco PFZ?

Ceramco PFZ has been engineered from cutting edge leucite

free, synthetic porcelain with the entire system being designed

to impart the fluorescence of natural dentition.

Is Ceramco PFZ compatible with all zirconia milled

frameworks?

It is suitable for use on all 100% zirconia frameworks and isdesigned to support a variety of indications from single crowns

to full restorations.

What can I expect from this material?

Ceramco PFZ in common with other Ceramco Porcelains

delivers exceptional aesthetics, thermal stability, with the

excellent handling and increased productivity associated with

Ceramco porcelains.

What shade options does it have?

Ceramco PFZ is available in the 16 classic shades and 26 3D

shades in either full or mini-kit form or as individual shades.

The complete system will provide the technician with the fullrange of opaques, dentines, incisal, modifier and effect

porcelains, to complete the most challenging cases. Four of

the most popular bleach shades from the Ceramco Illumin

bleach line are also available in Ceramco PFZ.

Dynamics

Ceramco PFZ,

Porcelain for ZirconiaRobert Carew, Product and TechnicalManager, DENTSPLY (UK) International

Do I have to use the liner?

Whilst it is not essential to apply the liner it is though highly

recommended particularly for cases where space and thereforegood shade matching will be an issue. The liner will prevent the

opacity of the framework from affecting the finished restoration

helping to maintain good shade reproduction where porcelain

thickness is less than 1mm.

Ceramco PFZ system has been designed to the highest quality

and is available for purchase from your local DENTSPLY sales

representative or dealer. Patients, technicians and dentists alike

will benefit from the aesthetics and excellent wear characteristics

of this system.

For more information on Ceramco PFZ and other Ceramco lines,

please visit www.dentsplymea.com or for technical support please

email [email protected]

Dynamics8


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Dynamics

Dynamics10

PRODUCT NEWSfrom DENTSPLY

The X-Smart Plus, the new generation of the popular X-Smart endo motor fromDENTSPLY Maillefer, is the endo motor of choice for General Dental Practitioners

performing root canal treatments with the reciprocating, single file technique or

traditional continuous rotation file systems.

The X-Smart user interface has been further improved by a large, bright colour screen,with a colour coded file library for file selection at a single glance making it the endo

motor of choice for all Protaper Universal users. In the X-Smart Plus you will recognise

the highly regarded X-Smart features such as the miniature contra-angle head and theOn / Off button on the motor headpiece.

DENTSPLY Maillefers new maccess brand, brings a comprehensive and

affordable hand file range to general practitioners in fast growing markets. The

complete range is designed to deliver quality at an affordable price.

maccess stainless steel files are ergonomically designed, with ISO colour coded

handles, in six sizes per pack across the whole range. maccess hand files offerconvenience and simplicity.

The silicone stop marker gives control to the practitioner, which further aids the tips

direction in the root canal. This feature improves the safety and effectiveness of the file

during treatments.

Crosslinked gutta-percha core obturator

Gutta Core is the first obturator with a crosslinked gutta-percha core. Crosslinking is a

well-established scientific process that connects the polymer chains and therefore,

makes the gutta-percha stronger, whilst keeping its best features:

Superior 3D fills

The hydraulic force sends warm gutta-percha flowing equally in three dimensions.Centrally compacted gutta-percha creates predictable and consistent 3D fill that

follows curves, finds accessory canals and flows into isthmuses. Gutta Core offers a

superior 3D fill with the ease of a single insertion.

Ease of retreatment

No plastic core remaining in the root canal. The obturators core comes out

efficiently, saving the dental practitioner time and effort.

Post space simplified

Fast and easy to create post space.

X-Smart Plus is everything you like about X-Smart with a Plus.


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Dynamics

Launching New CavitronJet Plus and Cavitron Plus with Tap-On Technology.

DENTSPLYs latest addition to the Cavitron range will give dental surgeries the moderntouch. The new Cavitron Jet Plus and Cavitron Plus have a 360 wireless foot control with

tap on technology. The new improved foot pedal mechanism reduces leg and foot fatigue.

The wireless foot pedal can be tapped to activate, then the foot can be relaxed during

the procedure (taken off the foot pedal) and then tapped again to deactivate.

