PowerPoint Presentationd1ue90e5sp4tcv.cloudfront.net/1946/images/Asset291031_v1.pdfWidescreen Test...
46
2/26/2016 1 Widescreen Test Pattern (16:9) Aspect Ratio Test (Should appear circular) 16x9 4x3 TODD C. SNYDER, DDS, AAACD • PRIVATE PRACTICE IN LAGUNA NIGUEL, CALIFORNIA • ACCREDITED, AMERICAN ACADEMY OF COSMETIC DENTISTRY • FORMER FACULTY, UCLA CENTER FOR ESTHETIC DENTISTRY • FACULTY, ESTHETIC PROFESSIONALS • MEMBER OF CATAPULT ELITE • F.A.C.E. GRADUATE • CBDO, CONTENTACTIVATOR.COM • CEO, MILES TO SMILES® Catapult Group is an organization which consists of top clinicians and educators from throughout the United States and Canada. This group of like- minded yet diverse dentist’s goal is to bring quality education to the dental community via multiple venues including; live lecture, participation, web based, and written formats. Todd Snyder, DDS, AAACD Laguna Niguel, CA Aesthetic Dental Designs ® Member of Catapult Elite [email protected] DISCLAIMER As a Catapult Group member we participate in multiple product reviews each year in order to stay at the fore front of the latest materials, techniques and services available, ensuring that the message we are delivering is current and relevant to today’s continuing education needs. Some of these products & services I will be sharing with you today. Today I am supported in part by: Dentsply All the work shown is my own and unaltered Digital Handouts WWW.DENTOOLZ.COM tomorrow
Transcript of PowerPoint Presentationd1ue90e5sp4tcv.cloudfront.net/1946/images/Asset291031_v1.pdfWidescreen Test...
2262016
1
Widescreen Test Pattern (169)
Aspect Ratio Test
(Should appear circular)
16x9
4x3
TODD C SNYDER DDS AAACD
bull PRIVATE PRACTICE IN LAGUNA NIGUEL CALIFORNIA
bull ACCREDITED AMERICAN ACADEMY OF COSMETIC DENTISTRY
bull FORMER FACULTY UCLA CENTER FOR ESTHETIC DENTISTRY
bull FACULTY ESTHETIC PROFESSIONALS
bull MEMBER OF CATAPULT ELITE
bull FACE GRADUATE
bull CBDO CONTENTACTIVATORCOM
bull CEO MILES TO SMILESreg
Catapult Group is an organization which consists of top clinicians and
educators from throughout the United States and Canada This group of like-
minded yet diverse dentistrsquos goal is to bring quality education to the dental
community via multiple venues including live lecture participation web based
and written formats
Todd Snyder DDS AAACD
Laguna Niguel CAAesthetic Dental Designsreg
Member of Catapult Elite
doctcsdentalcom
DISCLAIMER
As a Catapult Group member we participate in multiple product reviews
each year in order to stay at the fore front of the latest materials
techniques and services available ensuring that the message we are
delivering is current and relevant to todayrsquos continuing education needs
Some of these products amp services I will be sharing with you today
Today I am supported in part by
Dentsply
All the work shown is my own and unaltered
Digital Handouts
WWWDENTOOLZCOMtomorrow
2262016
2
Digital Handouts
Are you still diagnosing with this
50
accurate
Is it thru conventional radiographic analysisApproximately 25 demineralization must occur to see a cavity on a conventional radiograph
Equates to 40-60 demineralization on the tooth surface Radiographs miss 70-80 of
occlusal cavitiesDigital radiographs provide the ability to manipulate image size and appearance
67
accuracy
2262016
3
Thru intraoral photographic interpretation
How do you diagnose decay
2262016
4
What fluoresces in fluorescent-based technologies
Bacterial porphyrins (bacterial breakdown product)
Stain
Tartar
Food debris
All fluoresce under the wavelengths used in most caries detection devices
whether or not caries is present
bull Lussi A Imwinkelried S Pitts N Longbottom C Reich E Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro Caries Res 199933(4)261ndash266
bull Lussi A Hibst R Paulus R DIAGNOdent an optical method for caries detection J Dent Res 200483C C80ndash83
bull Verdonschot E H van der Veen M H Lasers in dentistry 2 Diagnosis of dental caries with lasers Ned Tijdschr Tandheelkd 2002109(4) 122ndash126
bull Konig K Flemming G Hibst R Laser-induced autofluorescence spectroscopy of dental caries Cell Mol Biol (Noisy-le-grand) 199844(8) 1293ndash1300
bull Alwas-Danowska HM Plasschaert AJ Suliborski S Verdonschot EH Reliability and validity issues of laser fluorescence measurements in occlusal caries diagnosis J Dent 200230(4)129-34
bull Rechmann P Rechmann BM Featherstone JD Caries detection using light-based diagnostic tools Compend Contin Educ Dent 201233(8)582-4 586 588-93 quiz 594 596
Fluorescent Technologies KAVO Dia Lux 2300LDexis CariVu
bull One can place a number of restorations or fillings and yet not treat the
underlying disease
bull The bacteria remain in the plaque on the teeth capable of creating new
areas of tooth decay
bull Patients value a shift from a surgical approach to disease management
and prevention
The Canary System Detects Cracks amp Cavities not
Visible on X-rays
+ Around amp beneath intact margins of fillings amp crowns
+ Under sealants (including opaque sealants)
+ On proximal surfaces
+ On smooth surfaces pits amp grooves
+ Around orthodontic brackets
Measures tooth structure breakdown allows for early
treatment
+ Restore conservatively
+ Remineralize back to health
+ Seal with confidence
Research claims validated by 60+ papers
15+ case reports amp 2 FDA CFR 21 clinical trials
bull Pulses (2 Hz) of laser light hit the tooth surface
bull Tooth glows (Luminescence LUM) and releases heat (Photo-Thermal Radiometry PTR)
bull Defective tooth crystal structure affects the retained heat and luminescence signatures
Energy Conversion Technology
Temperature
increase lt 1oC
not harmful
bull Detected signals reflect the toothrsquos condition
bull Detects 50 micron lesion up to 5 mm below the surface
2262016
5
Delegated Scanning amp Whitening Assistant
Study Designbull 20 tooth surfaces selected with
range of clinical conditions from healthy to early caries
bull Visual ranking by 2 dentists bull Canary Scanbull DIAGNODentbull Polarized Light Microscopy used as
the gold standard to confirm presence of lesion amp depth in that section
Caries Detection Method Canary System DIAGNODent
Sensitivity 100 18
Specificity 100 100
Spearman Correlation with Lesion
Depth
84 21
Jan J et al Caries Res 201448384ndash450 DOI 101159000360836
Objective
To compare the accuracy of The Canary System ICDAS-II and bitewing radiographs in detecting proximal caries
in vitro
Methods
ICDAS-II (Direct Visual Examination) Blinded examiners ranked 100 proximal surfaces using ICDAS-II by direct visual examination of the surfaces
Manikin mouth models The teeth were then set in manikin mouth models creating contacting proximal
surfaces that very closely resemble in vivo situation
Histological validation All surfaces were examined by polarizing-light microscopy to confirm the presence
and depth of the caries lesions
Conclusionbull BW radiographs could only identify 267 of the lesions which questions its ability to be the
gold standard
bull The Canary System is the only method examined with both high sensitivity and high specificity
bull The Canary System is more sensitive than bitewing radiographs in detecting interproximal
caries
No pathology on x-ray Canary Scan
Revealed Pathology on Mesial amp Distal
Marginal Ridge and Caries around the
Lingual Margin of the Amalgam
9758 36
97
58 36Crack on mesial and distal
marginal ridges with caries
Caries around the lingual
marginBitewing radiograph did not detect caries
Caries located on buccal aspect of the contact area
2262016
6
Demineralized
enamelCaries Detection
Method
The Canary
System
DIAGNOdent
Sensitivity 83 64
Specificity 79 46
bull Canary Numbers gt20 when scanning sealants (3Mtrade ESPEtrade Clinprotrade Sealant) placed over pit amp fissure caries
bull The caries detection ability of the Canary System was not affected by sealant amp was more accurate than DIAGNOdent
Sensitivities and specificities
for pit amp fissure caries
detection after sealant
placement
Canary Number 66
Canary Number 37Caries into
dentin
Post-sealant
Pre-sealant
Cross-section
Sealant
After all the cleaning and diagnostic technology being used what if you find something
bull More caries resistant
bull Remineralization
bull Desensitization
bull Apply twice a day AM amp PM
bull After brushing and flossing
bull Pea size amount on finger and rub it on the teeth
bull You can floss it between them as well
bull Rub the material around all the teeth with tongue
bull Leave on the teeth for approximately 3 minutes
bull Spit out excess but do not rinse or drink for 30
minutes
2262016
7
Minimally Invasive Treatment
bull Apply MIPaste Plus for 3 minutes
bull Patient applies at home 2xday
Minimally Invasive Treatment
bull Fluoride Calcium Phosphate and Xylitol
MI VARNISHtrade WITH RECALDENTtrade
(CPP-ACP)
Bioavailable calcium
phosphate and fluoride
Enamelon Now with Stannous Fluoride
Optimized with ACP Technology
bull Stabilized SnF2Formula
bull ACP Technology
bull RDA 8
bull Safe for all age groups
2262016
8
bull Clinpro 5000 with TCP (3M)
bull Enamelon with fluoride and ACP (Premier)
bull Remin Pro (Voco)
bull Sensodyne ProNamel
bull Arm amp Hammerrsquos Enamel Care
bull Arm amp Hammer Complete Care w Enamel Strengthening
bull Colgate Sensitive pro relief
bull Fluoride Varnishes
bull Glass Ionomers
Bacteria
Produce Acid
Attack Enamel
Demineralization
DECAY
Xylitol amp ProBiotics
MI Paste Enamelon
RemineralizeCanary System
Radiograph
SALIVA-CHECK BUFFER from GC America tests for salivary
flow and buffering capacity
Acidulated phosphate fluoride (ApF)
Non-acidic sodium fluoride (pHn)
bull No tooth reduction
bull Adhesive and mechanical retention
bull Radiolucent
Resin Infusion-ICON Resin Infusion-ICON
2262016
9
Huge Marketing Opportunity
bull Remineralizing teeth
bull Non Ionizing Diagnostic Tools
bull Minimally Invasive Dentistry
bull Health Product Sales
bull Community Educational Programs
bull Internet and Local Media Advertising
bull Post information on your responsive website
The same tooth sectioned showing the lesion
penetrating the underlying dentine
How will you diagnose this
How will you prepare
and treat this
TimeLabor Intensive
Layering
Material Adaptation
Polymerization Shrinkage
Volumetric Shrinkage
Sensitivity
Micro leakage
Others
2262016
10
How are you restoring
these different preparations
What Is Your First Step
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
What do you usehellip
hellipand why
2262016
11
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
Understanding Buffering 101
bull Local Anesthetics is an acidic solution with a pH of ~ 39
bull To achieve pulpal analgesia the body needs to raise the pH of the local anesthetic
toward physiological pH ( ~ 74) This can take up to 15 minutes per patient
bull Sodium Bicarbonate is a neutralizing additive solution
bull Buffering (adding sodium bicarbonate to anesthetics) brings pH level closer to
physiologic pH prior to injection meaning that the burning sensation of the injection
is greatly reduced and the patient gets numb almost immediately
bull Buffered Anesthetics more profound anesthesiamdash6000 times more active
anesthetic (active molecules) Logarithmic scale moving from 39 to 74 pH
bull A by-product of buffered anesthetics is a CO2 enriched microbubble that
readily crosses the nerve membrane and in itself contains anesthetic properties
not found in unbuffered anesthetics It essentially produces an immediate
effect similar to that of a topical
Understanding Buffering 102
ANUTRA
For Direct Restorations
Total-Etching
Bonding to EnamelDentin
2262016
12
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process ndash Total Etching
Dentin fluid
Dentin
OdontoblastDentinal tubule
Smear layer37 Phosphoric acid
Adhesion process ndash Total Etching
Dentin fluid
Adhesion process ndash Total-Etching
Adhesive
Etched dentin Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Composite resin
Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Dentin
2262016
13
Dentin
Phosphoric acid
Water
Dentin
No filtration into the collagen fiber Excess drying
Dentin
Shrinkage of collagen fiber
No filtration into the collagen fiber Excess drying
Adhesive
Dentin
Adhesive
Water
Insufficient drying
Dentin
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Use Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
2262016
14
Long term failure occurs at gingival margins and adhesive interfaces
Yiu CK Hiraishi N King NM Tay FR Effect of dentinal surface preparation on bond strength of self-etching adhesives J Adhes Dent 2008 Jun10(3)173-82
Higher bond strengths when using tungsten carbide burs with SE adhesives
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Adhesion process - Self-Etching
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Composite
Adhesion process - Self-EtchingBonding
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Factors that compromise bond durability in restorative dentistry
ldquoThe major shortcoming of contemporaryadhesive restoratives is their limited durability in vivordquo
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
2262016
15
Factors that compromise bond durability in restorative dentistry
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an average replacement time of 57
years due to secondary caries precipitated by bond failurerdquo
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of
intraoral function
Instability of hybrid layers- problem may be more severe than we realize
Factors that compromise bond durability
Hydrophilic dentin bonding (1956 - )
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped within
the mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdown
collagen fibrils that are not protected
Sukala et al (2007)Mazzoni et al (2007)
Franklin Tay amp Dave Pashley Med College of Georgia
BOND DEGREDATIONbull PASHLEY DH TAY FR IMAZATO S HOW TO INCREASE THE DURABILITY OF RESIN-DENTIN BONDS
COMPEND CONTIN EDUC DENT 2011 SEP32(7)60-4 66
RESIN-DENTIN BONDS ARE NOT AS DURABLE AS WAS
PREVIOUSLY THOUGHT MICROTENSILE BOND STRENGTHS
OFTEN FALL 30 TO 40 IN 6 TO 12 MONTHS
2262016
16
4th6th5th
7th
bullCOURTESY PACIFIC UNIVERSITY (DR MARC GUISBERGER)
bullCourtesy Pacific University (Dr Marc Guisberger)
INSTRONbull ULTRA TESTER (ULTRADENT)
bull ULTRA JIG (ULTADENT)
SHEAR BOND TEST RESULTS - 2012
Average Shear Bond Strength to Dentin 242
MPa
bullCourtesy Pacific University (Dr Marc Guisberger)
2262016
17
MaximumMinimum Shear Bond Strength per
Bonding Material
SHEAR BOND TEST RESULTS - 2012
bullCourtesy Pacific University (Dr Marc Guisberger)
NEW ldquoUNIVERSALrdquo SYSTEMS
bull SIMPLE amp EASY TO USE
bull DIRECT amp INDIRECT TECHNIQUES
bull USE AS TOTAL SELECTIVE OR SELF ETCH
bull LOW SENSITIVITY
bull LOTS OF MDP BASED PRODUCTS
Total etch Self etch of
components
Etchant
Primer
Adhesive
The Bonding Agents
Generation4th 5th 6th 7th
Universals
OR How are you restoring
these different preparations
bull Voco (Grandio SO HF Xtra Base)
bull Kerr (Revolution Premise Vertise)
bull Ivoclar (Tetric Flow)
bull Heraeus (Venus Diamond Flow Bulk Fill)
bull SDI (Wave MV HV)
bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)
bull GC America (G-aenial Universal Flo)
bull Dentsply (SureFil SDR EsthetX Flow)
bull Kuraray (Clearfil Majesty ES Flow)
bull Tokuyama (Estelite Flow Quick)
bull 3M (Filtek Supreme Flow Plus)
Flowables
How are you restoring
these different preparations
2262016
18
Tokyo Medical amp Dental University 2010 J Tagami et al
FLOWABLE COMPOSITE SHRINKAGE(2MM BULK FILL W 71WT FLOWABLE ON DENTIN ONLY)
SureFill SDR amp CLEARFIL SE BOND
Enamel amp Variable Dentin Bonding
ProblemVARYING TOOTH SUBSTRATES
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treatingldquoAdhesive dentistry could be expressed as a simple
relationship between bonds and stress If the bonds
can withstand the stress the restorative technique will
be successfulrdquo
Unterbrink and Liebenberg (1999)
2262016
19
ldquoC-FACTORrdquo DEFINITION
CONFIGURATION FACTOR
ldquoTHE RATIO OF BONDED TO UN-BONDED (FREE) SURFACESrdquo
FEILZER DEGEE DAVIDSON (1987) UNIVERSTIY OF AMSTERDAM ACTA
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
Excellent Flow amp Handling Base Lining
ldquoC-FACTORrdquoRESIN TO DENTIN HYBRID ZONE
PREPARATIONS gt 2MM
bull TRADITIONALLY NUMEROUS INCREMENTS HAVE TO BE PLACED TO DIMINISH POLYMERIZATION
SHRINKAGE AS WELL AS STRESS ON TOOTH STRUCTURE
Technique
05mm Flowable amp Bonding Agent
Composite
Normallyhellip
2mm
2262016
20
Technique
BOND STRENGTHS RELATED TO TYPE OF DENTITION
05
101520253035404550
45 45
30 30 30
10
Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210
Caries Detector
Caries Detector by
Kuraray Dental is the
original caries detecting
stain material It was
developed by Dr
Fusayama amp Kuraray
Dental at the Tokyo
Medical amp Dental School
in 1978
2262016
21
CARIES INDICATOR DYES
bull ROYDENT-TO DYE FOR
bull KURARAY-CARIES DETECTOR
bull ULTRADENT-SEEKSABLE SEEK
bull PROOPTIONS-CARIES INDICATOR
bull DANVILLE-CARIES FINDER
bull PULPDENT-SNOOP
bull VISTA-CARIES INDICATOR
bull RONVIG-SEE IT
bull PATTERSON-
bull HENRY SCHEIN-
bull PEARSON-
CARIES DETECTOR 86 ACCURACY
bull AS NOTED BY SOUTHERN ILLINOIS DENTAL SCHOOL IN-VITRO RESEARCH
bull ldquoCARIES DETECTOR SOLUTION IDENTIFIED 86 OF SUBSEQUENTLY CONFIRMED CARIES
LESIONS AFTER SECTIONINGrdquo
bull REFERENCE CARIES DETECTION ACCURACY BY
MULTIPLE CLINICIANS amp TECHNIQUES THOMAS LAND WILSON amp GREGORY STEWART DDS SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF DENTAL MEDICINE IADR ABSTRACT 3127 1998
CARIES REMOVAL BURSbull SS WHITE
bull SINGLE USE
bull POLYMER
bull HARDNESS
bull 5000-10000 RPMS
bull KOMET
bull MULTI USE
bull CERAMIC
bull HARDNESS
bull 1000-1500 RPMS
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443
Current concepts amp techniques for caries excavation amp adhesion to residual dentin
de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
2
Digital Handouts
Are you still diagnosing with this
50
accurate
Is it thru conventional radiographic analysisApproximately 25 demineralization must occur to see a cavity on a conventional radiograph
Equates to 40-60 demineralization on the tooth surface Radiographs miss 70-80 of
occlusal cavitiesDigital radiographs provide the ability to manipulate image size and appearance
67
accuracy
2262016
3
Thru intraoral photographic interpretation
How do you diagnose decay
2262016
4
What fluoresces in fluorescent-based technologies
Bacterial porphyrins (bacterial breakdown product)
Stain
Tartar
Food debris
All fluoresce under the wavelengths used in most caries detection devices
whether or not caries is present
bull Lussi A Imwinkelried S Pitts N Longbottom C Reich E Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro Caries Res 199933(4)261ndash266
bull Lussi A Hibst R Paulus R DIAGNOdent an optical method for caries detection J Dent Res 200483C C80ndash83
bull Verdonschot E H van der Veen M H Lasers in dentistry 2 Diagnosis of dental caries with lasers Ned Tijdschr Tandheelkd 2002109(4) 122ndash126
bull Konig K Flemming G Hibst R Laser-induced autofluorescence spectroscopy of dental caries Cell Mol Biol (Noisy-le-grand) 199844(8) 1293ndash1300
bull Alwas-Danowska HM Plasschaert AJ Suliborski S Verdonschot EH Reliability and validity issues of laser fluorescence measurements in occlusal caries diagnosis J Dent 200230(4)129-34
bull Rechmann P Rechmann BM Featherstone JD Caries detection using light-based diagnostic tools Compend Contin Educ Dent 201233(8)582-4 586 588-93 quiz 594 596
Fluorescent Technologies KAVO Dia Lux 2300LDexis CariVu
bull One can place a number of restorations or fillings and yet not treat the
underlying disease
bull The bacteria remain in the plaque on the teeth capable of creating new
areas of tooth decay