In addition the Cavitron Jet Plus supports air polishing, ultrasonic periodontal

debridement with turbo boost, the Blue Zone and deep pocket ultrasonic lavagedelivering medicament.

SDRnow available in syringes

In 2010, SDR flowable composite base material was successfully introduced in a

Compula form. From November 2012, SDR will also be available in a syringe,

making the application of this composite material even more flexible.With three years of clinical experience behind it, SDR has become a world success.Thanks to its extremely low polymerization stress, this bulk-fill composite base material

is self-levelling and adapts perfectly to the cavity walls. Unlike conventional flowables,

SDR can be applied in increments of 4mm in one step. It is designed for use as a base

in large class I and class II cavities and now also as a liner for smaller class I cavities

or as a fissure sealant, as well as for filling defects or undercuts in tooth preparations for

crowns, inlays or onlays. SDR can be overlaid with any methacrylate-based adhesive orcomposite.

From November, SDR will be available in pre-filled syringes, allowing multiple cavities to

be restored in one go. The syringe features an ergonomic easy-to-grip handle that

simplifies the application process. SDR in syringes is available in two package sizes, a

three-syringe refill pack and a ten-syringe eco refill pack.

For dentists placing Class II restorations, Palodent Plus is the new sectional matrix

system that delivers easy, predictable and accurate contact creation by utilising

advanced ring, matrix and wedge technology. Palodent Plus offers accurate contacts

and tight marginal seal, minimised overhang and finishing, easy placement and removal.

Palodent Plus delivers:

Consistently accurate, tight contacts: Rings are made with nickel-titanium to create

a consistent force to separate teeth, and then return to their original shape after use,

helping to deliver a tight gingival seal and anatomically-shaped restoration.

Wide applications for sectional matrix system use: Ring tine design helps the

system remain stable on significantly damaged teeth. Rings are stackable for multiple

restorations at once.

Minimised flash and finishing: Ring tines maintain a fit on the tooth that complements

the wedge and works with the matrix to seal and shape the restoration, minimising

required finishing.

Wedge compatibility and performance: The V-shape of the tines accommodates the

wedge from both sides. Fine wave-shaped wings compress and flare for easy

placement and minimise the impingement of soft tissue. Take the stress out of Class II restorations: Use a combination of Palodent Plus and

SDR Posterior Bulk Fill Flowable Base. SDR can be bulk filled up to 4mm and provides

excellent cavity adaption and reduced polymerization stress.

Dynamics 11


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Dynamics

Dynamics12

The increasing demands of patients and

clinicians regarding aesthetic restorations

together with the improvements in

adhesive materials, composite resins and

dental porcelains have brought thepossibility of conservative long-lasting

aesthetic treatments.1

Compositesrestorative materials are frequently

selected for the aesthetic restorations of

the posterior dentition due often to theirpotential for adhesion2,3 tooth

reinforcement and lifelike appearance.4

Posterior composite restorations can be a

challenging procedure especially in

relation to the formation of a tight proximalcontact as well as the attainment and

maintenance of the marginal seal

(marginal integration). Poor or lack of

proximal contact is promptly recognized as

an inconvenience by the patient due to thepotential and likelihood of food impaction,whereas a lack of marginal integration,

manifested clinically as white lines, poor

marginal adaptation and later interfacial

staining, is the most common reason for

failure of adhesive resin-based

restorations, and it predisposes therestorations to retention failures5 and

recurrent caries.6,7

Nevertheless, modern dental adhesives

have the potential to impart remarkable

and clinically proven retention and

marginal seal.5,6,7,8,9 A relatively recentscientific publication has shown a

promising survival rate of 89% for class V

bonded composite restorations after 12

years.5 Following the recommendations of

the American Dental Association (ADA)

guidelines, this recent study5 was

designed to evaluate the bond strength to

dentine on non-beveled class V

preparations. That is, preparations whichhave not received any type of extension or

beveling on enamel. Such a protocol (non-beveled) is quite common for studies

primarily investigating clinical bond

strengths to dentine. Under the yetdisputable premise that beveling the

enamel margins may increase the

marginal seal10,11 and fracture

resistance12,13 as well as to reduce the

occurrence of micro-cracks14 and increase

the surface area15 it is then plausible toassume that class V restorations placed

according to clinical guideline; that is,

restorations placed on beveled Class V

preparations have the potential to show an

even higher survival rate than the 89%after 12 years as reported in the studymentioned above.5

Continuing forward with this rationalization,

once accepted that there is potential for

long-term and successful bonding to tooth

structure, the operators next logical stepshould be to master a restorative

technique, which allows him to obtain an

immediate, effective and successful

integration between tooth and restoration.