bull Patients value a shift from a surgical approach to disease management
and prevention
The Canary System Detects Cracks amp Cavities not
Visible on X-rays
+ Around amp beneath intact margins of fillings amp crowns
+ Under sealants (including opaque sealants)
+ On proximal surfaces
+ On smooth surfaces pits amp grooves
+ Around orthodontic brackets
Measures tooth structure breakdown allows for early
treatment
+ Restore conservatively
+ Remineralize back to health
+ Seal with confidence
Research claims validated by 60+ papers
15+ case reports amp 2 FDA CFR 21 clinical trials
bull Pulses (2 Hz) of laser light hit the tooth surface
bull Tooth glows (Luminescence LUM) and releases heat (Photo-Thermal Radiometry PTR)
bull Defective tooth crystal structure affects the retained heat and luminescence signatures
Energy Conversion Technology
Temperature
increase lt 1oC
not harmful
bull Detected signals reflect the toothrsquos condition
bull Detects 50 micron lesion up to 5 mm below the surface
2262016
5
Delegated Scanning amp Whitening Assistant
Study Designbull 20 tooth surfaces selected with
range of clinical conditions from healthy to early caries
bull Visual ranking by 2 dentists bull Canary Scanbull DIAGNODentbull Polarized Light Microscopy used as
the gold standard to confirm presence of lesion amp depth in that section
Caries Detection Method Canary System DIAGNODent
Sensitivity 100 18
Specificity 100 100
Spearman Correlation with Lesion
Depth
84 21
Jan J et al Caries Res 201448384ndash450 DOI 101159000360836
Objective
To compare the accuracy of The Canary System ICDAS-II and bitewing radiographs in detecting proximal caries
in vitro
Methods
ICDAS-II (Direct Visual Examination) Blinded examiners ranked 100 proximal surfaces using ICDAS-II by direct visual examination of the surfaces
Manikin mouth models The teeth were then set in manikin mouth models creating contacting proximal
surfaces that very closely resemble in vivo situation
Histological validation All surfaces were examined by polarizing-light microscopy to confirm the presence
and depth of the caries lesions
Conclusionbull BW radiographs could only identify 267 of the lesions which questions its ability to be the
gold standard
bull The Canary System is the only method examined with both high sensitivity and high specificity
bull The Canary System is more sensitive than bitewing radiographs in detecting interproximal
caries
No pathology on x-ray Canary Scan
Revealed Pathology on Mesial amp Distal
Marginal Ridge and Caries around the
Lingual Margin of the Amalgam
9758 36
97
58 36Crack on mesial and distal
marginal ridges with caries
Caries around the lingual
marginBitewing radiograph did not detect caries
Caries located on buccal aspect of the contact area
2262016
6
Demineralized
enamelCaries Detection
Method
The Canary
System
DIAGNOdent
Sensitivity 83 64
Specificity 79 46
bull Canary Numbers gt20 when scanning sealants (3Mtrade ESPEtrade Clinprotrade Sealant) placed over pit amp fissure caries
bull The caries detection ability of the Canary System was not affected by sealant amp was more accurate than DIAGNOdent
Sensitivities and specificities
for pit amp fissure caries
detection after sealant
placement
Canary Number 66
Canary Number 37Caries into
dentin
Post-sealant
Pre-sealant
Cross-section
Sealant
After all the cleaning and diagnostic technology being used what if you find something
bull More caries resistant
bull Remineralization
bull Desensitization
bull Apply twice a day AM amp PM
bull After brushing and flossing
bull Pea size amount on finger and rub it on the teeth
bull You can floss it between them as well
bull Rub the material around all the teeth with tongue
bull Leave on the teeth for approximately 3 minutes
bull Spit out excess but do not rinse or drink for 30
minutes
2262016
7
Minimally Invasive Treatment
bull Apply MIPaste Plus for 3 minutes
bull Patient applies at home 2xday
Minimally Invasive Treatment
bull Fluoride Calcium Phosphate and Xylitol
MI VARNISHtrade WITH RECALDENTtrade
(CPP-ACP)
Bioavailable calcium
phosphate and fluoride
Enamelon Now with Stannous Fluoride
Optimized with ACP Technology
bull Stabilized SnF2Formula
bull ACP Technology
bull RDA 8
bull Safe for all age groups
2262016
8
bull Clinpro 5000 with TCP (3M)
bull Enamelon with fluoride and ACP (Premier)
bull Remin Pro (Voco)
bull Sensodyne ProNamel
bull Arm amp Hammerrsquos Enamel Care
bull Arm amp Hammer Complete Care w Enamel Strengthening
bull Colgate Sensitive pro relief
bull Fluoride Varnishes
bull Glass Ionomers
Bacteria
Produce Acid
Attack Enamel
Demineralization
DECAY
Xylitol amp ProBiotics
MI Paste Enamelon
RemineralizeCanary System
Radiograph
SALIVA-CHECK BUFFER from GC America tests for salivary
flow and buffering capacity
Acidulated phosphate fluoride (ApF)
Non-acidic sodium fluoride (pHn)
bull No tooth reduction
bull Adhesive and mechanical retention
bull Radiolucent
Resin Infusion-ICON Resin Infusion-ICON
2262016
9
Huge Marketing Opportunity
bull Remineralizing teeth
bull Non Ionizing Diagnostic Tools
bull Minimally Invasive Dentistry
bull Health Product Sales
bull Community Educational Programs
bull Internet and Local Media Advertising
bull Post information on your responsive website
The same tooth sectioned showing the lesion
penetrating the underlying dentine
How will you diagnose this
How will you prepare
and treat this
TimeLabor Intensive
Layering
Material Adaptation
Polymerization Shrinkage
Volumetric Shrinkage
Sensitivity
Micro leakage
Others
2262016
10
How are you restoring
these different preparations
What Is Your First Step
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
What do you usehellip
hellipand why
2262016
11
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
Understanding Buffering 101
bull Local Anesthetics is an acidic solution with a pH of ~ 39
bull To achieve pulpal analgesia the body needs to raise the pH of the local anesthetic
toward physiological pH ( ~ 74) This can take up to 15 minutes per patient
bull Sodium Bicarbonate is a neutralizing additive solution
bull Buffering (adding sodium bicarbonate to anesthetics) brings pH level closer to
physiologic pH prior to injection meaning that the burning sensation of the injection
is greatly reduced and the patient gets numb almost immediately
bull Buffered Anesthetics more profound anesthesiamdash6000 times more active
anesthetic (active molecules) Logarithmic scale moving from 39 to 74 pH
bull A by-product of buffered anesthetics is a CO2 enriched microbubble that
readily crosses the nerve membrane and in itself contains anesthetic properties
not found in unbuffered anesthetics It essentially produces an immediate
effect similar to that of a topical
Understanding Buffering 102
ANUTRA
For Direct Restorations
Total-Etching
Bonding to EnamelDentin
2262016
12
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process ndash Total Etching
Dentin fluid
Dentin
OdontoblastDentinal tubule
Smear layer37 Phosphoric acid
Adhesion process ndash Total Etching
Dentin fluid
Adhesion process ndash Total-Etching
Adhesive
Etched dentin Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Composite resin
Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Dentin
2262016
13
Dentin
Phosphoric acid
Water
Dentin
No filtration into the collagen fiber Excess drying
Dentin
Shrinkage of collagen fiber
No filtration into the collagen fiber Excess drying
Adhesive
Dentin
Adhesive
Water
Insufficient drying
Dentin
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Use Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
2262016
14
Long term failure occurs at gingival margins and adhesive interfaces
Yiu CK Hiraishi N King NM Tay FR Effect of dentinal surface preparation on bond strength of self-etching adhesives J Adhes Dent 2008 Jun10(3)173-82
Higher bond strengths when using tungsten carbide burs with SE adhesives
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Adhesion process - Self-Etching
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Composite
Adhesion process - Self-EtchingBonding
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Factors that compromise bond durability in restorative dentistry
ldquoThe major shortcoming of contemporaryadhesive restoratives is their limited durability in vivordquo
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
2262016
15
Factors that compromise bond durability in restorative dentistry
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an average replacement time of 57
years due to secondary caries precipitated by bond failurerdquo
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of
intraoral function
Instability of hybrid layers- problem may be more severe than we realize
Factors that compromise bond durability
Hydrophilic dentin bonding (1956 - )
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped within
the mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdown
collagen fibrils that are not protected
Sukala et al (2007)Mazzoni et al (2007)
Franklin Tay amp Dave Pashley Med College of Georgia
BOND DEGREDATIONbull PASHLEY DH TAY FR IMAZATO S HOW TO INCREASE THE DURABILITY OF RESIN-DENTIN BONDS
COMPEND CONTIN EDUC DENT 2011 SEP32(7)60-4 66
RESIN-DENTIN BONDS ARE NOT AS DURABLE AS WAS
PREVIOUSLY THOUGHT MICROTENSILE BOND STRENGTHS
OFTEN FALL 30 TO 40 IN 6 TO 12 MONTHS
2262016
16
4th6th5th
7th
bullCOURTESY PACIFIC UNIVERSITY (DR MARC GUISBERGER)
bullCourtesy Pacific University (Dr Marc Guisberger)
INSTRONbull ULTRA TESTER (ULTRADENT)
bull ULTRA JIG (ULTADENT)
SHEAR BOND TEST RESULTS - 2012
Average Shear Bond Strength to Dentin 242
MPa
bullCourtesy Pacific University (Dr Marc Guisberger)
2262016
17
MaximumMinimum Shear Bond Strength per
Bonding Material
SHEAR BOND TEST RESULTS - 2012
bullCourtesy Pacific University (Dr Marc Guisberger)
NEW ldquoUNIVERSALrdquo SYSTEMS
bull SIMPLE amp EASY TO USE
bull DIRECT amp INDIRECT TECHNIQUES
bull USE AS TOTAL SELECTIVE OR SELF ETCH
bull LOW SENSITIVITY
bull LOTS OF MDP BASED PRODUCTS
Total etch Self etch of
components
Etchant
Primer
Adhesive
The Bonding Agents
Generation4th 5th 6th 7th
Universals
OR How are you restoring
these different preparations
bull Voco (Grandio SO HF Xtra Base)
bull Kerr (Revolution Premise Vertise)
bull Ivoclar (Tetric Flow)
bull Heraeus (Venus Diamond Flow Bulk Fill)
bull SDI (Wave MV HV)
bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)
bull GC America (G-aenial Universal Flo)
bull Dentsply (SureFil SDR EsthetX Flow)
bull Kuraray (Clearfil Majesty ES Flow)
bull Tokuyama (Estelite Flow Quick)
bull 3M (Filtek Supreme Flow Plus)
Flowables
How are you restoring
these different preparations
2262016
18
Tokyo Medical amp Dental University 2010 J Tagami et al
FLOWABLE COMPOSITE SHRINKAGE(2MM BULK FILL W 71WT FLOWABLE ON DENTIN ONLY)
SureFill SDR amp CLEARFIL SE BOND
Enamel amp Variable Dentin Bonding
ProblemVARYING TOOTH SUBSTRATES
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treatingldquoAdhesive dentistry could be expressed as a simple
relationship between bonds and stress If the bonds
can withstand the stress the restorative technique will
be successfulrdquo
Unterbrink and Liebenberg (1999)
2262016
19
ldquoC-FACTORrdquo DEFINITION
CONFIGURATION FACTOR
ldquoTHE RATIO OF BONDED TO UN-BONDED (FREE) SURFACESrdquo
FEILZER DEGEE DAVIDSON (1987) UNIVERSTIY OF AMSTERDAM ACTA
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
Excellent Flow amp Handling Base Lining
ldquoC-FACTORrdquoRESIN TO DENTIN HYBRID ZONE
PREPARATIONS gt 2MM
bull TRADITIONALLY NUMEROUS INCREMENTS HAVE TO BE PLACED TO DIMINISH POLYMERIZATION
SHRINKAGE AS WELL AS STRESS ON TOOTH STRUCTURE
Technique
05mm Flowable amp Bonding Agent
Composite
Normallyhellip
2mm
2262016
20
Technique
BOND STRENGTHS RELATED TO TYPE OF DENTITION
05
101520253035404550
45 45
30 30 30
10
Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210
Caries Detector
Caries Detector by
Kuraray Dental is the
original caries detecting
stain material It was
developed by Dr
Fusayama amp Kuraray
Dental at the Tokyo
Medical amp Dental School
in 1978
2262016
21
CARIES INDICATOR DYES
bull ROYDENT-TO DYE FOR
bull KURARAY-CARIES DETECTOR
bull ULTRADENT-SEEKSABLE SEEK
bull PROOPTIONS-CARIES INDICATOR
bull DANVILLE-CARIES FINDER
bull PULPDENT-SNOOP
bull VISTA-CARIES INDICATOR
bull RONVIG-SEE IT
bull PATTERSON-
bull HENRY SCHEIN-
bull PEARSON-
CARIES DETECTOR 86 ACCURACY
bull AS NOTED BY SOUTHERN ILLINOIS DENTAL SCHOOL IN-VITRO RESEARCH
bull ldquoCARIES DETECTOR SOLUTION IDENTIFIED 86 OF SUBSEQUENTLY CONFIRMED CARIES
LESIONS AFTER SECTIONINGrdquo
bull REFERENCE CARIES DETECTION ACCURACY BY
MULTIPLE CLINICIANS amp TECHNIQUES THOMAS LAND WILSON amp GREGORY STEWART DDS SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF DENTAL MEDICINE IADR ABSTRACT 3127 1998
CARIES REMOVAL BURSbull SS WHITE
bull SINGLE USE
bull POLYMER
bull HARDNESS
bull 5000-10000 RPMS
bull KOMET
bull MULTI USE
bull CERAMIC
bull HARDNESS
bull 1000-1500 RPMS
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443
Current concepts amp techniques for caries excavation amp adhesion to residual dentin
de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
3
Thru intraoral photographic interpretation
How do you diagnose decay
2262016
4
What fluoresces in fluorescent-based technologies
Bacterial porphyrins (bacterial breakdown product)
Stain
Tartar
Food debris
All fluoresce under the wavelengths used in most caries detection devices
whether or not caries is present
bull Lussi A Imwinkelried S Pitts N Longbottom C Reich E Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro Caries Res 199933(4)261ndash266
bull Lussi A Hibst R Paulus R DIAGNOdent an optical method for caries detection J Dent Res 200483C C80ndash83
bull Verdonschot E H van der Veen M H Lasers in dentistry 2 Diagnosis of dental caries with lasers Ned Tijdschr Tandheelkd 2002109(4) 122ndash126
bull Konig K Flemming G Hibst R Laser-induced autofluorescence spectroscopy of dental caries Cell Mol Biol (Noisy-le-grand) 199844(8) 1293ndash1300
bull Alwas-Danowska HM Plasschaert AJ Suliborski S Verdonschot EH Reliability and validity issues of laser fluorescence measurements in occlusal caries diagnosis J Dent 200230(4)129-34
bull Rechmann P Rechmann BM Featherstone JD Caries detection using light-based diagnostic tools Compend Contin Educ Dent 201233(8)582-4 586 588-93 quiz 594 596
Fluorescent Technologies KAVO Dia Lux 2300LDexis CariVu
bull One can place a number of restorations or fillings and yet not treat the
underlying disease
bull The bacteria remain in the plaque on the teeth capable of creating new
areas of tooth decay
bull Patients value a shift from a surgical approach to disease management
and prevention
The Canary System Detects Cracks amp Cavities not
Visible on X-rays
+ Around amp beneath intact margins of fillings amp crowns
+ Under sealants (including opaque sealants)
+ On proximal surfaces
+ On smooth surfaces pits amp grooves
+ Around orthodontic brackets
Measures tooth structure breakdown allows for early
treatment
+ Restore conservatively
+ Remineralize back to health
+ Seal with confidence
Research claims validated by 60+ papers
15+ case reports amp 2 FDA CFR 21 clinical trials
bull Pulses (2 Hz) of laser light hit the tooth surface
bull Tooth glows (Luminescence LUM) and releases heat (Photo-Thermal Radiometry PTR)
bull Defective tooth crystal structure affects the retained heat and luminescence signatures
Energy Conversion Technology
Temperature
increase lt 1oC
not harmful
bull Detected signals reflect the toothrsquos condition
bull Detects 50 micron lesion up to 5 mm below the surface
2262016
5
Delegated Scanning amp Whitening Assistant
Study Designbull 20 tooth surfaces selected with
range of clinical conditions from healthy to early caries
bull Visual ranking by 2 dentists bull Canary Scanbull DIAGNODentbull Polarized Light Microscopy used as
the gold standard to confirm presence of lesion amp depth in that section
Caries Detection Method Canary System DIAGNODent
Sensitivity 100 18
Specificity 100 100
Spearman Correlation with Lesion
Depth
84 21
Jan J et al Caries Res 201448384ndash450 DOI 101159000360836
Objective
To compare the accuracy of The Canary System ICDAS-II and bitewing radiographs in detecting proximal caries
in vitro
Methods
ICDAS-II (Direct Visual Examination) Blinded examiners ranked 100 proximal surfaces using ICDAS-II by direct visual examination of the surfaces
Manikin mouth models The teeth were then set in manikin mouth models creating contacting proximal
surfaces that very closely resemble in vivo situation
Histological validation All surfaces were examined by polarizing-light microscopy to confirm the presence
and depth of the caries lesions
Conclusionbull BW radiographs could only identify 267 of the lesions which questions its ability to be the
gold standard
bull The Canary System is the only method examined with both high sensitivity and high specificity
bull The Canary System is more sensitive than bitewing radiographs in detecting interproximal
caries
No pathology on x-ray Canary Scan
Revealed Pathology on Mesial amp Distal
Marginal Ridge and Caries around the
Lingual Margin of the Amalgam
9758 36
97
58 36Crack on mesial and distal
marginal ridges with caries
Caries around the lingual
marginBitewing radiograph did not detect caries
Caries located on buccal aspect of the contact area
2262016
6
Demineralized
enamelCaries Detection
Method
The Canary
System
DIAGNOdent
Sensitivity 83 64
Specificity 79 46
bull Canary Numbers gt20 when scanning sealants (3Mtrade ESPEtrade Clinprotrade Sealant) placed over pit amp fissure caries
bull The caries detection ability of the Canary System was not affected by sealant amp was more accurate than DIAGNOdent
Sensitivities and specificities
for pit amp fissure caries
detection after sealant
placement
Canary Number 66
Canary Number 37Caries into
dentin
Post-sealant
Pre-sealant
Cross-section
Sealant
After all the cleaning and diagnostic technology being used what if you find something
bull More caries resistant
bull Remineralization
bull Desensitization
bull Apply twice a day AM amp PM
bull After brushing and flossing
bull Pea size amount on finger and rub it on the teeth
bull You can floss it between them as well
bull Rub the material around all the teeth with tongue
bull Leave on the teeth for approximately 3 minutes
bull Spit out excess but do not rinse or drink for 30
minutes
2262016
7
Minimally Invasive Treatment
bull Apply MIPaste Plus for 3 minutes
bull Patient applies at home 2xday
Minimally Invasive Treatment
bull Fluoride Calcium Phosphate and Xylitol
MI VARNISHtrade WITH RECALDENTtrade
(CPP-ACP)
Bioavailable calcium
phosphate and fluoride
Enamelon Now with Stannous Fluoride
Optimized with ACP Technology
bull Stabilized SnF2Formula
bull ACP Technology
bull RDA 8
bull Safe for all age groups
2262016
8
bull Clinpro 5000 with TCP (3M)
bull Enamelon with fluoride and ACP (Premier)
bull Remin Pro (Voco)
bull Sensodyne ProNamel
bull Arm amp Hammerrsquos Enamel Care
bull Arm amp Hammer Complete Care w Enamel Strengthening
bull Colgate Sensitive pro relief
bull Fluoride Varnishes
bull Glass Ionomers
Bacteria
Produce Acid
Attack Enamel
Demineralization
DECAY
Xylitol amp ProBiotics
MI Paste Enamelon
RemineralizeCanary System
Radiograph
SALIVA-CHECK BUFFER from GC America tests for salivary
flow and buffering capacity
Acidulated phosphate fluoride (ApF)
Non-acidic sodium fluoride (pHn)
bull No tooth reduction
bull Adhesive and mechanical retention
bull Radiolucent
Resin Infusion-ICON Resin Infusion-ICON
2262016
9
Huge Marketing Opportunity
bull Remineralizing teeth
bull Non Ionizing Diagnostic Tools
bull Minimally Invasive Dentistry
bull Health Product Sales
bull Community Educational Programs
bull Internet and Local Media Advertising
bull Post information on your responsive website
The same tooth sectioned showing the lesion
penetrating the underlying dentine
How will you diagnose this
How will you prepare
and treat this
TimeLabor Intensive
Layering
Material Adaptation
Polymerization Shrinkage
Volumetric Shrinkage
Sensitivity
Micro leakage
Others
2262016
10
How are you restoring
these different preparations
What Is Your First Step
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
What do you usehellip
hellipand why
2262016
11
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
Understanding Buffering 101
bull Local Anesthetics is an acidic solution with a pH of ~ 39
bull To achieve pulpal analgesia the body needs to raise the pH of the local anesthetic
toward physiological pH ( ~ 74) This can take up to 15 minutes per patient
bull Sodium Bicarbonate is a neutralizing additive solution
bull Buffering (adding sodium bicarbonate to anesthetics) brings pH level closer to
physiologic pH prior to injection meaning that the burning sensation of the injection
is greatly reduced and the patient gets numb almost immediately
bull Buffered Anesthetics more profound anesthesiamdash6000 times more active
anesthetic (active molecules) Logarithmic scale moving from 39 to 74 pH
bull A by-product of buffered anesthetics is a CO2 enriched microbubble that
readily crosses the nerve membrane and in itself contains anesthetic properties
not found in unbuffered anesthetics It essentially produces an immediate
effect similar to that of a topical
Understanding Buffering 102
ANUTRA
For Direct Restorations
Total-Etching
Bonding to EnamelDentin
2262016
12
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process ndash Total Etching
Dentin fluid
Dentin
OdontoblastDentinal tubule
Smear layer37 Phosphoric acid
Adhesion process ndash Total Etching
Dentin fluid
Adhesion process ndash Total-Etching
Adhesive
Etched dentin Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Composite resin
Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Dentin
2262016
13
Dentin
Phosphoric acid
Water
Dentin
No filtration into the collagen fiber Excess drying
Dentin
Shrinkage of collagen fiber
No filtration into the collagen fiber Excess drying
Adhesive
Dentin
Adhesive
Water
Insufficient drying
Dentin
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Use Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
2262016
14
Long term failure occurs at gingival margins and adhesive interfaces
Yiu CK Hiraishi N King NM Tay FR Effect of dentinal surface preparation on bond strength of self-etching adhesives J Adhes Dent 2008 Jun10(3)173-82
Higher bond strengths when using tungsten carbide burs with SE adhesives
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Adhesion process - Self-Etching
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Composite
Adhesion process - Self-EtchingBonding
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Factors that compromise bond durability in restorative dentistry
ldquoThe major shortcoming of contemporaryadhesive restoratives is their limited durability in vivordquo
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
2262016
15
Factors that compromise bond durability in restorative dentistry
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an average replacement time of 57
years due to secondary caries precipitated by bond failurerdquo
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of
intraoral function
Instability of hybrid layers- problem may be more severe than we realize
Factors that compromise bond durability
Hydrophilic dentin bonding (1956 - )
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped within
the mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdown
collagen fibrils that are not protected
Sukala et al (2007)Mazzoni et al (2007)
Franklin Tay amp Dave Pashley Med College of Georgia
BOND DEGREDATIONbull PASHLEY DH TAY FR IMAZATO S HOW TO INCREASE THE DURABILITY OF RESIN-DENTIN BONDS
COMPEND CONTIN EDUC DENT 2011 SEP32(7)60-4 66
RESIN-DENTIN BONDS ARE NOT AS DURABLE AS WAS
PREVIOUSLY THOUGHT MICROTENSILE BOND STRENGTHS
OFTEN FALL 30 TO 40 IN 6 TO 12 MONTHS
2262016
16
4th6th5th
7th
bullCOURTESY PACIFIC UNIVERSITY (DR MARC GUISBERGER)
bullCourtesy Pacific University (Dr Marc Guisberger)
INSTRONbull ULTRA TESTER (ULTRADENT)
bull ULTRA JIG (ULTADENT)
SHEAR BOND TEST RESULTS - 2012
Average Shear Bond Strength to Dentin 242
MPa
bullCourtesy Pacific University (Dr Marc Guisberger)
2262016
17
MaximumMinimum Shear Bond Strength per
Bonding Material
SHEAR BOND TEST RESULTS - 2012
bullCourtesy Pacific University (Dr Marc Guisberger)
NEW ldquoUNIVERSALrdquo SYSTEMS
bull SIMPLE amp EASY TO USE
bull DIRECT amp INDIRECT TECHNIQUES
bull USE AS TOTAL SELECTIVE OR SELF ETCH
bull LOW SENSITIVITY
bull LOTS OF MDP BASED PRODUCTS
Total etch Self etch of
components
Etchant
Primer
Adhesive
The Bonding Agents
Generation4th 5th 6th 7th
Universals
OR How are you restoring
these different preparations
bull Voco (Grandio SO HF Xtra Base)
bull Kerr (Revolution Premise Vertise)
bull Ivoclar (Tetric Flow)
bull Heraeus (Venus Diamond Flow Bulk Fill)
bull SDI (Wave MV HV)
bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)
bull GC America (G-aenial Universal Flo)
bull Dentsply (SureFil SDR EsthetX Flow)
bull Kuraray (Clearfil Majesty ES Flow)
bull Tokuyama (Estelite Flow Quick)
bull 3M (Filtek Supreme Flow Plus)
Flowables
How are you restoring
these different preparations
2262016
18
Tokyo Medical amp Dental University 2010 J Tagami et al
FLOWABLE COMPOSITE SHRINKAGE(2MM BULK FILL W 71WT FLOWABLE ON DENTIN ONLY)
SureFill SDR amp CLEARFIL SE BOND
Enamel amp Variable Dentin Bonding
ProblemVARYING TOOTH SUBSTRATES
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treatingldquoAdhesive dentistry could be expressed as a simple
relationship between bonds and stress If the bonds
can withstand the stress the restorative technique will
be successfulrdquo
Unterbrink and Liebenberg (1999)
2262016
19
ldquoC-FACTORrdquo DEFINITION
CONFIGURATION FACTOR
ldquoTHE RATIO OF BONDED TO UN-BONDED (FREE) SURFACESrdquo
FEILZER DEGEE DAVIDSON (1987) UNIVERSTIY OF AMSTERDAM ACTA
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
Excellent Flow amp Handling Base Lining
ldquoC-FACTORrdquoRESIN TO DENTIN HYBRID ZONE
PREPARATIONS gt 2MM
bull TRADITIONALLY NUMEROUS INCREMENTS HAVE TO BE PLACED TO DIMINISH POLYMERIZATION
SHRINKAGE AS WELL AS STRESS ON TOOTH STRUCTURE
Technique
05mm Flowable amp Bonding Agent
Composite
Normallyhellip
2mm
2262016
20
Technique
BOND STRENGTHS RELATED TO TYPE OF DENTITION
05
101520253035404550
45 45
30 30 30
10
Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210
Caries Detector
Caries Detector by
Kuraray Dental is the
original caries detecting
stain material It was
developed by Dr
Fusayama amp Kuraray
Dental at the Tokyo
Medical amp Dental School
in 1978
2262016
21
CARIES INDICATOR DYES
bull ROYDENT-TO DYE FOR
bull KURARAY-CARIES DETECTOR
bull ULTRADENT-SEEKSABLE SEEK
bull PROOPTIONS-CARIES INDICATOR
bull DANVILLE-CARIES FINDER
bull PULPDENT-SNOOP
bull VISTA-CARIES INDICATOR
bull RONVIG-SEE IT
bull PATTERSON-
bull HENRY SCHEIN-
bull PEARSON-
CARIES DETECTOR 86 ACCURACY
bull AS NOTED BY SOUTHERN ILLINOIS DENTAL SCHOOL IN-VITRO RESEARCH
bull ldquoCARIES DETECTOR SOLUTION IDENTIFIED 86 OF SUBSEQUENTLY CONFIRMED CARIES
LESIONS AFTER SECTIONINGrdquo
bull REFERENCE CARIES DETECTION ACCURACY BY
MULTIPLE CLINICIANS amp TECHNIQUES THOMAS LAND WILSON amp GREGORY STEWART DDS SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF DENTAL MEDICINE IADR ABSTRACT 3127 1998
CARIES REMOVAL BURSbull SS WHITE
bull SINGLE USE
bull POLYMER
bull HARDNESS
bull 5000-10000 RPMS
bull KOMET
bull MULTI USE
bull CERAMIC
bull HARDNESS
bull 1000-1500 RPMS
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443
Current concepts amp techniques for caries excavation amp adhesion to residual dentin
de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
4
What fluoresces in fluorescent-based technologies
Bacterial porphyrins (bacterial breakdown product)
Stain
Tartar
Food debris
All fluoresce under the wavelengths used in most caries detection devices
whether or not caries is present
bull Lussi A Imwinkelried S Pitts N Longbottom C Reich E Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro Caries Res 199933(4)261ndash266
bull Lussi A Hibst R Paulus R DIAGNOdent an optical method for caries detection J Dent Res 200483C C80ndash83
bull Verdonschot E H van der Veen M H Lasers in dentistry 2 Diagnosis of dental caries with lasers Ned Tijdschr Tandheelkd 2002109(4) 122ndash126
bull Konig K Flemming G Hibst R Laser-induced autofluorescence spectroscopy of dental caries Cell Mol Biol (Noisy-le-grand) 199844(8) 1293ndash1300
bull Alwas-Danowska HM Plasschaert AJ Suliborski S Verdonschot EH Reliability and validity issues of laser fluorescence measurements in occlusal caries diagnosis J Dent 200230(4)129-34
bull Rechmann P Rechmann BM Featherstone JD Caries detection using light-based diagnostic tools Compend Contin Educ Dent 201233(8)582-4 586 588-93 quiz 594 596
Fluorescent Technologies KAVO Dia Lux 2300LDexis CariVu
bull One can place a number of restorations or fillings and yet not treat the
underlying disease
bull The bacteria remain in the plaque on the teeth capable of creating new
areas of tooth decay
bull Patients value a shift from a surgical approach to disease management
and prevention
The Canary System Detects Cracks amp Cavities not
Visible on X-rays
+ Around amp beneath intact margins of fillings amp crowns
+ Under sealants (including opaque sealants)
+ On proximal surfaces
+ On smooth surfaces pits amp grooves
+ Around orthodontic brackets
Measures tooth structure breakdown allows for early
treatment
+ Restore conservatively
+ Remineralize back to health
+ Seal with confidence
Research claims validated by 60+ papers
15+ case reports amp 2 FDA CFR 21 clinical trials
bull Pulses (2 Hz) of laser light hit the tooth surface
bull Tooth glows (Luminescence LUM) and releases heat (Photo-Thermal Radiometry PTR)
bull Defective tooth crystal structure affects the retained heat and luminescence signatures
Energy Conversion Technology
Temperature
increase lt 1oC
not harmful
bull Detected signals reflect the toothrsquos condition
bull Detects 50 micron lesion up to 5 mm below the surface
2262016
5
Delegated Scanning amp Whitening Assistant
Study Designbull 20 tooth surfaces selected with
range of clinical conditions from healthy to early caries
bull Visual ranking by 2 dentists bull Canary Scanbull DIAGNODentbull Polarized Light Microscopy used as
the gold standard to confirm presence of lesion amp depth in that section
Caries Detection Method Canary System DIAGNODent
Sensitivity 100 18
Specificity 100 100
Spearman Correlation with Lesion
Depth
84 21
Jan J et al Caries Res 201448384ndash450 DOI 101159000360836
Objective
To compare the accuracy of The Canary System ICDAS-II and bitewing radiographs in detecting proximal caries
in vitro
Methods
ICDAS-II (Direct Visual Examination) Blinded examiners ranked 100 proximal surfaces using ICDAS-II by direct visual examination of the surfaces
Manikin mouth models The teeth were then set in manikin mouth models creating contacting proximal
surfaces that very closely resemble in vivo situation
Histological validation All surfaces were examined by polarizing-light microscopy to confirm the presence
and depth of the caries lesions
Conclusionbull BW radiographs could only identify 267 of the lesions which questions its ability to be the
gold standard
bull The Canary System is the only method examined with both high sensitivity and high specificity
bull The Canary System is more sensitive than bitewing radiographs in detecting interproximal
caries
No pathology on x-ray Canary Scan
Revealed Pathology on Mesial amp Distal
Marginal Ridge and Caries around the
Lingual Margin of the Amalgam
9758 36
97
58 36Crack on mesial and distal
marginal ridges with caries
Caries around the lingual
marginBitewing radiograph did not detect caries
Caries located on buccal aspect of the contact area
2262016
6
Demineralized
enamelCaries Detection
Method
The Canary
System
DIAGNOdent
Sensitivity 83 64
Specificity 79 46
bull Canary Numbers gt20 when scanning sealants (3Mtrade ESPEtrade Clinprotrade Sealant) placed over pit amp fissure caries
bull The caries detection ability of the Canary System was not affected by sealant amp was more accurate than DIAGNOdent
Sensitivities and specificities
for pit amp fissure caries
detection after sealant
placement
Canary Number 66
Canary Number 37Caries into
dentin
Post-sealant
Pre-sealant
Cross-section
Sealant
After all the cleaning and diagnostic technology being used what if you find something
bull More caries resistant
bull Remineralization
bull Desensitization
bull Apply twice a day AM amp PM
bull After brushing and flossing
bull Pea size amount on finger and rub it on the teeth
bull You can floss it between them as well
bull Rub the material around all the teeth with tongue
bull Leave on the teeth for approximately 3 minutes
bull Spit out excess but do not rinse or drink for 30
minutes
2262016
7
Minimally Invasive Treatment
bull Apply MIPaste Plus for 3 minutes
bull Patient applies at home 2xday
Minimally Invasive Treatment
bull Fluoride Calcium Phosphate and Xylitol
MI VARNISHtrade WITH RECALDENTtrade
(CPP-ACP)
Bioavailable calcium
phosphate and fluoride
Enamelon Now with Stannous Fluoride
Optimized with ACP Technology
bull Stabilized SnF2Formula
bull ACP Technology
bull RDA 8
bull Safe for all age groups
2262016
8
bull Clinpro 5000 with TCP (3M)
bull Enamelon with fluoride and ACP (Premier)
bull Remin Pro (Voco)
bull Sensodyne ProNamel
bull Arm amp Hammerrsquos Enamel Care
bull Arm amp Hammer Complete Care w Enamel Strengthening
bull Colgate Sensitive pro relief
bull Fluoride Varnishes
bull Glass Ionomers
Bacteria
Produce Acid
Attack Enamel
Demineralization
DECAY
Xylitol amp ProBiotics
MI Paste Enamelon
RemineralizeCanary System
Radiograph
SALIVA-CHECK BUFFER from GC America tests for salivary
flow and buffering capacity
Acidulated phosphate fluoride (ApF)
Non-acidic sodium fluoride (pHn)
bull No tooth reduction
bull Adhesive and mechanical retention
bull Radiolucent
Resin Infusion-ICON Resin Infusion-ICON
2262016
9
Huge Marketing Opportunity
bull Remineralizing teeth
bull Non Ionizing Diagnostic Tools
bull Minimally Invasive Dentistry
bull Health Product Sales
bull Community Educational Programs
bull Internet and Local Media Advertising
bull Post information on your responsive website
The same tooth sectioned showing the lesion
penetrating the underlying dentine
How will you diagnose this
How will you prepare
and treat this
TimeLabor Intensive
Layering
Material Adaptation
Polymerization Shrinkage
Volumetric Shrinkage
Sensitivity
Micro leakage
Others
2262016
10
How are you restoring
these different preparations
What Is Your First Step
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
What do you usehellip
hellipand why
2262016
11
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
Understanding Buffering 101
bull Local Anesthetics is an acidic solution with a pH of ~ 39
bull To achieve pulpal analgesia the body needs to raise the pH of the local anesthetic
toward physiological pH ( ~ 74) This can take up to 15 minutes per patient
bull Sodium Bicarbonate is a neutralizing additive solution
bull Buffering (adding sodium bicarbonate to anesthetics) brings pH level closer to
physiologic pH prior to injection meaning that the burning sensation of the injection
is greatly reduced and the patient gets numb almost immediately
bull Buffered Anesthetics more profound anesthesiamdash6000 times more active
anesthetic (active molecules) Logarithmic scale moving from 39 to 74 pH
bull A by-product of buffered anesthetics is a CO2 enriched microbubble that
readily crosses the nerve membrane and in itself contains anesthetic properties
not found in unbuffered anesthetics It essentially produces an immediate
effect similar to that of a topical
Understanding Buffering 102
ANUTRA
For Direct Restorations
Total-Etching
Bonding to EnamelDentin
2262016
12
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process ndash Total Etching
Dentin fluid
Dentin
OdontoblastDentinal tubule
Smear layer37 Phosphoric acid
Adhesion process ndash Total Etching
Dentin fluid
Adhesion process ndash Total-Etching
Adhesive
Etched dentin Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Composite resin
Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Dentin
2262016
13
Dentin
Phosphoric acid
Water
Dentin
No filtration into the collagen fiber Excess drying
Dentin
Shrinkage of collagen fiber
No filtration into the collagen fiber Excess drying
Adhesive
Dentin
Adhesive
Water
Insufficient drying
Dentin
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Use Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
2262016
14
Long term failure occurs at gingival margins and adhesive interfaces
Yiu CK Hiraishi N King NM Tay FR Effect of dentinal surface preparation on bond strength of self-etching adhesives J Adhes Dent 2008 Jun10(3)173-82
Higher bond strengths when using tungsten carbide burs with SE adhesives
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Adhesion process - Self-Etching
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Composite
Adhesion process - Self-EtchingBonding
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Factors that compromise bond durability in restorative dentistry
ldquoThe major shortcoming of contemporaryadhesive restoratives is their limited durability in vivordquo
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
2262016
15
Factors that compromise bond durability in restorative dentistry
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an average replacement time of 57
years due to secondary caries precipitated by bond failurerdquo
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of
intraoral function
Instability of hybrid layers- problem may be more severe than we realize
Factors that compromise bond durability
Hydrophilic dentin bonding (1956 - )
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped within
the mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdown
collagen fibrils that are not protected
Sukala et al (2007)Mazzoni et al (2007)
Franklin Tay amp Dave Pashley Med College of Georgia
BOND DEGREDATIONbull PASHLEY DH TAY FR IMAZATO S HOW TO INCREASE THE DURABILITY OF RESIN-DENTIN BONDS
COMPEND CONTIN EDUC DENT 2011 SEP32(7)60-4 66
RESIN-DENTIN BONDS ARE NOT AS DURABLE AS WAS
PREVIOUSLY THOUGHT MICROTENSILE BOND STRENGTHS
OFTEN FALL 30 TO 40 IN 6 TO 12 MONTHS
2262016
16
4th6th5th
7th
bullCOURTESY PACIFIC UNIVERSITY (DR MARC GUISBERGER)
bullCourtesy Pacific University (Dr Marc Guisberger)
INSTRONbull ULTRA TESTER (ULTRADENT)
bull ULTRA JIG (ULTADENT)
SHEAR BOND TEST RESULTS - 2012
Average Shear Bond Strength to Dentin 242
MPa
bullCourtesy Pacific University (Dr Marc Guisberger)
2262016
17
MaximumMinimum Shear Bond Strength per
Bonding Material
SHEAR BOND TEST RESULTS - 2012
bullCourtesy Pacific University (Dr Marc Guisberger)
NEW ldquoUNIVERSALrdquo SYSTEMS
bull SIMPLE amp EASY TO USE
bull DIRECT amp INDIRECT TECHNIQUES
bull USE AS TOTAL SELECTIVE OR SELF ETCH
bull LOW SENSITIVITY
bull LOTS OF MDP BASED PRODUCTS
Total etch Self etch of
components
Etchant
Primer
Adhesive
The Bonding Agents
Generation4th 5th 6th 7th
Universals
OR How are you restoring
these different preparations
bull Voco (Grandio SO HF Xtra Base)
bull Kerr (Revolution Premise Vertise)
bull Ivoclar (Tetric Flow)
bull Heraeus (Venus Diamond Flow Bulk Fill)
bull SDI (Wave MV HV)
bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)
bull GC America (G-aenial Universal Flo)
bull Dentsply (SureFil SDR EsthetX Flow)
bull Kuraray (Clearfil Majesty ES Flow)