In order to accomplish that, one needs to

obtain an excellent internal and marginal

seal at the restoration margins throughoutthe whole operative procedure, and should

be maintained during the effective life of

the restoration. Microleakage, not

retention, is the primary cause of clinical

failure in noncarious cervical restorations9

and no method of handling an adhesive

restoration can ensure that it is leak

proof.6,8,9

Nonetheless, it is clinicallyfeasible to obtain and maintain marginal

integrity throughout the placement

procedure as well as through the life-timeof the restoration, as the authors of the 12-

year recall and many other investigators

have repeatedly attested.5,9,15,17

This clinical case report aims to address a

few techniques and to a minor extent also

materials, in order to illustrate the modus

operandi of the authors, their simple

approach aiming a swift, effective andsuccessful restoration of complex clinical

cases on the posterior quadrant. More

specifically, the authors focus on their

approach to establish and maintain

marginal Integrity, which may increase thelongevity of the restoration.5,11,12,14,16,17

Additionally, a technique will be describedfor the effective and simultaneous

formation of proximal contact point

between teeth number 46 (DOB) and 47

(MOB) which may be easier than one

might expect given the right technique and

materials.

New techniques and tools forback-to-back Class II

restorations: A clinical casewith Palodent Plus and SDR

by Dr. Walter R. Dias, DDS, MS

Dental Marketing Manager and Lecturer

for DENTSPLY DETREY, Germany

Dr. Andre F. Reis, DDS, MS, PhDAssistant Professor, Guarulhos University,

Brazil


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Dynamics

Clinical Case: Patient of 32 years of age

with no relevant medical history presents

with temporary restorations and failed

composite restorations in teeth number 46(DOB) and 47 (MOB). The teeth presented

secondary caries radiographically. It was

decided to use the new Sectional Matrix

System Palodent

Plus (DENTSPLY)which allows for the simultaneous

restoration of back-to-back class II due toits integration between the ring and the

wedge. The restoration was performed

with an opaque flowable composite, SDR

Smart Dentin Replacement (DENTSPLY),

and Ceram.X Mono+ Universal Nano-

Ceramic Restorative in shade M2(DENTSPLY).

The removal of the previous restorations

was performed following the principles of

minimally invasive dentistry. The old

restorations as well as the demineralizedenamel were removed with a round stone

in high-speed and infected dentine was

eliminated with a slow-speed round

carbide bur. Care was taken not to disruptor remove the affected dentine, which is

firm and is not easily removed with adental excavator but it could be easily

removed by a rotary instrument. We used

a round diamond stone to remove the

defective restoration to prepare the enamel

and a round carbide bur with light pressure

for the removal of caries and infecteddentine.

Note the maintenance of the sclerotic and

affected dentine, especially on tooth

number 36. The presence of affected

dentine was confirmed with a dental

excavator and blunt dental explorer (non-sharp probe). No beveling was performed

on the margins, except that any acute

angle present was slightly rounded with a

diamond stone in slow speed in order to

facilitate the subsequent compositeadaptation and to ensure marginalintegration. Nevertheless, the authors tried

to be very conservative and avoid a

removal of more than 0.2mm of enamel, by

using very light pressure and avoiding

extended bur contact with a certain enamel

area for any given time. Also, the cavitywas performed alongside, removing any

internal stains or dark spots which might

become visible through the final

restoration. This is made with a diamond

bur in slow speed (for tissue preservation)

to ensure or at least aid to a seamlessmarginal integration and to avoid

unnecessary replacements of this

restoration by dentists who might mistake

these harmless discolorations as for

secondary decay and therefore indicate a

restoration replacement.