bull Tokuyama (Estelite Flow Quick)
bull 3M (Filtek Supreme Flow Plus)
Flowables
How are you restoring
these different preparations
2262016
18
Tokyo Medical amp Dental University 2010 J Tagami et al
FLOWABLE COMPOSITE SHRINKAGE(2MM BULK FILL W 71WT FLOWABLE ON DENTIN ONLY)
SureFill SDR amp CLEARFIL SE BOND
Enamel amp Variable Dentin Bonding
ProblemVARYING TOOTH SUBSTRATES
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treatingldquoAdhesive dentistry could be expressed as a simple
relationship between bonds and stress If the bonds
can withstand the stress the restorative technique will
be successfulrdquo
Unterbrink and Liebenberg (1999)
2262016
19
ldquoC-FACTORrdquo DEFINITION
CONFIGURATION FACTOR
ldquoTHE RATIO OF BONDED TO UN-BONDED (FREE) SURFACESrdquo
FEILZER DEGEE DAVIDSON (1987) UNIVERSTIY OF AMSTERDAM ACTA
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
Excellent Flow amp Handling Base Lining
ldquoC-FACTORrdquoRESIN TO DENTIN HYBRID ZONE
PREPARATIONS gt 2MM
bull TRADITIONALLY NUMEROUS INCREMENTS HAVE TO BE PLACED TO DIMINISH POLYMERIZATION
SHRINKAGE AS WELL AS STRESS ON TOOTH STRUCTURE
Technique
05mm Flowable amp Bonding Agent
Composite
Normallyhellip
2mm
2262016
20
Technique
BOND STRENGTHS RELATED TO TYPE OF DENTITION
05
101520253035404550
45 45
30 30 30
10
Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210
Caries Detector
Caries Detector by
Kuraray Dental is the
original caries detecting
stain material It was
developed by Dr
Fusayama amp Kuraray
Dental at the Tokyo
Medical amp Dental School
in 1978
2262016
21
CARIES INDICATOR DYES
bull ROYDENT-TO DYE FOR
bull KURARAY-CARIES DETECTOR
bull ULTRADENT-SEEKSABLE SEEK
bull PROOPTIONS-CARIES INDICATOR
bull DANVILLE-CARIES FINDER
bull PULPDENT-SNOOP
bull VISTA-CARIES INDICATOR
bull RONVIG-SEE IT
bull PATTERSON-
bull HENRY SCHEIN-
bull PEARSON-
CARIES DETECTOR 86 ACCURACY
bull AS NOTED BY SOUTHERN ILLINOIS DENTAL SCHOOL IN-VITRO RESEARCH
bull ldquoCARIES DETECTOR SOLUTION IDENTIFIED 86 OF SUBSEQUENTLY CONFIRMED CARIES
LESIONS AFTER SECTIONINGrdquo
bull REFERENCE CARIES DETECTION ACCURACY BY
MULTIPLE CLINICIANS amp TECHNIQUES THOMAS LAND WILSON amp GREGORY STEWART DDS SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF DENTAL MEDICINE IADR ABSTRACT 3127 1998
CARIES REMOVAL BURSbull SS WHITE
bull SINGLE USE
bull POLYMER
bull HARDNESS
bull 5000-10000 RPMS
bull KOMET
bull MULTI USE
bull CERAMIC
bull HARDNESS
bull 1000-1500 RPMS
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443
Current concepts amp techniques for caries excavation amp adhesion to residual dentin
de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
5
Delegated Scanning amp Whitening Assistant
Study Designbull 20 tooth surfaces selected with
range of clinical conditions from healthy to early caries
bull Visual ranking by 2 dentists bull Canary Scanbull DIAGNODentbull Polarized Light Microscopy used as
the gold standard to confirm presence of lesion amp depth in that section
Caries Detection Method Canary System DIAGNODent
Sensitivity 100 18
Specificity 100 100
Spearman Correlation with Lesion
Depth
84 21
Jan J et al Caries Res 201448384ndash450 DOI 101159000360836
Objective
To compare the accuracy of The Canary System ICDAS-II and bitewing radiographs in detecting proximal caries
in vitro
Methods
ICDAS-II (Direct Visual Examination) Blinded examiners ranked 100 proximal surfaces using ICDAS-II by direct visual examination of the surfaces
Manikin mouth models The teeth were then set in manikin mouth models creating contacting proximal
surfaces that very closely resemble in vivo situation
Histological validation All surfaces were examined by polarizing-light microscopy to confirm the presence
and depth of the caries lesions
Conclusionbull BW radiographs could only identify 267 of the lesions which questions its ability to be the
gold standard
bull The Canary System is the only method examined with both high sensitivity and high specificity
bull The Canary System is more sensitive than bitewing radiographs in detecting interproximal
caries
No pathology on x-ray Canary Scan
Revealed Pathology on Mesial amp Distal
Marginal Ridge and Caries around the
Lingual Margin of the Amalgam
9758 36
97
58 36Crack on mesial and distal
marginal ridges with caries
Caries around the lingual
marginBitewing radiograph did not detect caries
Caries located on buccal aspect of the contact area
2262016
6
Demineralized
enamelCaries Detection
Method
The Canary
System
DIAGNOdent
Sensitivity 83 64
Specificity 79 46
bull Canary Numbers gt20 when scanning sealants (3Mtrade ESPEtrade Clinprotrade Sealant) placed over pit amp fissure caries
bull The caries detection ability of the Canary System was not affected by sealant amp was more accurate than DIAGNOdent
Sensitivities and specificities
for pit amp fissure caries
detection after sealant
placement
Canary Number 66
Canary Number 37Caries into
dentin
Post-sealant
Pre-sealant
Cross-section
Sealant
After all the cleaning and diagnostic technology being used what if you find something
bull More caries resistant
bull Remineralization
bull Desensitization
bull Apply twice a day AM amp PM
bull After brushing and flossing
bull Pea size amount on finger and rub it on the teeth
bull You can floss it between them as well
bull Rub the material around all the teeth with tongue
bull Leave on the teeth for approximately 3 minutes
bull Spit out excess but do not rinse or drink for 30
minutes
2262016
7
Minimally Invasive Treatment
bull Apply MIPaste Plus for 3 minutes
bull Patient applies at home 2xday
Minimally Invasive Treatment
bull Fluoride Calcium Phosphate and Xylitol
MI VARNISHtrade WITH RECALDENTtrade
(CPP-ACP)
Bioavailable calcium
phosphate and fluoride
Enamelon Now with Stannous Fluoride
Optimized with ACP Technology
bull Stabilized SnF2Formula
bull ACP Technology
bull RDA 8
bull Safe for all age groups
2262016
8
bull Clinpro 5000 with TCP (3M)
bull Enamelon with fluoride and ACP (Premier)
bull Remin Pro (Voco)
bull Sensodyne ProNamel
bull Arm amp Hammerrsquos Enamel Care
bull Arm amp Hammer Complete Care w Enamel Strengthening
bull Colgate Sensitive pro relief
bull Fluoride Varnishes
bull Glass Ionomers
Bacteria
Produce Acid
Attack Enamel
Demineralization
DECAY
Xylitol amp ProBiotics
MI Paste Enamelon
RemineralizeCanary System
Radiograph
SALIVA-CHECK BUFFER from GC America tests for salivary
flow and buffering capacity
Acidulated phosphate fluoride (ApF)
Non-acidic sodium fluoride (pHn)
bull No tooth reduction
bull Adhesive and mechanical retention
bull Radiolucent
Resin Infusion-ICON Resin Infusion-ICON
2262016
9
Huge Marketing Opportunity
bull Remineralizing teeth
bull Non Ionizing Diagnostic Tools
bull Minimally Invasive Dentistry
bull Health Product Sales
bull Community Educational Programs
bull Internet and Local Media Advertising
bull Post information on your responsive website
The same tooth sectioned showing the lesion
penetrating the underlying dentine
How will you diagnose this
How will you prepare
and treat this
TimeLabor Intensive
Layering
Material Adaptation
Polymerization Shrinkage
Volumetric Shrinkage
Sensitivity
Micro leakage
Others
2262016
10
How are you restoring
these different preparations
What Is Your First Step
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
What do you usehellip
hellipand why
2262016
11
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
Understanding Buffering 101
bull Local Anesthetics is an acidic solution with a pH of ~ 39
bull To achieve pulpal analgesia the body needs to raise the pH of the local anesthetic
toward physiological pH ( ~ 74) This can take up to 15 minutes per patient
bull Sodium Bicarbonate is a neutralizing additive solution
bull Buffering (adding sodium bicarbonate to anesthetics) brings pH level closer to
physiologic pH prior to injection meaning that the burning sensation of the injection
is greatly reduced and the patient gets numb almost immediately
bull Buffered Anesthetics more profound anesthesiamdash6000 times more active
anesthetic (active molecules) Logarithmic scale moving from 39 to 74 pH
bull A by-product of buffered anesthetics is a CO2 enriched microbubble that
readily crosses the nerve membrane and in itself contains anesthetic properties
not found in unbuffered anesthetics It essentially produces an immediate
effect similar to that of a topical
Understanding Buffering 102
ANUTRA
For Direct Restorations
Total-Etching
Bonding to EnamelDentin
2262016
12
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process ndash Total Etching
Dentin fluid
Dentin
OdontoblastDentinal tubule
Smear layer37 Phosphoric acid
Adhesion process ndash Total Etching
Dentin fluid
Adhesion process ndash Total-Etching
Adhesive
Etched dentin Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Composite resin
Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Dentin
2262016
13
Dentin
Phosphoric acid
Water
Dentin
No filtration into the collagen fiber Excess drying
Dentin
Shrinkage of collagen fiber
No filtration into the collagen fiber Excess drying
Adhesive
Dentin
Adhesive
Water
Insufficient drying
Dentin
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Use Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
2262016
14
Long term failure occurs at gingival margins and adhesive interfaces
Yiu CK Hiraishi N King NM Tay FR Effect of dentinal surface preparation on bond strength of self-etching adhesives J Adhes Dent 2008 Jun10(3)173-82
Higher bond strengths when using tungsten carbide burs with SE adhesives
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Adhesion process - Self-Etching
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Composite
Adhesion process - Self-EtchingBonding
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Factors that compromise bond durability in restorative dentistry
ldquoThe major shortcoming of contemporaryadhesive restoratives is their limited durability in vivordquo
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
2262016
15
Factors that compromise bond durability in restorative dentistry
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an average replacement time of 57
years due to secondary caries precipitated by bond failurerdquo
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of
intraoral function
Instability of hybrid layers- problem may be more severe than we realize
Factors that compromise bond durability
Hydrophilic dentin bonding (1956 - )
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped within
the mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdown
collagen fibrils that are not protected
Sukala et al (2007)Mazzoni et al (2007)
Franklin Tay amp Dave Pashley Med College of Georgia
BOND DEGREDATIONbull PASHLEY DH TAY FR IMAZATO S HOW TO INCREASE THE DURABILITY OF RESIN-DENTIN BONDS
COMPEND CONTIN EDUC DENT 2011 SEP32(7)60-4 66
RESIN-DENTIN BONDS ARE NOT AS DURABLE AS WAS
PREVIOUSLY THOUGHT MICROTENSILE BOND STRENGTHS
OFTEN FALL 30 TO 40 IN 6 TO 12 MONTHS
2262016
16
4th6th5th
7th
bullCOURTESY PACIFIC UNIVERSITY (DR MARC GUISBERGER)
bullCourtesy Pacific University (Dr Marc Guisberger)
INSTRONbull ULTRA TESTER (ULTRADENT)
bull ULTRA JIG (ULTADENT)
SHEAR BOND TEST RESULTS - 2012
Average Shear Bond Strength to Dentin 242
MPa
bullCourtesy Pacific University (Dr Marc Guisberger)
2262016
17
MaximumMinimum Shear Bond Strength per
Bonding Material
SHEAR BOND TEST RESULTS - 2012
bullCourtesy Pacific University (Dr Marc Guisberger)
NEW ldquoUNIVERSALrdquo SYSTEMS
bull SIMPLE amp EASY TO USE
bull DIRECT amp INDIRECT TECHNIQUES
bull USE AS TOTAL SELECTIVE OR SELF ETCH
bull LOW SENSITIVITY
bull LOTS OF MDP BASED PRODUCTS
Total etch Self etch of
components
Etchant
Primer
Adhesive
The Bonding Agents
Generation4th 5th 6th 7th
Universals
OR How are you restoring
these different preparations
bull Voco (Grandio SO HF Xtra Base)
bull Kerr (Revolution Premise Vertise)
bull Ivoclar (Tetric Flow)
bull Heraeus (Venus Diamond Flow Bulk Fill)
bull SDI (Wave MV HV)
bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)
bull GC America (G-aenial Universal Flo)
bull Dentsply (SureFil SDR EsthetX Flow)
bull Kuraray (Clearfil Majesty ES Flow)
bull Tokuyama (Estelite Flow Quick)
bull 3M (Filtek Supreme Flow Plus)
Flowables
How are you restoring
these different preparations
2262016
18
Tokyo Medical amp Dental University 2010 J Tagami et al
FLOWABLE COMPOSITE SHRINKAGE(2MM BULK FILL W 71WT FLOWABLE ON DENTIN ONLY)
SureFill SDR amp CLEARFIL SE BOND
Enamel amp Variable Dentin Bonding
ProblemVARYING TOOTH SUBSTRATES
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treatingldquoAdhesive dentistry could be expressed as a simple
relationship between bonds and stress If the bonds
can withstand the stress the restorative technique will
be successfulrdquo
Unterbrink and Liebenberg (1999)
2262016
19
ldquoC-FACTORrdquo DEFINITION
CONFIGURATION FACTOR
ldquoTHE RATIO OF BONDED TO UN-BONDED (FREE) SURFACESrdquo
FEILZER DEGEE DAVIDSON (1987) UNIVERSTIY OF AMSTERDAM ACTA
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
Excellent Flow amp Handling Base Lining
ldquoC-FACTORrdquoRESIN TO DENTIN HYBRID ZONE
PREPARATIONS gt 2MM
bull TRADITIONALLY NUMEROUS INCREMENTS HAVE TO BE PLACED TO DIMINISH POLYMERIZATION
SHRINKAGE AS WELL AS STRESS ON TOOTH STRUCTURE
Technique
05mm Flowable amp Bonding Agent
Composite
Normallyhellip
2mm
2262016
20
Technique
BOND STRENGTHS RELATED TO TYPE OF DENTITION
05
101520253035404550
45 45
30 30 30
10
Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210
Caries Detector
Caries Detector by
Kuraray Dental is the
original caries detecting
stain material It was
developed by Dr
Fusayama amp Kuraray
Dental at the Tokyo
Medical amp Dental School
in 1978
2262016
21
CARIES INDICATOR DYES
bull ROYDENT-TO DYE FOR
bull KURARAY-CARIES DETECTOR
bull ULTRADENT-SEEKSABLE SEEK
bull PROOPTIONS-CARIES INDICATOR
bull DANVILLE-CARIES FINDER
bull PULPDENT-SNOOP
bull VISTA-CARIES INDICATOR
bull RONVIG-SEE IT
bull PATTERSON-
bull HENRY SCHEIN-
bull PEARSON-
CARIES DETECTOR 86 ACCURACY
bull AS NOTED BY SOUTHERN ILLINOIS DENTAL SCHOOL IN-VITRO RESEARCH
bull ldquoCARIES DETECTOR SOLUTION IDENTIFIED 86 OF SUBSEQUENTLY CONFIRMED CARIES
LESIONS AFTER SECTIONINGrdquo
bull REFERENCE CARIES DETECTION ACCURACY BY
MULTIPLE CLINICIANS amp TECHNIQUES THOMAS LAND WILSON amp GREGORY STEWART DDS SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF DENTAL MEDICINE IADR ABSTRACT 3127 1998
CARIES REMOVAL BURSbull SS WHITE
bull SINGLE USE
bull POLYMER
bull HARDNESS
bull 5000-10000 RPMS
bull KOMET
bull MULTI USE
bull CERAMIC
bull HARDNESS
bull 1000-1500 RPMS
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443
Current concepts amp techniques for caries excavation amp adhesion to residual dentin
de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
6
Demineralized
enamelCaries Detection
Method
The Canary
System
DIAGNOdent
Sensitivity 83 64
Specificity 79 46
bull Canary Numbers gt20 when scanning sealants (3Mtrade ESPEtrade Clinprotrade Sealant) placed over pit amp fissure caries
bull The caries detection ability of the Canary System was not affected by sealant amp was more accurate than DIAGNOdent
Sensitivities and specificities
for pit amp fissure caries
detection after sealant
placement
Canary Number 66
Canary Number 37Caries into
dentin
Post-sealant
Pre-sealant
Cross-section
Sealant
After all the cleaning and diagnostic technology being used what if you find something
bull More caries resistant
bull Remineralization
bull Desensitization
bull Apply twice a day AM amp PM
bull After brushing and flossing
bull Pea size amount on finger and rub it on the teeth
bull You can floss it between them as well
bull Rub the material around all the teeth with tongue
bull Leave on the teeth for approximately 3 minutes
bull Spit out excess but do not rinse or drink for 30
minutes
2262016
7
Minimally Invasive Treatment
bull Apply MIPaste Plus for 3 minutes
bull Patient applies at home 2xday
Minimally Invasive Treatment
bull Fluoride Calcium Phosphate and Xylitol
MI VARNISHtrade WITH RECALDENTtrade
(CPP-ACP)
Bioavailable calcium
phosphate and fluoride
Enamelon Now with Stannous Fluoride
Optimized with ACP Technology
bull Stabilized SnF2Formula
bull ACP Technology
bull RDA 8
bull Safe for all age groups
2262016
8
bull Clinpro 5000 with TCP (3M)
bull Enamelon with fluoride and ACP (Premier)
bull Remin Pro (Voco)
bull Sensodyne ProNamel
bull Arm amp Hammerrsquos Enamel Care
bull Arm amp Hammer Complete Care w Enamel Strengthening
bull Colgate Sensitive pro relief
bull Fluoride Varnishes
bull Glass Ionomers
Bacteria
Produce Acid
Attack Enamel
Demineralization
DECAY
Xylitol amp ProBiotics
MI Paste Enamelon
RemineralizeCanary System
Radiograph
SALIVA-CHECK BUFFER from GC America tests for salivary
flow and buffering capacity
Acidulated phosphate fluoride (ApF)
Non-acidic sodium fluoride (pHn)
bull No tooth reduction
bull Adhesive and mechanical retention
bull Radiolucent
Resin Infusion-ICON Resin Infusion-ICON
2262016
9
Huge Marketing Opportunity
bull Remineralizing teeth
bull Non Ionizing Diagnostic Tools
bull Minimally Invasive Dentistry
bull Health Product Sales
bull Community Educational Programs
bull Internet and Local Media Advertising
bull Post information on your responsive website
The same tooth sectioned showing the lesion
penetrating the underlying dentine
How will you diagnose this
How will you prepare
and treat this
TimeLabor Intensive
Layering
Material Adaptation
Polymerization Shrinkage
Volumetric Shrinkage
Sensitivity
Micro leakage
Others
2262016
10
How are you restoring
these different preparations
What Is Your First Step
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
What do you usehellip
hellipand why
2262016
11
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
Understanding Buffering 101
bull Local Anesthetics is an acidic solution with a pH of ~ 39
bull To achieve pulpal analgesia the body needs to raise the pH of the local anesthetic
toward physiological pH ( ~ 74) This can take up to 15 minutes per patient
bull Sodium Bicarbonate is a neutralizing additive solution
bull Buffering (adding sodium bicarbonate to anesthetics) brings pH level closer to
physiologic pH prior to injection meaning that the burning sensation of the injection
is greatly reduced and the patient gets numb almost immediately
bull Buffered Anesthetics more profound anesthesiamdash6000 times more active
anesthetic (active molecules) Logarithmic scale moving from 39 to 74 pH
bull A by-product of buffered anesthetics is a CO2 enriched microbubble that
readily crosses the nerve membrane and in itself contains anesthetic properties
not found in unbuffered anesthetics It essentially produces an immediate
effect similar to that of a topical
Understanding Buffering 102
ANUTRA
For Direct Restorations
Total-Etching
Bonding to EnamelDentin
2262016
12
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process ndash Total Etching
Dentin fluid
Dentin
OdontoblastDentinal tubule
Smear layer37 Phosphoric acid
Adhesion process ndash Total Etching
Dentin fluid
Adhesion process ndash Total-Etching
Adhesive
Etched dentin Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Composite resin
Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Dentin
2262016
13
Dentin
Phosphoric acid
Water
Dentin
No filtration into the collagen fiber Excess drying
Dentin
Shrinkage of collagen fiber
No filtration into the collagen fiber Excess drying
Adhesive
Dentin
Adhesive
Water
Insufficient drying
Dentin
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Use Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
2262016
14
Long term failure occurs at gingival margins and adhesive interfaces
Yiu CK Hiraishi N King NM Tay FR Effect of dentinal surface preparation on bond strength of self-etching adhesives J Adhes Dent 2008 Jun10(3)173-82