This step is a good example of where good

materials can synergistically propel good

techniques to a better result. The matrix

band has been designed with holes in the

top and at the sides to use them in

conjunction with Palodent Plus Pin-Tweezers; this way, it is easier to place and

remove the matrix band properly.

This is only possible thanks to the unique

design of this particular wedge, which does

not aim to achieve a separation between

the teeth, but actually to seal the cervical-gingival wall of the proximal box. It is

important to note that this feature is

applied to specific clinical cases and in

some other cases the wedge should be

placed after the placement of the ring.

Dynamics 13

Fig. 1

Fig. 1. Lingual View. Failed composite

restorations and provisional material

on teeth number 46 (DOB) and 47

(MOB).

Fig. 2A

Fig. 2B

Fig. 2C

Figs. 2A, 2B, 2C. Cavity preparation

principles and procedure.

Fig. 3A

Fig. 3B

Figs. 3A, 3B. Final preparation.

Fig. 4

Fig. 4. Placement of the Palodent Plus

matrix band.

Fig. 5

Fig. 5. Placement of the second

Palodent Plus interproximal matrix

band, observing that this was done

after the Palodent Plus Wedgeinsertion.

Fig. 6A

Continued over page >>>


14/22

Dynamics

Dynamics14

Although recommended, this step is

optional. It is also important to note that the

Palodent Plus wedges are stackable and

design to impart lateral seal rather than toseparate the teeth. The subsequent ring

placement will impart all the necessarytooth separation, in a predictable and

effective manner, so that a successful

proximal contact can be obtained. Actually,

more than two wedges can be securelystacked in the same inter-proximal area if

need be.

After acid etching with phosphoric acid

36% (minimum of 15 seconds on enamel

and an additional maximum of 15 secondson dentine), XP BOND was applied.

The opaque flowable material was applied

over the dark sclerotic dentine areas formasking effect.20 SDR was applied as a

base over all the dentinal areas and

cervical enamel. SDR imparts remarkable

low shrinkage stress and allows amaximum depth of cure of 4mm. SDR self-

adapting feature avoids unnecessary

handling or modeling of the material, which

enables the operator to save precious

operative time. With more time to spare,

the operator is more likely to strive for amore precise and optimal placement of the

occlusal layer using a composite of choice.

Notice the good fit obtained after the

placement of the base material SDR.

There was neither inclusion nor presenceof air bubbles as well as no visible

imperfections. With the time savings that

SDR provides, one can concentrate more

readily in subsequent and more critical

parts of the restoration, as the formation of

the lateral (buccal and lingual) grooves,cusp ridges as the creation of the marginal

ridge and secondary grooves and ridges.

Ceram.X Mono+ shade M2 was the

material of choice for complete build up of

the occlusal layer. As M2 is a body-shade

composite, it presents ideal translucency,

being able to emulate both dentine andenamel, it imparts a chameleon like

property making it an ideal material for the

posterior composite restorations. Here we

see the simultaneous placement and

adaptation of the composite material to the

distal marginal ridge of tooth number 46and to the adjacent mesial ridge of tooth

number 47.

Note the accurate placement and optimalformation of the buccal and lingual

embrasures. Given the simplified and swift

approach it is also remarkable the

absence of excess material and of gapsbetween the restoration and the tooth

surface. The application of SDR basematerial and the simultaneous restoration

of the marginal ridges were carried out in

just less than four minutes.

Fig. 10A

Fig. 11A

Fig. 10B

Figs. 10A, 10B. Simultaneous

restoration of the marginal ridges.

Fig. 11B

Fig. 7A

Fig. 7B

Fig. 7C

Figs. 7A, 7B, 7C. Etching and

adhesive application (XP BOND,

DENTSPLY).

Fig. 8

Fig. 8. Placement of SDR

(DENTSPLY) as a base material after

the application of the flow opaquematerial.

Fig. 9

Fig. 9.Adaptation of SDR.

Fig. 6B

Figs. 6A, 6B. Placement of a

secondary Palodent Plus wedge to

securely seal the gingival and proximal

walls of the respective adjacentproximal boxes.


15/22

Dynamics

Dynamics 15

Each cusp is (occlusal or buccal) and ridge

was individually restored with individual

oblique increments and provisionally tack

cured for 3 seconds each (step-curetechnique).18,19 This technique not only

significantly reduces the stress of

polymerization and probably the

subsequent formation of white lines, but it

also significantly reduces the working

time.20 Please note, that no attempt was

made to restore the buccal and occlusalsurfaces at the same time. Instead, the

occlusal ridges and anatomy was given

priority in order to maximize accuracy and

avoid excess placement, which causes

excess occlusal adjustment. The buccalareas were restored by separate (and

therefore more accurate) increments,

which were also tack-cured for 3 seconds

each. After placement and finishing of the

occlusal surface, all increments in each

restoration were simultaneously light-cured for 20 seconds each using a curing

light with output greater than 800 mW/cm2.

The application of the tint material

demonstrates the formation of detailedaesthetic and functional anatomy including

the central fossae, primary and secondary

grooves as well as secondary ridges. This

step is performed with didactical purposes

in mind and has little if any value for the

patient himself.

Enhance Finishing System is an

aluminum-oxide based material which

finishes the composite to a matt luster.

Enhance has the interesting ability of not

scratching or harming enamel, being ableto remove the composite material well

enough for finishing of the margins, as well

as small to medium adjustments (gross or

large adjustments should be performed

with a fine or extra-fine diamond orfinishing carbide bur). The buccal and

lingual embrasures were minimally

finished (because little excess was

present) with an experimental finishing

disk.

It was necessary to carry out minor

adjustments using a fine-grit finishing

diamond on the distal-buccal cusp of the

second lower molar. Polishing was

accomplished with PoGo and Prisma

Gloss Polishing Pastes (aluminum-oxide

based, DENTSPLY). The natural anatomy

and the obvious resulting marginal

integration are excellent, with no post-

operative sensitivity detected. Moreover,

the restoration boasts a natural secondaryanatomy as well as a correct and

functional anatomy of the cusp ridges and

buccal surfaces. Because these structures

are corresponding to a natural anatomy

and are occlusaly adjusted, the restoration

will most likely be more resistant since itwas possible to add more composite to the

whole area of the restoration without

incurring on interferences during the

mandibular excursions.

Discussion and Conclusions

The use of an evidence-based and

simplified technique greatly facilitates and

reduces working time allowing for

predictable and assured results. A reduced

work time ensures better accuracy and

acuity, which translate into predictabilityand reproducibility. The right materials also

have a remarkable potential to

synergistically interact with the right

techniques, culminating in easier and fast

restorations. The minimal invasive

technique used to prepare the teeth

promotes tissue conservation andmaintenance of undermined enamel,

which greatly reduces the external

extension and size of the preparation.5,6,7

The preservation of the affected dentine

minimizes potential for pulpal inflammationor pulpal necrosis. In addition, several

studies have demonstrated that smaller

composite restorations impart a higher

survival rate and the clinician should

therefore maintain as much sound tissue

as possible, even if that meansunsupported enamel (unsupported enamel

can be reinforced with a base or regular

composite material). The cavity promotesbetter adhesion as well as cleaner

surfaces to bond to and therefore have an

aesthetic appeal. The use of round bursprevents the formation of acute angles,

which might induce to stress areas and

induce crack formation and propagation.

The use of a dental adhesive based on

tertiary-butanol solvent (XP BOND,DENTSPLY) allows for a larger window of

opportunity regarding the control of

dentinal moisture prior to the adhesive

placement.

Fig. 11C

Fig. 11D

Figs. 11A, 11B, 11C, 11D. Placement

of the occlusal increments.

Fig. 15A

Fig. 15B

Figs. 15A, 15B. Immediate final

results after minor occlusal adjustment

and polishing with PoGo (One StepDiamond Micro-Polisher, DENTSPLY).

Fig. 12

Fig. 12.Application of tint material.

Fig. 13

Fig. 13. Final polymerization of each

restoration for 20 seconds with a

minimum output of 800 mW/cm2

Fig. 14

Fig. 14. Finishing performed withEnhance (DENTSPLY).