Higher bond strengths when using tungsten carbide burs with SE adhesives
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Adhesion process - Self-Etching
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Composite
Adhesion process - Self-EtchingBonding
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Factors that compromise bond durability in restorative dentistry
ldquoThe major shortcoming of contemporaryadhesive restoratives is their limited durability in vivordquo
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
2262016
15
Factors that compromise bond durability in restorative dentistry
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an average replacement time of 57
years due to secondary caries precipitated by bond failurerdquo
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of
intraoral function
Instability of hybrid layers- problem may be more severe than we realize
Factors that compromise bond durability
Hydrophilic dentin bonding (1956 - )
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped within
the mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdown
collagen fibrils that are not protected
Sukala et al (2007)Mazzoni et al (2007)
Franklin Tay amp Dave Pashley Med College of Georgia
BOND DEGREDATIONbull PASHLEY DH TAY FR IMAZATO S HOW TO INCREASE THE DURABILITY OF RESIN-DENTIN BONDS
COMPEND CONTIN EDUC DENT 2011 SEP32(7)60-4 66
RESIN-DENTIN BONDS ARE NOT AS DURABLE AS WAS
PREVIOUSLY THOUGHT MICROTENSILE BOND STRENGTHS
OFTEN FALL 30 TO 40 IN 6 TO 12 MONTHS
2262016
16
4th6th5th
7th
bullCOURTESY PACIFIC UNIVERSITY (DR MARC GUISBERGER)
bullCourtesy Pacific University (Dr Marc Guisberger)
INSTRONbull ULTRA TESTER (ULTRADENT)
bull ULTRA JIG (ULTADENT)
SHEAR BOND TEST RESULTS - 2012
Average Shear Bond Strength to Dentin 242
MPa
bullCourtesy Pacific University (Dr Marc Guisberger)
2262016
17
MaximumMinimum Shear Bond Strength per
Bonding Material
SHEAR BOND TEST RESULTS - 2012
bullCourtesy Pacific University (Dr Marc Guisberger)
NEW ldquoUNIVERSALrdquo SYSTEMS
bull SIMPLE amp EASY TO USE
bull DIRECT amp INDIRECT TECHNIQUES
bull USE AS TOTAL SELECTIVE OR SELF ETCH
bull LOW SENSITIVITY
bull LOTS OF MDP BASED PRODUCTS
Total etch Self etch of
components
Etchant
Primer
Adhesive
The Bonding Agents
Generation4th 5th 6th 7th
Universals
OR How are you restoring
these different preparations
bull Voco (Grandio SO HF Xtra Base)
bull Kerr (Revolution Premise Vertise)
bull Ivoclar (Tetric Flow)
bull Heraeus (Venus Diamond Flow Bulk Fill)
bull SDI (Wave MV HV)
bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)
bull GC America (G-aenial Universal Flo)
bull Dentsply (SureFil SDR EsthetX Flow)
bull Kuraray (Clearfil Majesty ES Flow)
bull Tokuyama (Estelite Flow Quick)
bull 3M (Filtek Supreme Flow Plus)
Flowables
How are you restoring
these different preparations
2262016
18
Tokyo Medical amp Dental University 2010 J Tagami et al
FLOWABLE COMPOSITE SHRINKAGE(2MM BULK FILL W 71WT FLOWABLE ON DENTIN ONLY)
SureFill SDR amp CLEARFIL SE BOND
Enamel amp Variable Dentin Bonding
ProblemVARYING TOOTH SUBSTRATES
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treatingldquoAdhesive dentistry could be expressed as a simple
relationship between bonds and stress If the bonds
can withstand the stress the restorative technique will
be successfulrdquo
Unterbrink and Liebenberg (1999)
2262016
19
ldquoC-FACTORrdquo DEFINITION
CONFIGURATION FACTOR
ldquoTHE RATIO OF BONDED TO UN-BONDED (FREE) SURFACESrdquo
FEILZER DEGEE DAVIDSON (1987) UNIVERSTIY OF AMSTERDAM ACTA
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
Excellent Flow amp Handling Base Lining
ldquoC-FACTORrdquoRESIN TO DENTIN HYBRID ZONE
PREPARATIONS gt 2MM
bull TRADITIONALLY NUMEROUS INCREMENTS HAVE TO BE PLACED TO DIMINISH POLYMERIZATION
SHRINKAGE AS WELL AS STRESS ON TOOTH STRUCTURE
Technique
05mm Flowable amp Bonding Agent
Composite
Normallyhellip
2mm
2262016
20
Technique
BOND STRENGTHS RELATED TO TYPE OF DENTITION
05
101520253035404550
45 45
30 30 30
10
Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210
Caries Detector
Caries Detector by
Kuraray Dental is the
original caries detecting
stain material It was
developed by Dr
Fusayama amp Kuraray
Dental at the Tokyo
Medical amp Dental School
in 1978
2262016
21
CARIES INDICATOR DYES
bull ROYDENT-TO DYE FOR
bull KURARAY-CARIES DETECTOR
bull ULTRADENT-SEEKSABLE SEEK
bull PROOPTIONS-CARIES INDICATOR
bull DANVILLE-CARIES FINDER
bull PULPDENT-SNOOP
bull VISTA-CARIES INDICATOR
bull RONVIG-SEE IT
bull PATTERSON-
bull HENRY SCHEIN-
bull PEARSON-
CARIES DETECTOR 86 ACCURACY
bull AS NOTED BY SOUTHERN ILLINOIS DENTAL SCHOOL IN-VITRO RESEARCH
bull ldquoCARIES DETECTOR SOLUTION IDENTIFIED 86 OF SUBSEQUENTLY CONFIRMED CARIES
LESIONS AFTER SECTIONINGrdquo
bull REFERENCE CARIES DETECTION ACCURACY BY
MULTIPLE CLINICIANS amp TECHNIQUES THOMAS LAND WILSON amp GREGORY STEWART DDS SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF DENTAL MEDICINE IADR ABSTRACT 3127 1998
CARIES REMOVAL BURSbull SS WHITE
bull SINGLE USE
bull POLYMER
bull HARDNESS
bull 5000-10000 RPMS
bull KOMET
bull MULTI USE
bull CERAMIC
bull HARDNESS
bull 1000-1500 RPMS
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443
Current concepts amp techniques for caries excavation amp adhesion to residual dentin
de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
7
Minimally Invasive Treatment
bull Apply MIPaste Plus for 3 minutes
bull Patient applies at home 2xday
Minimally Invasive Treatment
bull Fluoride Calcium Phosphate and Xylitol
MI VARNISHtrade WITH RECALDENTtrade
(CPP-ACP)
Bioavailable calcium
phosphate and fluoride
Enamelon Now with Stannous Fluoride
Optimized with ACP Technology
bull Stabilized SnF2Formula
bull ACP Technology
bull RDA 8
bull Safe for all age groups
2262016
8
bull Clinpro 5000 with TCP (3M)
bull Enamelon with fluoride and ACP (Premier)
bull Remin Pro (Voco)
bull Sensodyne ProNamel
bull Arm amp Hammerrsquos Enamel Care
bull Arm amp Hammer Complete Care w Enamel Strengthening
bull Colgate Sensitive pro relief
bull Fluoride Varnishes
bull Glass Ionomers
Bacteria
Produce Acid
Attack Enamel
Demineralization
DECAY
Xylitol amp ProBiotics
MI Paste Enamelon
RemineralizeCanary System
Radiograph
SALIVA-CHECK BUFFER from GC America tests for salivary
flow and buffering capacity
Acidulated phosphate fluoride (ApF)
Non-acidic sodium fluoride (pHn)
bull No tooth reduction
bull Adhesive and mechanical retention
bull Radiolucent
Resin Infusion-ICON Resin Infusion-ICON
2262016
9
Huge Marketing Opportunity
bull Remineralizing teeth
bull Non Ionizing Diagnostic Tools
bull Minimally Invasive Dentistry
bull Health Product Sales
bull Community Educational Programs
bull Internet and Local Media Advertising
bull Post information on your responsive website
The same tooth sectioned showing the lesion
penetrating the underlying dentine
How will you diagnose this
How will you prepare
and treat this
TimeLabor Intensive
Layering
Material Adaptation
Polymerization Shrinkage
Volumetric Shrinkage
Sensitivity
Micro leakage
Others
2262016
10
How are you restoring
these different preparations
What Is Your First Step
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
What do you usehellip
hellipand why
2262016
11
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
Understanding Buffering 101
bull Local Anesthetics is an acidic solution with a pH of ~ 39
bull To achieve pulpal analgesia the body needs to raise the pH of the local anesthetic
toward physiological pH ( ~ 74) This can take up to 15 minutes per patient
bull Sodium Bicarbonate is a neutralizing additive solution
bull Buffering (adding sodium bicarbonate to anesthetics) brings pH level closer to
physiologic pH prior to injection meaning that the burning sensation of the injection
is greatly reduced and the patient gets numb almost immediately
bull Buffered Anesthetics more profound anesthesiamdash6000 times more active
anesthetic (active molecules) Logarithmic scale moving from 39 to 74 pH
bull A by-product of buffered anesthetics is a CO2 enriched microbubble that
readily crosses the nerve membrane and in itself contains anesthetic properties
not found in unbuffered anesthetics It essentially produces an immediate
effect similar to that of a topical
Understanding Buffering 102
ANUTRA
For Direct Restorations
Total-Etching
Bonding to EnamelDentin
2262016
12
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process ndash Total Etching
Dentin fluid
Dentin
OdontoblastDentinal tubule
Smear layer37 Phosphoric acid
Adhesion process ndash Total Etching
Dentin fluid
Adhesion process ndash Total-Etching
Adhesive
Etched dentin Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Composite resin
Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Dentin
2262016
13
Dentin
Phosphoric acid
Water
Dentin
No filtration into the collagen fiber Excess drying
Dentin
Shrinkage of collagen fiber
No filtration into the collagen fiber Excess drying
Adhesive
Dentin
Adhesive
Water
Insufficient drying
Dentin
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Use Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
2262016
14
Long term failure occurs at gingival margins and adhesive interfaces
Yiu CK Hiraishi N King NM Tay FR Effect of dentinal surface preparation on bond strength of self-etching adhesives J Adhes Dent 2008 Jun10(3)173-82
Higher bond strengths when using tungsten carbide burs with SE adhesives
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Adhesion process - Self-Etching
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Composite
Adhesion process - Self-EtchingBonding
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Factors that compromise bond durability in restorative dentistry
ldquoThe major shortcoming of contemporaryadhesive restoratives is their limited durability in vivordquo
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
2262016
15
Factors that compromise bond durability in restorative dentistry
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an average replacement time of 57
years due to secondary caries precipitated by bond failurerdquo
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of
intraoral function
Instability of hybrid layers- problem may be more severe than we realize
Factors that compromise bond durability
Hydrophilic dentin bonding (1956 - )
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped within
the mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdown
collagen fibrils that are not protected
Sukala et al (2007)Mazzoni et al (2007)
Franklin Tay amp Dave Pashley Med College of Georgia
BOND DEGREDATIONbull PASHLEY DH TAY FR IMAZATO S HOW TO INCREASE THE DURABILITY OF RESIN-DENTIN BONDS
COMPEND CONTIN EDUC DENT 2011 SEP32(7)60-4 66
RESIN-DENTIN BONDS ARE NOT AS DURABLE AS WAS
PREVIOUSLY THOUGHT MICROTENSILE BOND STRENGTHS
OFTEN FALL 30 TO 40 IN 6 TO 12 MONTHS
2262016
16
4th6th5th
7th
bullCOURTESY PACIFIC UNIVERSITY (DR MARC GUISBERGER)
bullCourtesy Pacific University (Dr Marc Guisberger)
INSTRONbull ULTRA TESTER (ULTRADENT)
bull ULTRA JIG (ULTADENT)
SHEAR BOND TEST RESULTS - 2012
Average Shear Bond Strength to Dentin 242
MPa
bullCourtesy Pacific University (Dr Marc Guisberger)
2262016
17
MaximumMinimum Shear Bond Strength per
Bonding Material
SHEAR BOND TEST RESULTS - 2012
bullCourtesy Pacific University (Dr Marc Guisberger)
NEW ldquoUNIVERSALrdquo SYSTEMS
bull SIMPLE amp EASY TO USE
bull DIRECT amp INDIRECT TECHNIQUES
bull USE AS TOTAL SELECTIVE OR SELF ETCH
bull LOW SENSITIVITY
bull LOTS OF MDP BASED PRODUCTS
Total etch Self etch of
components
Etchant
Primer
Adhesive
The Bonding Agents
Generation4th 5th 6th 7th
Universals
OR How are you restoring
these different preparations
bull Voco (Grandio SO HF Xtra Base)
bull Kerr (Revolution Premise Vertise)
bull Ivoclar (Tetric Flow)
bull Heraeus (Venus Diamond Flow Bulk Fill)
bull SDI (Wave MV HV)
bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)
bull GC America (G-aenial Universal Flo)
bull Dentsply (SureFil SDR EsthetX Flow)
bull Kuraray (Clearfil Majesty ES Flow)
bull Tokuyama (Estelite Flow Quick)
bull 3M (Filtek Supreme Flow Plus)
Flowables
How are you restoring
these different preparations
2262016
18
Tokyo Medical amp Dental University 2010 J Tagami et al
FLOWABLE COMPOSITE SHRINKAGE(2MM BULK FILL W 71WT FLOWABLE ON DENTIN ONLY)
SureFill SDR amp CLEARFIL SE BOND
Enamel amp Variable Dentin Bonding
ProblemVARYING TOOTH SUBSTRATES
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treatingldquoAdhesive dentistry could be expressed as a simple
relationship between bonds and stress If the bonds
can withstand the stress the restorative technique will
be successfulrdquo
Unterbrink and Liebenberg (1999)
2262016
19
ldquoC-FACTORrdquo DEFINITION
CONFIGURATION FACTOR
ldquoTHE RATIO OF BONDED TO UN-BONDED (FREE) SURFACESrdquo
FEILZER DEGEE DAVIDSON (1987) UNIVERSTIY OF AMSTERDAM ACTA
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
Excellent Flow amp Handling Base Lining
ldquoC-FACTORrdquoRESIN TO DENTIN HYBRID ZONE
PREPARATIONS gt 2MM
bull TRADITIONALLY NUMEROUS INCREMENTS HAVE TO BE PLACED TO DIMINISH POLYMERIZATION
SHRINKAGE AS WELL AS STRESS ON TOOTH STRUCTURE
Technique
05mm Flowable amp Bonding Agent
Composite
Normallyhellip
2mm
2262016
20
Technique
BOND STRENGTHS RELATED TO TYPE OF DENTITION
05
101520253035404550
45 45
30 30 30
10
Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210
Caries Detector
Caries Detector by
Kuraray Dental is the
original caries detecting
stain material It was
developed by Dr
Fusayama amp Kuraray
Dental at the Tokyo
Medical amp Dental School
in 1978
2262016
21
CARIES INDICATOR DYES
bull ROYDENT-TO DYE FOR
bull KURARAY-CARIES DETECTOR
bull ULTRADENT-SEEKSABLE SEEK
bull PROOPTIONS-CARIES INDICATOR
bull DANVILLE-CARIES FINDER
bull PULPDENT-SNOOP
bull VISTA-CARIES INDICATOR
bull RONVIG-SEE IT
bull PATTERSON-
bull HENRY SCHEIN-
bull PEARSON-
CARIES DETECTOR 86 ACCURACY
bull AS NOTED BY SOUTHERN ILLINOIS DENTAL SCHOOL IN-VITRO RESEARCH
bull ldquoCARIES DETECTOR SOLUTION IDENTIFIED 86 OF SUBSEQUENTLY CONFIRMED CARIES
LESIONS AFTER SECTIONINGrdquo
bull REFERENCE CARIES DETECTION ACCURACY BY
MULTIPLE CLINICIANS amp TECHNIQUES THOMAS LAND WILSON amp GREGORY STEWART DDS SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF DENTAL MEDICINE IADR ABSTRACT 3127 1998
CARIES REMOVAL BURSbull SS WHITE
bull SINGLE USE
bull POLYMER
bull HARDNESS
bull 5000-10000 RPMS
bull KOMET
bull MULTI USE
bull CERAMIC
bull HARDNESS
bull 1000-1500 RPMS
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443
Current concepts amp techniques for caries excavation amp adhesion to residual dentin
de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
8
bull Clinpro 5000 with TCP (3M)
bull Enamelon with fluoride and ACP (Premier)
bull Remin Pro (Voco)
bull Sensodyne ProNamel
bull Arm amp Hammerrsquos Enamel Care
bull Arm amp Hammer Complete Care w Enamel Strengthening
bull Colgate Sensitive pro relief
bull Fluoride Varnishes
bull Glass Ionomers
Bacteria
Produce Acid
Attack Enamel
Demineralization
DECAY
Xylitol amp ProBiotics
MI Paste Enamelon
RemineralizeCanary System
Radiograph
SALIVA-CHECK BUFFER from GC America tests for salivary
flow and buffering capacity
Acidulated phosphate fluoride (ApF)
Non-acidic sodium fluoride (pHn)
bull No tooth reduction
bull Adhesive and mechanical retention
bull Radiolucent
Resin Infusion-ICON Resin Infusion-ICON
2262016
9
Huge Marketing Opportunity
bull Remineralizing teeth
bull Non Ionizing Diagnostic Tools
bull Minimally Invasive Dentistry
bull Health Product Sales
bull Community Educational Programs
bull Internet and Local Media Advertising
bull Post information on your responsive website
The same tooth sectioned showing the lesion
penetrating the underlying dentine
How will you diagnose this
How will you prepare
and treat this
TimeLabor Intensive
Layering
Material Adaptation
Polymerization Shrinkage
Volumetric Shrinkage
Sensitivity
Micro leakage
Others
2262016
10
How are you restoring
these different preparations
What Is Your First Step
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
What do you usehellip
hellipand why
2262016
11
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
Understanding Buffering 101
bull Local Anesthetics is an acidic solution with a pH of ~ 39
bull To achieve pulpal analgesia the body needs to raise the pH of the local anesthetic
toward physiological pH ( ~ 74) This can take up to 15 minutes per patient
bull Sodium Bicarbonate is a neutralizing additive solution
bull Buffering (adding sodium bicarbonate to anesthetics) brings pH level closer to
physiologic pH prior to injection meaning that the burning sensation of the injection
is greatly reduced and the patient gets numb almost immediately
bull Buffered Anesthetics more profound anesthesiamdash6000 times more active
anesthetic (active molecules) Logarithmic scale moving from 39 to 74 pH
bull A by-product of buffered anesthetics is a CO2 enriched microbubble that
readily crosses the nerve membrane and in itself contains anesthetic properties
not found in unbuffered anesthetics It essentially produces an immediate
effect similar to that of a topical
Understanding Buffering 102
ANUTRA
For Direct Restorations
Total-Etching
Bonding to EnamelDentin
2262016
12
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process ndash Total Etching
Dentin fluid
Dentin
OdontoblastDentinal tubule
Smear layer37 Phosphoric acid
Adhesion process ndash Total Etching
Dentin fluid
Adhesion process ndash Total-Etching
Adhesive
Etched dentin Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Composite resin
Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Dentin
2262016
13
Dentin
Phosphoric acid
Water
Dentin
No filtration into the collagen fiber Excess drying
Dentin
Shrinkage of collagen fiber
No filtration into the collagen fiber Excess drying
Adhesive
Dentin
Adhesive
Water
Insufficient drying
Dentin
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Use Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
2262016
14
Long term failure occurs at gingival margins and adhesive interfaces
Yiu CK Hiraishi N King NM Tay FR Effect of dentinal surface preparation on bond strength of self-etching adhesives J Adhes Dent 2008 Jun10(3)173-82
Higher bond strengths when using tungsten carbide burs with SE adhesives
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Adhesion process - Self-Etching
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Composite
Adhesion process - Self-EtchingBonding
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Factors that compromise bond durability in restorative dentistry
ldquoThe major shortcoming of contemporaryadhesive restoratives is their limited durability in vivordquo
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
2262016
15
Factors that compromise bond durability in restorative dentistry
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an average replacement time of 57
years due to secondary caries precipitated by bond failurerdquo
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of
intraoral function
Instability of hybrid layers- problem may be more severe than we realize
Factors that compromise bond durability
Hydrophilic dentin bonding (1956 - )
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped within
the mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdown
collagen fibrils that are not protected
Sukala et al (2007)Mazzoni et al (2007)
Franklin Tay amp Dave Pashley Med College of Georgia
BOND DEGREDATIONbull PASHLEY DH TAY FR IMAZATO S HOW TO INCREASE THE DURABILITY OF RESIN-DENTIN BONDS
COMPEND CONTIN EDUC DENT 2011 SEP32(7)60-4 66
RESIN-DENTIN BONDS ARE NOT AS DURABLE AS WAS
PREVIOUSLY THOUGHT MICROTENSILE BOND STRENGTHS
OFTEN FALL 30 TO 40 IN 6 TO 12 MONTHS
2262016
16
4th6th5th
7th