Continued over page >>>


16/22

Dynamics

Dynamics16

The immediate dentinal sealing technique

(SDR, DENTSPLY) protects the dentinal

bond obtained and ensures for long-term

retention, as far as the dentinal bonding is

concerned.

The use of a sectional matrix system withintegrated wedge system such as

Palodent Plus allowed for a somewhat

unprecedented procedure involving the

restoration of two class II restorationssimultaneously using the same ring and

the same wedge for both preparations.

Further, the Palodent Plus Sectional Matrix

System allowed for a natural contour of the

bands, a better control of the points of

contact and minimized finishing and

polishing. The use of the base material

SDR, which presents self-leveling, self-adaptation, 4-milimeter increment

application and low-shrinkage stressallows the clinician to operate in a user-

friendly, predictable, consistent and

reproducible manner. Incidentally, the time

spared with the base build-up allows theoperator to dedicate more time for an

effective and more realistic occlusal

restoration, which on its turn favouring

a final restoration with less occlusal

adjustments and finishing requirements.

Composite restorative materials are

frequently selected for the aesthetic

restorations of the posterior dentition dueoften to their potential for adhesion2,3 tooth

reinforcement and lifelike appearance.

With the right materials and technique, the

clinician can not only accomplish a

biological, mechanical and aestheticrestoration, but also in an effective and

swift manner and actually enjoy it and

have fun during the process.


17/22

In a class II of its own

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onth

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36 MonthClinical Trial Results*

No ailures attributable to SDR

No recurrent caries No post-operative sensitivities

NEW

Increments up to 4mm withoutlayering

Unique sel-levelling consistency Excellent fow-like cavity adaption Compatible with your current

adhesive**

** chemically compatible with methacrylate basedadhesives and composites.

Advanced Matrix System

Bulk fll up to 4 mm

Predictable tight contacts Tight gingival seal Less flash, less finishing Easy-to-use system

* Data on le


18/22

Dynamics

Dynamics18

Clinical application of theDENTSPLY Endo-

Resto Systemby Claudia Schaller, Dr. med. dent.

The recently introduced DENTSPLY Endo-Resto System has been

designed for immediate post-endodontic restorative treatment. This

perfectly matched kit contains all the materials necessary to create

a safe post-endodontic adhesive seal of root canal fillings. Studies

have shown that root canal fillings alone never offer a reliable seal,

regardless of the material or technique employed (Magura et al.,

1991; Wu et al., 1998). For this reason, the importance of an

effective post-endodontic seal for the long-term prognosis of an

endodontically treated tooth is similar to that of the endodontic

treatment itself: The success rate of even a good root canal

obturation is massively reduced if the seal is poor and insufficient

(Ray and Trope, 1995)

If a root canal filling is exposed to the oral

environment for more than three months,

one must expect it to be infected

throughout (Wu et al., 1998). This situationis not all that uncommon in everyday

practice, as core restorations, fillings or

crowns may develop leakage. If the

affected teeth are subsequently re-treated,

they will often develop apical lesions, or

existing apical lesions may fail to heal.Health insurance guidelines that preclude

immediate post-endodontic restorative

treatment unintentionally aggravate the

problem.

The Endo-Resto System is a completesolution (Figure 1) that facilitates cleaning

of the endodontic cavity following root

canal treatment. The AH Plus Cleaner

removes all excess AH Plus sealer. In a

second step, the cavity floor and walls are

lined with a thin-flowing composite resin(SDR) for a complete anti-bacterial seal.

This article describes how this was

implemented in a specific clinical re-

treatment case.

A 32-year-old man in general good health

presented with minor complaints

emanating from tooth 46. He had soughtemergency dental help the previous

weekend due to increasing occlusal pain

in the right mandible. The emergency

dentist had prescribed an antibiotic and

recommended to have the tooth removed

or and an apicoectomy to be performed.

At the time of presentation, the complaints

had largely subsided. The patient reportedhaving noted a sensation of pressure on

previous occasions, at times accompanied

by a bad taste. The root canal treatment

for this tooth had been performed many

years previously, while the crown

restoration had been delivered only three

or four years ago (Figure 2).

An intraoral fistula was found at site 46.The tooth was slightly tender to

percussion. Pocket depth was between 2

and 4 mm. The tooth was not mobile and

showed incipient grade I furcation

involvement. Radiographs showed an

insufficiently endodontically treated tooth46 with a pronounced peri-radicular

translucency, primarily around the distal

root, and in incipient interradicular

translucency. In addition to three treated

root canals that were underfilled, it was

suspected that a fourth canal was present(Figure 3).

Fig. 1

Fig. 3

Fig. 2


19/22

Dynamics

Dynamics 19

The patient was advised of the possibilities

associated with revision surgery as well as

of alternative treatment modes (extraction

followed by bridge or implant treatment).The patient was very keen on preserving

the tooth and opted for revision surgery.

Rubber dam having been duly placed, the

metal-ceramic crown was trephined. Thepulp cavity exhibited a greasy gangrenousmass mixed with sealer and excess gutta-

percha from the old root canal filling,

accompanied by fetor (Figure 4). After

cleaning and rinsing with NaClO, it was

found that four root canal orifices were in

fact present. The distal lingual canal hadnot been treated. The old root canal filling

material was removed completely. All four

canals could be instrumented up to the

apical constriction and were prepared in a

hybrid technique using manual files and

the ProTaper Universal system (Figure

5).

This was followed by sonic NaClO rinses

and application of a calcium hydroxide

medical root canal dressing. The accesscavity was adhesively sealed (using atemporary filling material, XP Bond and

SDR). Six weeks later, the patient, by

now pain-free, presented for placement of

the new root canal filling. He reported that

the fistula had disappeared as soon as

three days after the previous treatment.

Rubber dam was once again placed and

the adhesive seal removed. This was

followed by another extensive sonic rinse

(EndoActivator) with NaClO, EDTA and

CHX and subsequent drying of the canals.

The filling material was introducedthermoplastically using vertical compaction

with gutta-percha and AH Plus. During a

radiological inspection of the root canal

filling (Figure 6), it was noted that the

periapical and interradicular translucencies

had already subsided somewhat.

Following the radiological control of the

root canal filling, the gutta-percha in all four

canals was cut off slightly below the orifice,

making sure that no residual gutta-percha

remained on the cavity floor or walls

(Figure 7).

Using small foam rubber pellets (Roeko

Endo Frost Pellets) soaked in AH Plus

Cleaner, the entire cavity was cleaned

from sealer residue. AH Plus Cleaner was

developed specifically for the removal ofAH Plus. The cleaning procedure was

repeated until the milky-white layer had

disappeared, followed by a thorough rinse

with water spray. The floor of the pulp

cavity and the trephined access cavity

were then etched with phosphoric acid(DETREY Conditioner) for 15 seconds.

Another rinse was performed to ensure

that the etch gel was removed completely.

After drying, XP Bond was introduced withan applicator, allowed to soak for 20

seconds and then air-thinned forapproximately 5 seconds. While no excess

liquid should remain in the cavity, the

dentine should not be excessively dry,

either. The XP Bond was then light-cured

for 10 seconds. The next step was theapplication of a thin layer of SDR, which

thanks to the long metal cannula of the

compula is easily directed specifically to

the canal orifices. SDR is flowable; the

material will distribute evenly all by itself

(Figure 8). If, in rare cases, a small air

bubble does form, it can be removed witha probe and the SDR can be spread to fill

the void. The first layer was polymerized

with a curing lamp for 20 seconds. Given

the high transparency of SDR, thorough

curing is possible even in deep cavities;

layers may be up to 4 mm in depth. Since

the material is not designed for occlusalareas, definitive occlusal closure is always

made with a methacrylate-based universal

composite resin.

The Endo-Resto System provides a useful

match of endodontic and post-endodontic

components. This combination of materialshas been scientifically examined (Hopp et

al., 2010) and certified as a system. I

personally consider it a great help for in-

office quality management. From a clinical

point of view, I appreciate that theimmediate adhesive seal of the endodontic

cavity renders reinfection or microleakage

less likely. Furcal accessory canals in

molars such as those frequently seen in

younger patients are also sealed

effectively. Finally, tooth stability, which iscompromised by the endodontic access

cavity and reduced by approximately 60%,

is increased because the adhesive

chemical bond between the SDR, the

capping (composite resin) and the tooth

has a stabilizing effect. None of thesepositive effects can be achieved with non-

adhesive sealer such as cements.