bullCOURTESY PACIFIC UNIVERSITY (DR MARC GUISBERGER)
bullCourtesy Pacific University (Dr Marc Guisberger)
INSTRONbull ULTRA TESTER (ULTRADENT)
bull ULTRA JIG (ULTADENT)
SHEAR BOND TEST RESULTS - 2012
Average Shear Bond Strength to Dentin 242
MPa
bullCourtesy Pacific University (Dr Marc Guisberger)
2262016
17
MaximumMinimum Shear Bond Strength per
Bonding Material
SHEAR BOND TEST RESULTS - 2012
bullCourtesy Pacific University (Dr Marc Guisberger)
NEW ldquoUNIVERSALrdquo SYSTEMS
bull SIMPLE amp EASY TO USE
bull DIRECT amp INDIRECT TECHNIQUES
bull USE AS TOTAL SELECTIVE OR SELF ETCH
bull LOW SENSITIVITY
bull LOTS OF MDP BASED PRODUCTS
Total etch Self etch of
components
Etchant
Primer
Adhesive
The Bonding Agents
Generation4th 5th 6th 7th
Universals
OR How are you restoring
these different preparations
bull Voco (Grandio SO HF Xtra Base)
bull Kerr (Revolution Premise Vertise)
bull Ivoclar (Tetric Flow)
bull Heraeus (Venus Diamond Flow Bulk Fill)
bull SDI (Wave MV HV)
bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)
bull GC America (G-aenial Universal Flo)
bull Dentsply (SureFil SDR EsthetX Flow)
bull Kuraray (Clearfil Majesty ES Flow)
bull Tokuyama (Estelite Flow Quick)
bull 3M (Filtek Supreme Flow Plus)
Flowables
How are you restoring
these different preparations
2262016
18
Tokyo Medical amp Dental University 2010 J Tagami et al
FLOWABLE COMPOSITE SHRINKAGE(2MM BULK FILL W 71WT FLOWABLE ON DENTIN ONLY)
SureFill SDR amp CLEARFIL SE BOND
Enamel amp Variable Dentin Bonding
ProblemVARYING TOOTH SUBSTRATES
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treatingldquoAdhesive dentistry could be expressed as a simple
relationship between bonds and stress If the bonds
can withstand the stress the restorative technique will
be successfulrdquo
Unterbrink and Liebenberg (1999)
2262016
19
ldquoC-FACTORrdquo DEFINITION
CONFIGURATION FACTOR
ldquoTHE RATIO OF BONDED TO UN-BONDED (FREE) SURFACESrdquo
FEILZER DEGEE DAVIDSON (1987) UNIVERSTIY OF AMSTERDAM ACTA
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
Excellent Flow amp Handling Base Lining
ldquoC-FACTORrdquoRESIN TO DENTIN HYBRID ZONE
PREPARATIONS gt 2MM
bull TRADITIONALLY NUMEROUS INCREMENTS HAVE TO BE PLACED TO DIMINISH POLYMERIZATION
SHRINKAGE AS WELL AS STRESS ON TOOTH STRUCTURE
Technique
05mm Flowable amp Bonding Agent
Composite
Normallyhellip
2mm
2262016
20
Technique
BOND STRENGTHS RELATED TO TYPE OF DENTITION
05
101520253035404550
45 45
30 30 30
10
Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210
Caries Detector
Caries Detector by
Kuraray Dental is the
original caries detecting
stain material It was
developed by Dr
Fusayama amp Kuraray
Dental at the Tokyo
Medical amp Dental School
in 1978
2262016
21
CARIES INDICATOR DYES
bull ROYDENT-TO DYE FOR
bull KURARAY-CARIES DETECTOR
bull ULTRADENT-SEEKSABLE SEEK
bull PROOPTIONS-CARIES INDICATOR
bull DANVILLE-CARIES FINDER
bull PULPDENT-SNOOP
bull VISTA-CARIES INDICATOR
bull RONVIG-SEE IT
bull PATTERSON-
bull HENRY SCHEIN-
bull PEARSON-
CARIES DETECTOR 86 ACCURACY
bull AS NOTED BY SOUTHERN ILLINOIS DENTAL SCHOOL IN-VITRO RESEARCH
bull ldquoCARIES DETECTOR SOLUTION IDENTIFIED 86 OF SUBSEQUENTLY CONFIRMED CARIES
LESIONS AFTER SECTIONINGrdquo
bull REFERENCE CARIES DETECTION ACCURACY BY
MULTIPLE CLINICIANS amp TECHNIQUES THOMAS LAND WILSON amp GREGORY STEWART DDS SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF DENTAL MEDICINE IADR ABSTRACT 3127 1998
CARIES REMOVAL BURSbull SS WHITE
bull SINGLE USE
bull POLYMER
bull HARDNESS
bull 5000-10000 RPMS
bull KOMET
bull MULTI USE
bull CERAMIC
bull HARDNESS
bull 1000-1500 RPMS
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443
Current concepts amp techniques for caries excavation amp adhesion to residual dentin
de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
9
Huge Marketing Opportunity
bull Remineralizing teeth
bull Non Ionizing Diagnostic Tools
bull Minimally Invasive Dentistry
bull Health Product Sales
bull Community Educational Programs
bull Internet and Local Media Advertising
bull Post information on your responsive website
The same tooth sectioned showing the lesion
penetrating the underlying dentine
How will you diagnose this
How will you prepare
and treat this
TimeLabor Intensive
Layering
Material Adaptation
Polymerization Shrinkage
Volumetric Shrinkage
Sensitivity
Micro leakage
Others
2262016
10
How are you restoring
these different preparations
What Is Your First Step
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
What do you usehellip
hellipand why
2262016
11
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
Understanding Buffering 101
bull Local Anesthetics is an acidic solution with a pH of ~ 39
bull To achieve pulpal analgesia the body needs to raise the pH of the local anesthetic
toward physiological pH ( ~ 74) This can take up to 15 minutes per patient
bull Sodium Bicarbonate is a neutralizing additive solution
bull Buffering (adding sodium bicarbonate to anesthetics) brings pH level closer to
physiologic pH prior to injection meaning that the burning sensation of the injection
is greatly reduced and the patient gets numb almost immediately
bull Buffered Anesthetics more profound anesthesiamdash6000 times more active
anesthetic (active molecules) Logarithmic scale moving from 39 to 74 pH
bull A by-product of buffered anesthetics is a CO2 enriched microbubble that
readily crosses the nerve membrane and in itself contains anesthetic properties
not found in unbuffered anesthetics It essentially produces an immediate
effect similar to that of a topical
Understanding Buffering 102
ANUTRA
For Direct Restorations
Total-Etching
Bonding to EnamelDentin
2262016
12
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process ndash Total Etching
Dentin fluid
Dentin
OdontoblastDentinal tubule
Smear layer37 Phosphoric acid
Adhesion process ndash Total Etching
Dentin fluid
Adhesion process ndash Total-Etching
Adhesive
Etched dentin Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Composite resin
Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Dentin
2262016
13
Dentin
Phosphoric acid
Water
Dentin
No filtration into the collagen fiber Excess drying
Dentin
Shrinkage of collagen fiber
No filtration into the collagen fiber Excess drying
Adhesive
Dentin
Adhesive
Water
Insufficient drying
Dentin
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Use Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
2262016
14
Long term failure occurs at gingival margins and adhesive interfaces
Yiu CK Hiraishi N King NM Tay FR Effect of dentinal surface preparation on bond strength of self-etching adhesives J Adhes Dent 2008 Jun10(3)173-82
Higher bond strengths when using tungsten carbide burs with SE adhesives
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Adhesion process - Self-Etching
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Composite
Adhesion process - Self-EtchingBonding
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Factors that compromise bond durability in restorative dentistry
ldquoThe major shortcoming of contemporaryadhesive restoratives is their limited durability in vivordquo
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
2262016
15
Factors that compromise bond durability in restorative dentistry
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an average replacement time of 57
years due to secondary caries precipitated by bond failurerdquo
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of
intraoral function
Instability of hybrid layers- problem may be more severe than we realize
Factors that compromise bond durability
Hydrophilic dentin bonding (1956 - )
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped within
the mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdown
collagen fibrils that are not protected
Sukala et al (2007)Mazzoni et al (2007)
Franklin Tay amp Dave Pashley Med College of Georgia
BOND DEGREDATIONbull PASHLEY DH TAY FR IMAZATO S HOW TO INCREASE THE DURABILITY OF RESIN-DENTIN BONDS
COMPEND CONTIN EDUC DENT 2011 SEP32(7)60-4 66
RESIN-DENTIN BONDS ARE NOT AS DURABLE AS WAS
PREVIOUSLY THOUGHT MICROTENSILE BOND STRENGTHS
OFTEN FALL 30 TO 40 IN 6 TO 12 MONTHS
2262016
16
4th6th5th
7th
bullCOURTESY PACIFIC UNIVERSITY (DR MARC GUISBERGER)
bullCourtesy Pacific University (Dr Marc Guisberger)
INSTRONbull ULTRA TESTER (ULTRADENT)
bull ULTRA JIG (ULTADENT)
SHEAR BOND TEST RESULTS - 2012
Average Shear Bond Strength to Dentin 242
MPa
bullCourtesy Pacific University (Dr Marc Guisberger)
2262016
17
MaximumMinimum Shear Bond Strength per
Bonding Material
SHEAR BOND TEST RESULTS - 2012
bullCourtesy Pacific University (Dr Marc Guisberger)
NEW ldquoUNIVERSALrdquo SYSTEMS
bull SIMPLE amp EASY TO USE
bull DIRECT amp INDIRECT TECHNIQUES
bull USE AS TOTAL SELECTIVE OR SELF ETCH
bull LOW SENSITIVITY
bull LOTS OF MDP BASED PRODUCTS
Total etch Self etch of
components
Etchant
Primer
Adhesive
The Bonding Agents
Generation4th 5th 6th 7th
Universals
OR How are you restoring
these different preparations
bull Voco (Grandio SO HF Xtra Base)
bull Kerr (Revolution Premise Vertise)
bull Ivoclar (Tetric Flow)
bull Heraeus (Venus Diamond Flow Bulk Fill)
bull SDI (Wave MV HV)
bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)
bull GC America (G-aenial Universal Flo)
bull Dentsply (SureFil SDR EsthetX Flow)
bull Kuraray (Clearfil Majesty ES Flow)
bull Tokuyama (Estelite Flow Quick)
bull 3M (Filtek Supreme Flow Plus)
Flowables
How are you restoring
these different preparations
2262016
18
Tokyo Medical amp Dental University 2010 J Tagami et al
FLOWABLE COMPOSITE SHRINKAGE(2MM BULK FILL W 71WT FLOWABLE ON DENTIN ONLY)
SureFill SDR amp CLEARFIL SE BOND
Enamel amp Variable Dentin Bonding
ProblemVARYING TOOTH SUBSTRATES
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treatingldquoAdhesive dentistry could be expressed as a simple
relationship between bonds and stress If the bonds
can withstand the stress the restorative technique will
be successfulrdquo
Unterbrink and Liebenberg (1999)
2262016
19
ldquoC-FACTORrdquo DEFINITION
CONFIGURATION FACTOR
ldquoTHE RATIO OF BONDED TO UN-BONDED (FREE) SURFACESrdquo
FEILZER DEGEE DAVIDSON (1987) UNIVERSTIY OF AMSTERDAM ACTA
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
Excellent Flow amp Handling Base Lining
ldquoC-FACTORrdquoRESIN TO DENTIN HYBRID ZONE
PREPARATIONS gt 2MM
bull TRADITIONALLY NUMEROUS INCREMENTS HAVE TO BE PLACED TO DIMINISH POLYMERIZATION
SHRINKAGE AS WELL AS STRESS ON TOOTH STRUCTURE
Technique
05mm Flowable amp Bonding Agent
Composite
Normallyhellip
2mm
2262016
20
Technique
BOND STRENGTHS RELATED TO TYPE OF DENTITION
05
101520253035404550
45 45
30 30 30
10
Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210
Caries Detector
Caries Detector by
Kuraray Dental is the
original caries detecting
stain material It was
developed by Dr
Fusayama amp Kuraray
Dental at the Tokyo
Medical amp Dental School
in 1978
2262016
21
CARIES INDICATOR DYES
bull ROYDENT-TO DYE FOR
bull KURARAY-CARIES DETECTOR
bull ULTRADENT-SEEKSABLE SEEK
bull PROOPTIONS-CARIES INDICATOR
bull DANVILLE-CARIES FINDER
bull PULPDENT-SNOOP
bull VISTA-CARIES INDICATOR
bull RONVIG-SEE IT
bull PATTERSON-
bull HENRY SCHEIN-
bull PEARSON-
CARIES DETECTOR 86 ACCURACY
bull AS NOTED BY SOUTHERN ILLINOIS DENTAL SCHOOL IN-VITRO RESEARCH
bull ldquoCARIES DETECTOR SOLUTION IDENTIFIED 86 OF SUBSEQUENTLY CONFIRMED CARIES
LESIONS AFTER SECTIONINGrdquo
bull REFERENCE CARIES DETECTION ACCURACY BY
MULTIPLE CLINICIANS amp TECHNIQUES THOMAS LAND WILSON amp GREGORY STEWART DDS SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF DENTAL MEDICINE IADR ABSTRACT 3127 1998
CARIES REMOVAL BURSbull SS WHITE
bull SINGLE USE
bull POLYMER
bull HARDNESS
bull 5000-10000 RPMS
bull KOMET
bull MULTI USE
bull CERAMIC
bull HARDNESS
bull 1000-1500 RPMS
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443
Current concepts amp techniques for caries excavation amp adhesion to residual dentin
de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
10
How are you restoring
these different preparations
What Is Your First Step
Red Blood Cells 2 ndash 5um
200-500nm
Human Hair 60 ndash120um
6000 ndash 12000nm
What do you usehellip
hellipand why
2262016
11
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
Understanding Buffering 101
bull Local Anesthetics is an acidic solution with a pH of ~ 39
bull To achieve pulpal analgesia the body needs to raise the pH of the local anesthetic
toward physiological pH ( ~ 74) This can take up to 15 minutes per patient
bull Sodium Bicarbonate is a neutralizing additive solution
bull Buffering (adding sodium bicarbonate to anesthetics) brings pH level closer to
physiologic pH prior to injection meaning that the burning sensation of the injection
is greatly reduced and the patient gets numb almost immediately
bull Buffered Anesthetics more profound anesthesiamdash6000 times more active
anesthetic (active molecules) Logarithmic scale moving from 39 to 74 pH
bull A by-product of buffered anesthetics is a CO2 enriched microbubble that
readily crosses the nerve membrane and in itself contains anesthetic properties
not found in unbuffered anesthetics It essentially produces an immediate
effect similar to that of a topical
Understanding Buffering 102
ANUTRA
For Direct Restorations
Total-Etching
Bonding to EnamelDentin
2262016
12
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process ndash Total Etching
Dentin fluid
Dentin
OdontoblastDentinal tubule
Smear layer37 Phosphoric acid
Adhesion process ndash Total Etching
Dentin fluid
Adhesion process ndash Total-Etching
Adhesive
Etched dentin Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Composite resin
Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Dentin
2262016
13
Dentin
Phosphoric acid
Water
Dentin
No filtration into the collagen fiber Excess drying
Dentin
Shrinkage of collagen fiber
No filtration into the collagen fiber Excess drying
Adhesive
Dentin
Adhesive
Water
Insufficient drying
Dentin
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Use Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
2262016
14
Long term failure occurs at gingival margins and adhesive interfaces
Yiu CK Hiraishi N King NM Tay FR Effect of dentinal surface preparation on bond strength of self-etching adhesives J Adhes Dent 2008 Jun10(3)173-82
Higher bond strengths when using tungsten carbide burs with SE adhesives
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Adhesion process - Self-Etching
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Composite
Adhesion process - Self-EtchingBonding
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Factors that compromise bond durability in restorative dentistry
ldquoThe major shortcoming of contemporaryadhesive restoratives is their limited durability in vivordquo
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
2262016
15
Factors that compromise bond durability in restorative dentistry
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an average replacement time of 57
years due to secondary caries precipitated by bond failurerdquo
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of
intraoral function
Instability of hybrid layers- problem may be more severe than we realize
Factors that compromise bond durability
Hydrophilic dentin bonding (1956 - )
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped within
the mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdown
collagen fibrils that are not protected
Sukala et al (2007)Mazzoni et al (2007)
Franklin Tay amp Dave Pashley Med College of Georgia
BOND DEGREDATIONbull PASHLEY DH TAY FR IMAZATO S HOW TO INCREASE THE DURABILITY OF RESIN-DENTIN BONDS
COMPEND CONTIN EDUC DENT 2011 SEP32(7)60-4 66
RESIN-DENTIN BONDS ARE NOT AS DURABLE AS WAS
PREVIOUSLY THOUGHT MICROTENSILE BOND STRENGTHS
OFTEN FALL 30 TO 40 IN 6 TO 12 MONTHS
2262016
16
4th6th5th
7th
bullCOURTESY PACIFIC UNIVERSITY (DR MARC GUISBERGER)
bullCourtesy Pacific University (Dr Marc Guisberger)
INSTRONbull ULTRA TESTER (ULTRADENT)
bull ULTRA JIG (ULTADENT)
SHEAR BOND TEST RESULTS - 2012
Average Shear Bond Strength to Dentin 242
MPa
bullCourtesy Pacific University (Dr Marc Guisberger)
2262016
17
MaximumMinimum Shear Bond Strength per
Bonding Material
SHEAR BOND TEST RESULTS - 2012
bullCourtesy Pacific University (Dr Marc Guisberger)
NEW ldquoUNIVERSALrdquo SYSTEMS
bull SIMPLE amp EASY TO USE
bull DIRECT amp INDIRECT TECHNIQUES
bull USE AS TOTAL SELECTIVE OR SELF ETCH
bull LOW SENSITIVITY
bull LOTS OF MDP BASED PRODUCTS
Total etch Self etch of
components
Etchant
Primer
Adhesive
The Bonding Agents
Generation4th 5th 6th 7th
Universals
OR How are you restoring
these different preparations
bull Voco (Grandio SO HF Xtra Base)
bull Kerr (Revolution Premise Vertise)
bull Ivoclar (Tetric Flow)
bull Heraeus (Venus Diamond Flow Bulk Fill)
bull SDI (Wave MV HV)
bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)
bull GC America (G-aenial Universal Flo)
bull Dentsply (SureFil SDR EsthetX Flow)
bull Kuraray (Clearfil Majesty ES Flow)
bull Tokuyama (Estelite Flow Quick)
bull 3M (Filtek Supreme Flow Plus)
Flowables
How are you restoring
these different preparations
2262016
18
Tokyo Medical amp Dental University 2010 J Tagami et al
FLOWABLE COMPOSITE SHRINKAGE(2MM BULK FILL W 71WT FLOWABLE ON DENTIN ONLY)
SureFill SDR amp CLEARFIL SE BOND
Enamel amp Variable Dentin Bonding
ProblemVARYING TOOTH SUBSTRATES
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treatingldquoAdhesive dentistry could be expressed as a simple
relationship between bonds and stress If the bonds
can withstand the stress the restorative technique will
be successfulrdquo
Unterbrink and Liebenberg (1999)
2262016
19
ldquoC-FACTORrdquo DEFINITION
CONFIGURATION FACTOR
ldquoTHE RATIO OF BONDED TO UN-BONDED (FREE) SURFACESrdquo
FEILZER DEGEE DAVIDSON (1987) UNIVERSTIY OF AMSTERDAM ACTA
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
Excellent Flow amp Handling Base Lining
ldquoC-FACTORrdquoRESIN TO DENTIN HYBRID ZONE
PREPARATIONS gt 2MM
bull TRADITIONALLY NUMEROUS INCREMENTS HAVE TO BE PLACED TO DIMINISH POLYMERIZATION
SHRINKAGE AS WELL AS STRESS ON TOOTH STRUCTURE
Technique
05mm Flowable amp Bonding Agent
Composite
Normallyhellip
2mm
2262016
20
Technique
BOND STRENGTHS RELATED TO TYPE OF DENTITION
05
101520253035404550
45 45
30 30 30
10
Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210
Caries Detector
Caries Detector by
Kuraray Dental is the
original caries detecting
stain material It was
developed by Dr
Fusayama amp Kuraray
Dental at the Tokyo
Medical amp Dental School
in 1978
2262016
21
CARIES INDICATOR DYES
bull ROYDENT-TO DYE FOR
bull KURARAY-CARIES DETECTOR
bull ULTRADENT-SEEKSABLE SEEK
bull PROOPTIONS-CARIES INDICATOR
bull DANVILLE-CARIES FINDER
bull PULPDENT-SNOOP
bull VISTA-CARIES INDICATOR
bull RONVIG-SEE IT
bull PATTERSON-
bull HENRY SCHEIN-
bull PEARSON-
CARIES DETECTOR 86 ACCURACY
bull AS NOTED BY SOUTHERN ILLINOIS DENTAL SCHOOL IN-VITRO RESEARCH
bull ldquoCARIES DETECTOR SOLUTION IDENTIFIED 86 OF SUBSEQUENTLY CONFIRMED CARIES
LESIONS AFTER SECTIONINGrdquo
bull REFERENCE CARIES DETECTION ACCURACY BY
MULTIPLE CLINICIANS amp TECHNIQUES THOMAS LAND WILSON amp GREGORY STEWART DDS SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF DENTAL MEDICINE IADR ABSTRACT 3127 1998
CARIES REMOVAL BURSbull SS WHITE
bull SINGLE USE
bull POLYMER
bull HARDNESS
bull 5000-10000 RPMS
bull KOMET
bull MULTI USE
bull CERAMIC
bull HARDNESS
bull 1000-1500 RPMS
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443
Current concepts amp techniques for caries excavation amp adhesion to residual dentin
de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
11
What do you usehellip
hellipand why
8microm articulating paper
Available in blue
And red too
Understanding Buffering 101
bull Local Anesthetics is an acidic solution with a pH of ~ 39
bull To achieve pulpal analgesia the body needs to raise the pH of the local anesthetic
toward physiological pH ( ~ 74) This can take up to 15 minutes per patient
bull Sodium Bicarbonate is a neutralizing additive solution
bull Buffering (adding sodium bicarbonate to anesthetics) brings pH level closer to
physiologic pH prior to injection meaning that the burning sensation of the injection
is greatly reduced and the patient gets numb almost immediately
bull Buffered Anesthetics more profound anesthesiamdash6000 times more active
anesthetic (active molecules) Logarithmic scale moving from 39 to 74 pH
bull A by-product of buffered anesthetics is a CO2 enriched microbubble that
readily crosses the nerve membrane and in itself contains anesthetic properties
not found in unbuffered anesthetics It essentially produces an immediate
effect similar to that of a topical
Understanding Buffering 102
ANUTRA
For Direct Restorations
Total-Etching
Bonding to EnamelDentin
2262016
12
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process ndash Total Etching
Dentin fluid
Dentin
OdontoblastDentinal tubule
Smear layer37 Phosphoric acid
Adhesion process ndash Total Etching
Dentin fluid
Adhesion process ndash Total-Etching
Adhesive
Etched dentin Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Composite resin
Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Dentin
2262016
13
Dentin
Phosphoric acid
Water
Dentin
No filtration into the collagen fiber Excess drying
Dentin
Shrinkage of collagen fiber
No filtration into the collagen fiber Excess drying
Adhesive
Dentin
Adhesive
Water
Insufficient drying
Dentin
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Use Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
2262016
14
Long term failure occurs at gingival margins and adhesive interfaces
Yiu CK Hiraishi N King NM Tay FR Effect of dentinal surface preparation on bond strength of self-etching adhesives J Adhes Dent 2008 Jun10(3)173-82
Higher bond strengths when using tungsten carbide burs with SE adhesives
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Adhesion process - Self-Etching
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Composite
Adhesion process - Self-EtchingBonding
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Factors that compromise bond durability in restorative dentistry
ldquoThe major shortcoming of contemporaryadhesive restoratives is their limited durability in vivordquo
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
2262016
15
Factors that compromise bond durability in restorative dentistry
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an average replacement time of 57
years due to secondary caries precipitated by bond failurerdquo
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of
intraoral function
Instability of hybrid layers- problem may be more severe than we realize
Factors that compromise bond durability
Hydrophilic dentin bonding (1956 - )
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped within
the mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdown
collagen fibrils that are not protected
Sukala et al (2007)Mazzoni et al (2007)
Franklin Tay amp Dave Pashley Med College of Georgia
BOND DEGREDATIONbull PASHLEY DH TAY FR IMAZATO S HOW TO INCREASE THE DURABILITY OF RESIN-DENTIN BONDS
COMPEND CONTIN EDUC DENT 2011 SEP32(7)60-4 66
RESIN-DENTIN BONDS ARE NOT AS DURABLE AS WAS
PREVIOUSLY THOUGHT MICROTENSILE BOND STRENGTHS
OFTEN FALL 30 TO 40 IN 6 TO 12 MONTHS
2262016
16
4th6th5th
7th
bullCOURTESY PACIFIC UNIVERSITY (DR MARC GUISBERGER)
bullCourtesy Pacific University (Dr Marc Guisberger)
INSTRONbull ULTRA TESTER (ULTRADENT)
bull ULTRA JIG (ULTADENT)
SHEAR BOND TEST RESULTS - 2012
Average Shear Bond Strength to Dentin 242
MPa
bullCourtesy Pacific University (Dr Marc Guisberger)
2262016
17
MaximumMinimum Shear Bond Strength per
Bonding Material
SHEAR BOND TEST RESULTS - 2012
bullCourtesy Pacific University (Dr Marc Guisberger)
NEW ldquoUNIVERSALrdquo SYSTEMS
bull SIMPLE amp EASY TO USE
bull DIRECT amp INDIRECT TECHNIQUES
bull USE AS TOTAL SELECTIVE OR SELF ETCH
bull LOW SENSITIVITY
bull LOTS OF MDP BASED PRODUCTS
Total etch Self etch of
components
Etchant
Primer
Adhesive
The Bonding Agents
Generation4th 5th 6th 7th
Universals
OR How are you restoring
these different preparations
bull Voco (Grandio SO HF Xtra Base)
bull Kerr (Revolution Premise Vertise)
bull Ivoclar (Tetric Flow)
bull Heraeus (Venus Diamond Flow Bulk Fill)
bull SDI (Wave MV HV)
bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)
bull GC America (G-aenial Universal Flo)
bull Dentsply (SureFil SDR EsthetX Flow)
bull Kuraray (Clearfil Majesty ES Flow)
bull Tokuyama (Estelite Flow Quick)
bull 3M (Filtek Supreme Flow Plus)
Flowables
How are you restoring
these different preparations
2262016
18
Tokyo Medical amp Dental University 2010 J Tagami et al
FLOWABLE COMPOSITE SHRINKAGE(2MM BULK FILL W 71WT FLOWABLE ON DENTIN ONLY)
SureFill SDR amp CLEARFIL SE BOND
Enamel amp Variable Dentin Bonding
ProblemVARYING TOOTH SUBSTRATES
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treatingldquoAdhesive dentistry could be expressed as a simple
relationship between bonds and stress If the bonds
can withstand the stress the restorative technique will
be successfulrdquo
Unterbrink and Liebenberg (1999)
2262016
19
ldquoC-FACTORrdquo DEFINITION
CONFIGURATION FACTOR
ldquoTHE RATIO OF BONDED TO UN-BONDED (FREE) SURFACESrdquo
FEILZER DEGEE DAVIDSON (1987) UNIVERSTIY OF AMSTERDAM ACTA
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
Excellent Flow amp Handling Base Lining
ldquoC-FACTORrdquoRESIN TO DENTIN HYBRID ZONE
PREPARATIONS gt 2MM
bull TRADITIONALLY NUMEROUS INCREMENTS HAVE TO BE PLACED TO DIMINISH POLYMERIZATION
SHRINKAGE AS WELL AS STRESS ON TOOTH STRUCTURE
Technique
05mm Flowable amp Bonding Agent
Composite
Normallyhellip
2mm
2262016
20
Technique
BOND STRENGTHS RELATED TO TYPE OF DENTITION
05
101520253035404550
45 45
30 30 30
10
Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210
Caries Detector
Caries Detector by
Kuraray Dental is the
original caries detecting
stain material It was
developed by Dr
Fusayama amp Kuraray
Dental at the Tokyo
Medical amp Dental School
in 1978
2262016
21
CARIES INDICATOR DYES
bull ROYDENT-TO DYE FOR
bull KURARAY-CARIES DETECTOR
bull ULTRADENT-SEEKSABLE SEEK
bull PROOPTIONS-CARIES INDICATOR
bull DANVILLE-CARIES FINDER
bull PULPDENT-SNOOP
bull VISTA-CARIES INDICATOR
bull RONVIG-SEE IT
bull PATTERSON-
bull HENRY SCHEIN-
bull PEARSON-
CARIES DETECTOR 86 ACCURACY
bull AS NOTED BY SOUTHERN ILLINOIS DENTAL SCHOOL IN-VITRO RESEARCH
bull ldquoCARIES DETECTOR SOLUTION IDENTIFIED 86 OF SUBSEQUENTLY CONFIRMED CARIES
LESIONS AFTER SECTIONINGrdquo
bull REFERENCE CARIES DETECTION ACCURACY BY
MULTIPLE CLINICIANS amp TECHNIQUES THOMAS LAND WILSON amp GREGORY STEWART DDS SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF DENTAL MEDICINE IADR ABSTRACT 3127 1998
CARIES REMOVAL BURSbull SS WHITE
bull SINGLE USE
bull POLYMER
bull HARDNESS
bull 5000-10000 RPMS
bull KOMET
bull MULTI USE
bull CERAMIC
bull HARDNESS
bull 1000-1500 RPMS
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443
Current concepts amp techniques for caries excavation amp adhesion to residual dentin
de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
12
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process ndash Total Etching
Dentin fluid
Dentin
OdontoblastDentinal tubule
Smear layer37 Phosphoric acid
Adhesion process ndash Total Etching
Dentin fluid
Adhesion process ndash Total-Etching
Adhesive
Etched dentin Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Composite resin
Post- Operative Sensitivity
Adhesion process ndash Total-Etching
Dentin
2262016
13
Dentin
Phosphoric acid
Water
Dentin
No filtration into the collagen fiber Excess drying
Dentin
Shrinkage of collagen fiber
No filtration into the collagen fiber Excess drying
Adhesive
Dentin
Adhesive
Water
Insufficient drying
Dentin
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Use Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
2262016
14
Long term failure occurs at gingival margins and adhesive interfaces
Yiu CK Hiraishi N King NM Tay FR Effect of dentinal surface preparation on bond strength of self-etching adhesives J Adhes Dent 2008 Jun10(3)173-82
Higher bond strengths when using tungsten carbide burs with SE adhesives
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Adhesion process - Self-Etching
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Composite
Adhesion process - Self-EtchingBonding
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Factors that compromise bond durability in restorative dentistry
ldquoThe major shortcoming of contemporaryadhesive restoratives is their limited durability in vivordquo
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
2262016
15
Factors that compromise bond durability in restorative dentistry
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an average replacement time of 57
years due to secondary caries precipitated by bond failurerdquo
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of
intraoral function
Instability of hybrid layers- problem may be more severe than we realize
Factors that compromise bond durability
Hydrophilic dentin bonding (1956 - )
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped within
the mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdown
collagen fibrils that are not protected
Sukala et al (2007)Mazzoni et al (2007)
Franklin Tay amp Dave Pashley Med College of Georgia
BOND DEGREDATIONbull PASHLEY DH TAY FR IMAZATO S HOW TO INCREASE THE DURABILITY OF RESIN-DENTIN BONDS
COMPEND CONTIN EDUC DENT 2011 SEP32(7)60-4 66
RESIN-DENTIN BONDS ARE NOT AS DURABLE AS WAS
PREVIOUSLY THOUGHT MICROTENSILE BOND STRENGTHS
OFTEN FALL 30 TO 40 IN 6 TO 12 MONTHS
2262016
16
4th6th5th
7th
bullCOURTESY PACIFIC UNIVERSITY (DR MARC GUISBERGER)
bullCourtesy Pacific University (Dr Marc Guisberger)
INSTRONbull ULTRA TESTER (ULTRADENT)
bull ULTRA JIG (ULTADENT)
SHEAR BOND TEST RESULTS - 2012
Average Shear Bond Strength to Dentin 242
MPa
bullCourtesy Pacific University (Dr Marc Guisberger)
2262016
17
MaximumMinimum Shear Bond Strength per
Bonding Material
SHEAR BOND TEST RESULTS - 2012
bullCourtesy Pacific University (Dr Marc Guisberger)
NEW ldquoUNIVERSALrdquo SYSTEMS
bull SIMPLE amp EASY TO USE
bull DIRECT amp INDIRECT TECHNIQUES
bull USE AS TOTAL SELECTIVE OR SELF ETCH
bull LOW SENSITIVITY
bull LOTS OF MDP BASED PRODUCTS
Total etch Self etch of
components
Etchant
Primer
Adhesive
The Bonding Agents
Generation4th 5th 6th 7th
Universals
OR How are you restoring
these different preparations
bull Voco (Grandio SO HF Xtra Base)
bull Kerr (Revolution Premise Vertise)
bull Ivoclar (Tetric Flow)
bull Heraeus (Venus Diamond Flow Bulk Fill)
bull SDI (Wave MV HV)
bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)
bull GC America (G-aenial Universal Flo)
bull Dentsply (SureFil SDR EsthetX Flow)
bull Kuraray (Clearfil Majesty ES Flow)
bull Tokuyama (Estelite Flow Quick)
bull 3M (Filtek Supreme Flow Plus)
Flowables
How are you restoring
these different preparations
2262016
18
Tokyo Medical amp Dental University 2010 J Tagami et al
FLOWABLE COMPOSITE SHRINKAGE(2MM BULK FILL W 71WT FLOWABLE ON DENTIN ONLY)
SureFill SDR amp CLEARFIL SE BOND
Enamel amp Variable Dentin Bonding
ProblemVARYING TOOTH SUBSTRATES
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treatingldquoAdhesive dentistry could be expressed as a simple
relationship between bonds and stress If the bonds
can withstand the stress the restorative technique will
be successfulrdquo
Unterbrink and Liebenberg (1999)
2262016
19
ldquoC-FACTORrdquo DEFINITION
CONFIGURATION FACTOR
ldquoTHE RATIO OF BONDED TO UN-BONDED (FREE) SURFACESrdquo
FEILZER DEGEE DAVIDSON (1987) UNIVERSTIY OF AMSTERDAM ACTA
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
Excellent Flow amp Handling Base Lining
ldquoC-FACTORrdquoRESIN TO DENTIN HYBRID ZONE
PREPARATIONS gt 2MM
bull TRADITIONALLY NUMEROUS INCREMENTS HAVE TO BE PLACED TO DIMINISH POLYMERIZATION
SHRINKAGE AS WELL AS STRESS ON TOOTH STRUCTURE
Technique
05mm Flowable amp Bonding Agent
Composite
Normallyhellip
2mm
2262016
20
Technique
BOND STRENGTHS RELATED TO TYPE OF DENTITION
05
101520253035404550
45 45
30 30 30
10
Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210
Caries Detector
Caries Detector by
Kuraray Dental is the
original caries detecting
stain material It was
developed by Dr
Fusayama amp Kuraray
Dental at the Tokyo
Medical amp Dental School
in 1978
2262016
21
CARIES INDICATOR DYES
bull ROYDENT-TO DYE FOR
bull KURARAY-CARIES DETECTOR
bull ULTRADENT-SEEKSABLE SEEK
bull PROOPTIONS-CARIES INDICATOR
bull DANVILLE-CARIES FINDER
bull PULPDENT-SNOOP
bull VISTA-CARIES INDICATOR
bull RONVIG-SEE IT
bull PATTERSON-
bull HENRY SCHEIN-
bull PEARSON-
CARIES DETECTOR 86 ACCURACY
bull AS NOTED BY SOUTHERN ILLINOIS DENTAL SCHOOL IN-VITRO RESEARCH
bull ldquoCARIES DETECTOR SOLUTION IDENTIFIED 86 OF SUBSEQUENTLY CONFIRMED CARIES
LESIONS AFTER SECTIONINGrdquo
bull REFERENCE CARIES DETECTION ACCURACY BY
MULTIPLE CLINICIANS amp TECHNIQUES THOMAS LAND WILSON amp GREGORY STEWART DDS SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF DENTAL MEDICINE IADR ABSTRACT 3127 1998
CARIES REMOVAL BURSbull SS WHITE
bull SINGLE USE
bull POLYMER
bull HARDNESS
bull 5000-10000 RPMS
bull KOMET
bull MULTI USE
bull CERAMIC
bull HARDNESS
bull 1000-1500 RPMS
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443
Current concepts amp techniques for caries excavation amp adhesion to residual dentin
de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
13
Dentin
Phosphoric acid
Water
Dentin
No filtration into the collagen fiber Excess drying
Dentin
Shrinkage of collagen fiber
No filtration into the collagen fiber Excess drying
Adhesive
Dentin
Adhesive
Water
Insufficient drying
Dentin
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Use Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
2262016
14
Long term failure occurs at gingival margins and adhesive interfaces
Yiu CK Hiraishi N King NM Tay FR Effect of dentinal surface preparation on bond strength of self-etching adhesives J Adhes Dent 2008 Jun10(3)173-82
Higher bond strengths when using tungsten carbide burs with SE adhesives
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Adhesion process - Self-Etching
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Composite
Adhesion process - Self-EtchingBonding
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Factors that compromise bond durability in restorative dentistry
ldquoThe major shortcoming of contemporaryadhesive restoratives is their limited durability in vivordquo
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
2262016
15
Factors that compromise bond durability in restorative dentistry
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an average replacement time of 57
years due to secondary caries precipitated by bond failurerdquo
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of
intraoral function
Instability of hybrid layers- problem may be more severe than we realize
Factors that compromise bond durability
Hydrophilic dentin bonding (1956 - )
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped within
the mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdown
collagen fibrils that are not protected
Sukala et al (2007)Mazzoni et al (2007)
Franklin Tay amp Dave Pashley Med College of Georgia
BOND DEGREDATIONbull PASHLEY DH TAY FR IMAZATO S HOW TO INCREASE THE DURABILITY OF RESIN-DENTIN BONDS
COMPEND CONTIN EDUC DENT 2011 SEP32(7)60-4 66
RESIN-DENTIN BONDS ARE NOT AS DURABLE AS WAS
PREVIOUSLY THOUGHT MICROTENSILE BOND STRENGTHS
OFTEN FALL 30 TO 40 IN 6 TO 12 MONTHS
2262016
16
4th6th5th
7th
bullCOURTESY PACIFIC UNIVERSITY (DR MARC GUISBERGER)
bullCourtesy Pacific University (Dr Marc Guisberger)
INSTRONbull ULTRA TESTER (ULTRADENT)
bull ULTRA JIG (ULTADENT)
SHEAR BOND TEST RESULTS - 2012
Average Shear Bond Strength to Dentin 242
MPa
bullCourtesy Pacific University (Dr Marc Guisberger)
2262016
17
MaximumMinimum Shear Bond Strength per
Bonding Material
SHEAR BOND TEST RESULTS - 2012
bullCourtesy Pacific University (Dr Marc Guisberger)
NEW ldquoUNIVERSALrdquo SYSTEMS
bull SIMPLE amp EASY TO USE
bull DIRECT amp INDIRECT TECHNIQUES
bull USE AS TOTAL SELECTIVE OR SELF ETCH
bull LOW SENSITIVITY
bull LOTS OF MDP BASED PRODUCTS
Total etch Self etch of
components
Etchant
Primer
Adhesive
The Bonding Agents
Generation4th 5th 6th 7th
Universals
OR How are you restoring
these different preparations
bull Voco (Grandio SO HF Xtra Base)
bull Kerr (Revolution Premise Vertise)
bull Ivoclar (Tetric Flow)
bull Heraeus (Venus Diamond Flow Bulk Fill)
bull SDI (Wave MV HV)
bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)
bull GC America (G-aenial Universal Flo)
bull Dentsply (SureFil SDR EsthetX Flow)
bull Kuraray (Clearfil Majesty ES Flow)
bull Tokuyama (Estelite Flow Quick)
bull 3M (Filtek Supreme Flow Plus)
Flowables
How are you restoring
these different preparations
2262016
18
Tokyo Medical amp Dental University 2010 J Tagami et al
FLOWABLE COMPOSITE SHRINKAGE(2MM BULK FILL W 71WT FLOWABLE ON DENTIN ONLY)
SureFill SDR amp CLEARFIL SE BOND
Enamel amp Variable Dentin Bonding
ProblemVARYING TOOTH SUBSTRATES
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treatingldquoAdhesive dentistry could be expressed as a simple
relationship between bonds and stress If the bonds
can withstand the stress the restorative technique will
be successfulrdquo
Unterbrink and Liebenberg (1999)
2262016
19
ldquoC-FACTORrdquo DEFINITION
CONFIGURATION FACTOR
ldquoTHE RATIO OF BONDED TO UN-BONDED (FREE) SURFACESrdquo
FEILZER DEGEE DAVIDSON (1987) UNIVERSTIY OF AMSTERDAM ACTA
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
Excellent Flow amp Handling Base Lining
ldquoC-FACTORrdquoRESIN TO DENTIN HYBRID ZONE
PREPARATIONS gt 2MM
bull TRADITIONALLY NUMEROUS INCREMENTS HAVE TO BE PLACED TO DIMINISH POLYMERIZATION
SHRINKAGE AS WELL AS STRESS ON TOOTH STRUCTURE
Technique
05mm Flowable amp Bonding Agent
Composite
Normallyhellip
2mm
2262016
20
Technique
BOND STRENGTHS RELATED TO TYPE OF DENTITION
05
101520253035404550
45 45
30 30 30
10
Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210
Caries Detector
Caries Detector by
Kuraray Dental is the
original caries detecting
stain material It was
developed by Dr
Fusayama amp Kuraray
Dental at the Tokyo
Medical amp Dental School
in 1978
2262016
21
CARIES INDICATOR DYES
bull ROYDENT-TO DYE FOR
bull KURARAY-CARIES DETECTOR
bull ULTRADENT-SEEKSABLE SEEK
bull PROOPTIONS-CARIES INDICATOR
bull DANVILLE-CARIES FINDER
bull PULPDENT-SNOOP
bull VISTA-CARIES INDICATOR
bull RONVIG-SEE IT
bull PATTERSON-
bull HENRY SCHEIN-
bull PEARSON-
CARIES DETECTOR 86 ACCURACY
bull AS NOTED BY SOUTHERN ILLINOIS DENTAL SCHOOL IN-VITRO RESEARCH
bull ldquoCARIES DETECTOR SOLUTION IDENTIFIED 86 OF SUBSEQUENTLY CONFIRMED CARIES
LESIONS AFTER SECTIONINGrdquo
bull REFERENCE CARIES DETECTION ACCURACY BY
MULTIPLE CLINICIANS amp TECHNIQUES THOMAS LAND WILSON amp GREGORY STEWART DDS SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF DENTAL MEDICINE IADR ABSTRACT 3127 1998
CARIES REMOVAL BURSbull SS WHITE
bull SINGLE USE
bull POLYMER
bull HARDNESS
bull 5000-10000 RPMS
bull KOMET
bull MULTI USE
bull CERAMIC
bull HARDNESS
bull 1000-1500 RPMS
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443
Current concepts amp techniques for caries excavation amp adhesion to residual dentin
de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
14
Long term failure occurs at gingival margins and adhesive interfaces
Yiu CK Hiraishi N King NM Tay FR Effect of dentinal surface preparation on bond strength of self-etching adhesives J Adhes Dent 2008 Jun10(3)173-82