References

Hopp I, Roggendorf M, Petschelt A, Ebert

J. Secondary protective seal with SDR.Part 1: dye penetration test. IFEA (2010).

Magura ME, Kafrawy AH, Brown CE, Jr.,

Newton CW (1991). Human saliva coronalmicroleakage in obturated root canals: an

in vitro study. J Endod17(7):324-31.

Ray HA, Trope M (1995). Periapical status

of endodontically treated teeth in relation

to the technical quality of the root filling and

the coronal restoration. Int Endod J

28(1):12-8.

Wu MK, Pehlivan Y, Kontakiotis EG,

Wesselink PR (1998). Microleakage along

apical root fillings and cemented posts. J

Prosthet Dent79(3):264-9.

(First publication in Endodontie Journal

2/2012)

Fig. 4

Fig. 5

Fig. 7

Fig. 6

Fig. 8


20/22

Dynamics

Dynamics20

Fig 1. Initial situation. Fig 2. Plaque disclosed in

the patients mouth.

Fig 3. Debridement. Fig 4.Application of Nupro

Sensodyne prophy

paste at end of

treatment.

Fig 1.Advanced Periodontal

disease in the patient.

Fig 2. Pre-treatment

application of NuproSensodyne prophy

paste.

Fig 3. Periodontal treatmentafter use of the

Nupro Sensodyne

prophy paste.

by Dr. Antonella Abbinante (Bari, Italy)

Discover all the benefits of the new prophylaxis paste, Nupro

Sensodyne, now enriched with exclusive Novamintechnology for

immediate relief from dentinal sensitivity.1

Nupro Sensodyne prophy paste actually provides immediate relief from dentinalsensitivity while continuing to offer all the benefits which you would expect from the

Nupro brand, including excellent polishing properties.

Nupro Sensodyne is the only prophy paste to offer the triple benefit of stain

removal, polishing and desensitisation in a single step.

Clinical case number one

Nupro Sensodyne: Hypersensitivity (post-treatment)Female patient, 70 years, non-smoker.

Diagnosis: Periodontitis (mild to moderate), recession,

plaque and tartar. After debridement the patient indicatedsome sensitivity. Debridement procedures frequently cause

gingival recession, and even patients who do not normally

suffer dentinal sensitivity can experience the problem after

professional oral hygiene treatments. At the end of the

procedure Nupro Sensodyne prophy paste was used (stain

removal).

After use of the paste, the patient noted a reduction in

sensitivity and was able to continue as normal without

reporting discomfort from the debridement. Nupro Sensodyne

prophy paste (stain removal) was used to reduce bothsensitivity and surface discolouration.

Clinical case number two

Nupro Sensodyne: Hypersensitivity (pre-treatment)

Female patient, 65 years, non-smoker.

Diagnosis:Advanced periodontal diseaseSymptoms: Hypersensitivity prior to non-surgical periodontal

treatment.

Nupro Sensodyne prophy paste (polishing) was applied

before commencing periodontal treatment. Symptoms were

significantly reduced after use and allowed non-surgical

periodontal treatment to be carried out without anaesthesia

and without causing discomfort to the patient, despite the

compromised pre-treatment clinical situation. Use of theprophy paste allowed periodontal debridement to be carried

out without further symptoms.

The paste was also used after treatment (stain removal) to

reduce post-treatment symptoms and to remove the majorityof the stains.

Pictures by kind permission of

Dr. Antonella Abbinante, Italy

1Data on file


21/22


22/22

For dental professionals striving for greater comfort!

Te next big step in ultrasonicscaling: ap-On echnology

NEW! The next big steps in ultrasonic scaling: NEW Tap-On Technology is designed to reduce hygienist leg strain A single tap activates or deactivates scaling or air polishing, allowing

you to rest your oot during the procedure

Prophy Mode Auto Cycles designed to improve ef ciency

Additional power options enable quick removal o tenacious calculus Expanded Blue Zone or improved patient comort

Patented Sustained Perormance System: SPS to maintain tip strokeautomatically

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dynamics 17 web version.pdf

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