Higher bond strengths when using tungsten carbide burs with SE adhesives
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Dentin
OdontoblastDentinal tubule
Smear layer
Adhesion process - Self-Etching
Dentin fluid
Self-etching adhesiveUse Carbide Burs Large layers inhibit acidic monomers
Duration of exposureamp acidity
Adhesion process - Self-Etching
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Composite
Adhesion process - Self-EtchingBonding
No Post- Operative Sensitivity
Excellent sealing and desensitizing
FixingOdontoblast
Sealingthe Dentin
Hybrid layer
Factors that compromise bond durability in restorative dentistry
ldquoThe major shortcoming of contemporaryadhesive restoratives is their limited durability in vivordquo
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
2262016
15
Factors that compromise bond durability in restorative dentistry
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an average replacement time of 57
years due to secondary caries precipitated by bond failurerdquo
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of
intraoral function
Instability of hybrid layers- problem may be more severe than we realize
Factors that compromise bond durability
Hydrophilic dentin bonding (1956 - )
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped within
the mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdown
collagen fibrils that are not protected
Sukala et al (2007)Mazzoni et al (2007)
Franklin Tay amp Dave Pashley Med College of Georgia
BOND DEGREDATIONbull PASHLEY DH TAY FR IMAZATO S HOW TO INCREASE THE DURABILITY OF RESIN-DENTIN BONDS
COMPEND CONTIN EDUC DENT 2011 SEP32(7)60-4 66
RESIN-DENTIN BONDS ARE NOT AS DURABLE AS WAS
PREVIOUSLY THOUGHT MICROTENSILE BOND STRENGTHS
OFTEN FALL 30 TO 40 IN 6 TO 12 MONTHS
2262016
16
4th6th5th
7th
bullCOURTESY PACIFIC UNIVERSITY (DR MARC GUISBERGER)
bullCourtesy Pacific University (Dr Marc Guisberger)
INSTRONbull ULTRA TESTER (ULTRADENT)
bull ULTRA JIG (ULTADENT)
SHEAR BOND TEST RESULTS - 2012
Average Shear Bond Strength to Dentin 242
MPa
bullCourtesy Pacific University (Dr Marc Guisberger)
2262016
17
MaximumMinimum Shear Bond Strength per
Bonding Material
SHEAR BOND TEST RESULTS - 2012
bullCourtesy Pacific University (Dr Marc Guisberger)
NEW ldquoUNIVERSALrdquo SYSTEMS
bull SIMPLE amp EASY TO USE
bull DIRECT amp INDIRECT TECHNIQUES
bull USE AS TOTAL SELECTIVE OR SELF ETCH
bull LOW SENSITIVITY
bull LOTS OF MDP BASED PRODUCTS
Total etch Self etch of
components
Etchant
Primer
Adhesive
The Bonding Agents
Generation4th 5th 6th 7th
Universals
OR How are you restoring
these different preparations
bull Voco (Grandio SO HF Xtra Base)
bull Kerr (Revolution Premise Vertise)
bull Ivoclar (Tetric Flow)
bull Heraeus (Venus Diamond Flow Bulk Fill)
bull SDI (Wave MV HV)
bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)
bull GC America (G-aenial Universal Flo)
bull Dentsply (SureFil SDR EsthetX Flow)
bull Kuraray (Clearfil Majesty ES Flow)
bull Tokuyama (Estelite Flow Quick)
bull 3M (Filtek Supreme Flow Plus)
Flowables
How are you restoring
these different preparations
2262016
18
Tokyo Medical amp Dental University 2010 J Tagami et al
FLOWABLE COMPOSITE SHRINKAGE(2MM BULK FILL W 71WT FLOWABLE ON DENTIN ONLY)
SureFill SDR amp CLEARFIL SE BOND
Enamel amp Variable Dentin Bonding
ProblemVARYING TOOTH SUBSTRATES
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treatingldquoAdhesive dentistry could be expressed as a simple
relationship between bonds and stress If the bonds
can withstand the stress the restorative technique will
be successfulrdquo
Unterbrink and Liebenberg (1999)
2262016
19
ldquoC-FACTORrdquo DEFINITION
CONFIGURATION FACTOR
ldquoTHE RATIO OF BONDED TO UN-BONDED (FREE) SURFACESrdquo
FEILZER DEGEE DAVIDSON (1987) UNIVERSTIY OF AMSTERDAM ACTA
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
Excellent Flow amp Handling Base Lining
ldquoC-FACTORrdquoRESIN TO DENTIN HYBRID ZONE
PREPARATIONS gt 2MM
bull TRADITIONALLY NUMEROUS INCREMENTS HAVE TO BE PLACED TO DIMINISH POLYMERIZATION
SHRINKAGE AS WELL AS STRESS ON TOOTH STRUCTURE
Technique
05mm Flowable amp Bonding Agent
Composite
Normallyhellip
2mm
2262016
20
Technique
BOND STRENGTHS RELATED TO TYPE OF DENTITION
05
101520253035404550
45 45
30 30 30
10
Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210
Caries Detector
Caries Detector by
Kuraray Dental is the
original caries detecting
stain material It was
developed by Dr
Fusayama amp Kuraray
Dental at the Tokyo
Medical amp Dental School
in 1978
2262016
21
CARIES INDICATOR DYES
bull ROYDENT-TO DYE FOR
bull KURARAY-CARIES DETECTOR
bull ULTRADENT-SEEKSABLE SEEK
bull PROOPTIONS-CARIES INDICATOR
bull DANVILLE-CARIES FINDER
bull PULPDENT-SNOOP
bull VISTA-CARIES INDICATOR
bull RONVIG-SEE IT
bull PATTERSON-
bull HENRY SCHEIN-
bull PEARSON-
CARIES DETECTOR 86 ACCURACY
bull AS NOTED BY SOUTHERN ILLINOIS DENTAL SCHOOL IN-VITRO RESEARCH
bull ldquoCARIES DETECTOR SOLUTION IDENTIFIED 86 OF SUBSEQUENTLY CONFIRMED CARIES
LESIONS AFTER SECTIONINGrdquo
bull REFERENCE CARIES DETECTION ACCURACY BY
MULTIPLE CLINICIANS amp TECHNIQUES THOMAS LAND WILSON amp GREGORY STEWART DDS SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF DENTAL MEDICINE IADR ABSTRACT 3127 1998
CARIES REMOVAL BURSbull SS WHITE
bull SINGLE USE
bull POLYMER
bull HARDNESS
bull 5000-10000 RPMS
bull KOMET
bull MULTI USE
bull CERAMIC
bull HARDNESS
bull 1000-1500 RPMS
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443
Current concepts amp techniques for caries excavation amp adhesion to residual dentin
de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
15
Factors that compromise bond durability in restorative dentistry
alarming
words hellip
but
the
reality
we
face
should
trigger
alarm
Hydrophilic dentin bonding (1956 - )
(RFA-DE-10-004) ldquoTooth-colored resin restorations have an average replacement time of 57
years due to secondary caries precipitated by bond failurerdquo
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong
direction
Water sorptionPolymer swelling
Decline in mechanical propertiesLeaching of hydrolyzed resin components
Factors that compromise bond durability in restorative dentistry
Hydrophilic dentin bonding (1956 - )
Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of
intraoral function
Instability of hybrid layers- problem may be more severe than we realize
Factors that compromise bond durability
Hydrophilic dentin bonding (1956 - )
MMP-8MMP-2MMP-9
Demineralizing dentin is like openingthe Pandorarsquos box releasing
endogenous enzymes (Matrix Metalloproteinases - MMPs)
that were trapped within
the mineralized dentin matrix
In the presence of water (such as thatderived from water sorption or from
adhesives MMPs (28 amp 9) can breakdown
collagen fibrils that are not protected
Sukala et al (2007)Mazzoni et al (2007)
Franklin Tay amp Dave Pashley Med College of Georgia
BOND DEGREDATIONbull PASHLEY DH TAY FR IMAZATO S HOW TO INCREASE THE DURABILITY OF RESIN-DENTIN BONDS
COMPEND CONTIN EDUC DENT 2011 SEP32(7)60-4 66
RESIN-DENTIN BONDS ARE NOT AS DURABLE AS WAS
PREVIOUSLY THOUGHT MICROTENSILE BOND STRENGTHS
OFTEN FALL 30 TO 40 IN 6 TO 12 MONTHS
2262016
16
4th6th5th
7th
bullCOURTESY PACIFIC UNIVERSITY (DR MARC GUISBERGER)
bullCourtesy Pacific University (Dr Marc Guisberger)
INSTRONbull ULTRA TESTER (ULTRADENT)
bull ULTRA JIG (ULTADENT)
SHEAR BOND TEST RESULTS - 2012
Average Shear Bond Strength to Dentin 242
MPa
bullCourtesy Pacific University (Dr Marc Guisberger)
2262016
17
MaximumMinimum Shear Bond Strength per
Bonding Material
SHEAR BOND TEST RESULTS - 2012
bullCourtesy Pacific University (Dr Marc Guisberger)
NEW ldquoUNIVERSALrdquo SYSTEMS
bull SIMPLE amp EASY TO USE
bull DIRECT amp INDIRECT TECHNIQUES
bull USE AS TOTAL SELECTIVE OR SELF ETCH
bull LOW SENSITIVITY
bull LOTS OF MDP BASED PRODUCTS
Total etch Self etch of
components
Etchant
Primer
Adhesive
The Bonding Agents
Generation4th 5th 6th 7th
Universals
OR How are you restoring
these different preparations
bull Voco (Grandio SO HF Xtra Base)
bull Kerr (Revolution Premise Vertise)
bull Ivoclar (Tetric Flow)
bull Heraeus (Venus Diamond Flow Bulk Fill)
bull SDI (Wave MV HV)
bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)
bull GC America (G-aenial Universal Flo)
bull Dentsply (SureFil SDR EsthetX Flow)
bull Kuraray (Clearfil Majesty ES Flow)
bull Tokuyama (Estelite Flow Quick)
bull 3M (Filtek Supreme Flow Plus)
Flowables
How are you restoring
these different preparations
2262016
18
Tokyo Medical amp Dental University 2010 J Tagami et al
FLOWABLE COMPOSITE SHRINKAGE(2MM BULK FILL W 71WT FLOWABLE ON DENTIN ONLY)
SureFill SDR amp CLEARFIL SE BOND
Enamel amp Variable Dentin Bonding
ProblemVARYING TOOTH SUBSTRATES
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treatingldquoAdhesive dentistry could be expressed as a simple
relationship between bonds and stress If the bonds
can withstand the stress the restorative technique will
be successfulrdquo
Unterbrink and Liebenberg (1999)
2262016
19
ldquoC-FACTORrdquo DEFINITION
CONFIGURATION FACTOR
ldquoTHE RATIO OF BONDED TO UN-BONDED (FREE) SURFACESrdquo
FEILZER DEGEE DAVIDSON (1987) UNIVERSTIY OF AMSTERDAM ACTA
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
Excellent Flow amp Handling Base Lining
ldquoC-FACTORrdquoRESIN TO DENTIN HYBRID ZONE
PREPARATIONS gt 2MM
bull TRADITIONALLY NUMEROUS INCREMENTS HAVE TO BE PLACED TO DIMINISH POLYMERIZATION
SHRINKAGE AS WELL AS STRESS ON TOOTH STRUCTURE
Technique
05mm Flowable amp Bonding Agent
Composite
Normallyhellip
2mm
2262016
20
Technique
BOND STRENGTHS RELATED TO TYPE OF DENTITION
05
101520253035404550
45 45
30 30 30
10
Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210
Caries Detector
Caries Detector by
Kuraray Dental is the
original caries detecting
stain material It was
developed by Dr
Fusayama amp Kuraray
Dental at the Tokyo
Medical amp Dental School
in 1978
2262016
21
CARIES INDICATOR DYES
bull ROYDENT-TO DYE FOR
bull KURARAY-CARIES DETECTOR
bull ULTRADENT-SEEKSABLE SEEK
bull PROOPTIONS-CARIES INDICATOR
bull DANVILLE-CARIES FINDER
bull PULPDENT-SNOOP
bull VISTA-CARIES INDICATOR
bull RONVIG-SEE IT
bull PATTERSON-
bull HENRY SCHEIN-
bull PEARSON-
CARIES DETECTOR 86 ACCURACY
bull AS NOTED BY SOUTHERN ILLINOIS DENTAL SCHOOL IN-VITRO RESEARCH
bull ldquoCARIES DETECTOR SOLUTION IDENTIFIED 86 OF SUBSEQUENTLY CONFIRMED CARIES
LESIONS AFTER SECTIONINGrdquo
bull REFERENCE CARIES DETECTION ACCURACY BY
MULTIPLE CLINICIANS amp TECHNIQUES THOMAS LAND WILSON amp GREGORY STEWART DDS SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF DENTAL MEDICINE IADR ABSTRACT 3127 1998
CARIES REMOVAL BURSbull SS WHITE
bull SINGLE USE
bull POLYMER
bull HARDNESS
bull 5000-10000 RPMS
bull KOMET
bull MULTI USE
bull CERAMIC
bull HARDNESS
bull 1000-1500 RPMS
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443
Current concepts amp techniques for caries excavation amp adhesion to residual dentin
de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
16
4th6th5th
7th
bullCOURTESY PACIFIC UNIVERSITY (DR MARC GUISBERGER)
bullCourtesy Pacific University (Dr Marc Guisberger)
INSTRONbull ULTRA TESTER (ULTRADENT)
bull ULTRA JIG (ULTADENT)
SHEAR BOND TEST RESULTS - 2012
Average Shear Bond Strength to Dentin 242
MPa
bullCourtesy Pacific University (Dr Marc Guisberger)
2262016
17
MaximumMinimum Shear Bond Strength per
Bonding Material
SHEAR BOND TEST RESULTS - 2012
bullCourtesy Pacific University (Dr Marc Guisberger)
NEW ldquoUNIVERSALrdquo SYSTEMS
bull SIMPLE amp EASY TO USE
bull DIRECT amp INDIRECT TECHNIQUES
bull USE AS TOTAL SELECTIVE OR SELF ETCH
bull LOW SENSITIVITY
bull LOTS OF MDP BASED PRODUCTS
Total etch Self etch of
components
Etchant
Primer
Adhesive
The Bonding Agents
Generation4th 5th 6th 7th
Universals
OR How are you restoring
these different preparations
bull Voco (Grandio SO HF Xtra Base)
bull Kerr (Revolution Premise Vertise)
bull Ivoclar (Tetric Flow)
bull Heraeus (Venus Diamond Flow Bulk Fill)
bull SDI (Wave MV HV)
bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)
bull GC America (G-aenial Universal Flo)
bull Dentsply (SureFil SDR EsthetX Flow)
bull Kuraray (Clearfil Majesty ES Flow)
bull Tokuyama (Estelite Flow Quick)
bull 3M (Filtek Supreme Flow Plus)
Flowables
How are you restoring
these different preparations
2262016
18
Tokyo Medical amp Dental University 2010 J Tagami et al
FLOWABLE COMPOSITE SHRINKAGE(2MM BULK FILL W 71WT FLOWABLE ON DENTIN ONLY)
SureFill SDR amp CLEARFIL SE BOND
Enamel amp Variable Dentin Bonding
ProblemVARYING TOOTH SUBSTRATES
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treatingldquoAdhesive dentistry could be expressed as a simple
relationship between bonds and stress If the bonds
can withstand the stress the restorative technique will
be successfulrdquo
Unterbrink and Liebenberg (1999)
2262016
19
ldquoC-FACTORrdquo DEFINITION
CONFIGURATION FACTOR
ldquoTHE RATIO OF BONDED TO UN-BONDED (FREE) SURFACESrdquo
FEILZER DEGEE DAVIDSON (1987) UNIVERSTIY OF AMSTERDAM ACTA
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
Excellent Flow amp Handling Base Lining
ldquoC-FACTORrdquoRESIN TO DENTIN HYBRID ZONE
PREPARATIONS gt 2MM
bull TRADITIONALLY NUMEROUS INCREMENTS HAVE TO BE PLACED TO DIMINISH POLYMERIZATION
SHRINKAGE AS WELL AS STRESS ON TOOTH STRUCTURE
Technique
05mm Flowable amp Bonding Agent
Composite
Normallyhellip
2mm
2262016
20
Technique
BOND STRENGTHS RELATED TO TYPE OF DENTITION
05
101520253035404550
45 45
30 30 30
10
Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210
Caries Detector
Caries Detector by
Kuraray Dental is the
original caries detecting
stain material It was
developed by Dr
Fusayama amp Kuraray
Dental at the Tokyo
Medical amp Dental School
in 1978
2262016
21
CARIES INDICATOR DYES
bull ROYDENT-TO DYE FOR
bull KURARAY-CARIES DETECTOR
bull ULTRADENT-SEEKSABLE SEEK
bull PROOPTIONS-CARIES INDICATOR
bull DANVILLE-CARIES FINDER
bull PULPDENT-SNOOP
bull VISTA-CARIES INDICATOR
bull RONVIG-SEE IT
bull PATTERSON-
bull HENRY SCHEIN-
bull PEARSON-
CARIES DETECTOR 86 ACCURACY
bull AS NOTED BY SOUTHERN ILLINOIS DENTAL SCHOOL IN-VITRO RESEARCH
bull ldquoCARIES DETECTOR SOLUTION IDENTIFIED 86 OF SUBSEQUENTLY CONFIRMED CARIES
LESIONS AFTER SECTIONINGrdquo
bull REFERENCE CARIES DETECTION ACCURACY BY
MULTIPLE CLINICIANS amp TECHNIQUES THOMAS LAND WILSON amp GREGORY STEWART DDS SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF DENTAL MEDICINE IADR ABSTRACT 3127 1998
CARIES REMOVAL BURSbull SS WHITE
bull SINGLE USE
bull POLYMER
bull HARDNESS
bull 5000-10000 RPMS
bull KOMET
bull MULTI USE
bull CERAMIC
bull HARDNESS
bull 1000-1500 RPMS
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443
Current concepts amp techniques for caries excavation amp adhesion to residual dentin
de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
17
MaximumMinimum Shear Bond Strength per
Bonding Material
SHEAR BOND TEST RESULTS - 2012
bullCourtesy Pacific University (Dr Marc Guisberger)
NEW ldquoUNIVERSALrdquo SYSTEMS
bull SIMPLE amp EASY TO USE
bull DIRECT amp INDIRECT TECHNIQUES
bull USE AS TOTAL SELECTIVE OR SELF ETCH
bull LOW SENSITIVITY
bull LOTS OF MDP BASED PRODUCTS
Total etch Self etch of
components
Etchant
Primer
Adhesive
The Bonding Agents
Generation4th 5th 6th 7th
Universals
OR How are you restoring
these different preparations
bull Voco (Grandio SO HF Xtra Base)
bull Kerr (Revolution Premise Vertise)
bull Ivoclar (Tetric Flow)
bull Heraeus (Venus Diamond Flow Bulk Fill)
bull SDI (Wave MV HV)
bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)
bull GC America (G-aenial Universal Flo)
bull Dentsply (SureFil SDR EsthetX Flow)
bull Kuraray (Clearfil Majesty ES Flow)
bull Tokuyama (Estelite Flow Quick)
bull 3M (Filtek Supreme Flow Plus)
Flowables
How are you restoring
these different preparations
2262016
18
Tokyo Medical amp Dental University 2010 J Tagami et al
FLOWABLE COMPOSITE SHRINKAGE(2MM BULK FILL W 71WT FLOWABLE ON DENTIN ONLY)
SureFill SDR amp CLEARFIL SE BOND
Enamel amp Variable Dentin Bonding
ProblemVARYING TOOTH SUBSTRATES
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treatingldquoAdhesive dentistry could be expressed as a simple
relationship between bonds and stress If the bonds
can withstand the stress the restorative technique will
be successfulrdquo
Unterbrink and Liebenberg (1999)
2262016
19
ldquoC-FACTORrdquo DEFINITION
CONFIGURATION FACTOR
ldquoTHE RATIO OF BONDED TO UN-BONDED (FREE) SURFACESrdquo
FEILZER DEGEE DAVIDSON (1987) UNIVERSTIY OF AMSTERDAM ACTA
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
Excellent Flow amp Handling Base Lining
ldquoC-FACTORrdquoRESIN TO DENTIN HYBRID ZONE
PREPARATIONS gt 2MM
bull TRADITIONALLY NUMEROUS INCREMENTS HAVE TO BE PLACED TO DIMINISH POLYMERIZATION
SHRINKAGE AS WELL AS STRESS ON TOOTH STRUCTURE
Technique
05mm Flowable amp Bonding Agent
Composite
Normallyhellip
2mm
2262016
20
Technique
BOND STRENGTHS RELATED TO TYPE OF DENTITION
05
101520253035404550
45 45
30 30 30
10
Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210
Caries Detector
Caries Detector by
Kuraray Dental is the
original caries detecting
stain material It was
developed by Dr
Fusayama amp Kuraray
Dental at the Tokyo
Medical amp Dental School
in 1978
2262016
21
CARIES INDICATOR DYES
bull ROYDENT-TO DYE FOR
bull KURARAY-CARIES DETECTOR
bull ULTRADENT-SEEKSABLE SEEK
bull PROOPTIONS-CARIES INDICATOR
bull DANVILLE-CARIES FINDER
bull PULPDENT-SNOOP
bull VISTA-CARIES INDICATOR
bull RONVIG-SEE IT
bull PATTERSON-
bull HENRY SCHEIN-
bull PEARSON-
CARIES DETECTOR 86 ACCURACY
bull AS NOTED BY SOUTHERN ILLINOIS DENTAL SCHOOL IN-VITRO RESEARCH
bull ldquoCARIES DETECTOR SOLUTION IDENTIFIED 86 OF SUBSEQUENTLY CONFIRMED CARIES
LESIONS AFTER SECTIONINGrdquo
bull REFERENCE CARIES DETECTION ACCURACY BY
MULTIPLE CLINICIANS amp TECHNIQUES THOMAS LAND WILSON amp GREGORY STEWART DDS SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF DENTAL MEDICINE IADR ABSTRACT 3127 1998
CARIES REMOVAL BURSbull SS WHITE
bull SINGLE USE
bull POLYMER
bull HARDNESS
bull 5000-10000 RPMS
bull KOMET
bull MULTI USE
bull CERAMIC
bull HARDNESS
bull 1000-1500 RPMS
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443
Current concepts amp techniques for caries excavation amp adhesion to residual dentin
de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
18
Tokyo Medical amp Dental University 2010 J Tagami et al
FLOWABLE COMPOSITE SHRINKAGE(2MM BULK FILL W 71WT FLOWABLE ON DENTIN ONLY)
SureFill SDR amp CLEARFIL SE BOND
Enamel amp Variable Dentin Bonding
ProblemVARYING TOOTH SUBSTRATES
Class I or II
Composite Preparation
3x Tubule Density Equals Higher Fluid amp
Increased Difficulty for Bonding 30 Decrease in
Bond Strengths with most bonding systems
What substrate are we treatingldquoAdhesive dentistry could be expressed as a simple
relationship between bonds and stress If the bonds
can withstand the stress the restorative technique will
be successfulrdquo
Unterbrink and Liebenberg (1999)
2262016
19
ldquoC-FACTORrdquo DEFINITION
CONFIGURATION FACTOR
ldquoTHE RATIO OF BONDED TO UN-BONDED (FREE) SURFACESrdquo
FEILZER DEGEE DAVIDSON (1987) UNIVERSTIY OF AMSTERDAM ACTA
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
Excellent Flow amp Handling Base Lining
ldquoC-FACTORrdquoRESIN TO DENTIN HYBRID ZONE
PREPARATIONS gt 2MM
bull TRADITIONALLY NUMEROUS INCREMENTS HAVE TO BE PLACED TO DIMINISH POLYMERIZATION
SHRINKAGE AS WELL AS STRESS ON TOOTH STRUCTURE
Technique
05mm Flowable amp Bonding Agent
Composite
Normallyhellip
2mm
2262016
20
Technique
BOND STRENGTHS RELATED TO TYPE OF DENTITION
05
101520253035404550
45 45
30 30 30
10
Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210
Caries Detector
Caries Detector by
Kuraray Dental is the
original caries detecting
stain material It was
developed by Dr
Fusayama amp Kuraray
Dental at the Tokyo
Medical amp Dental School
in 1978
2262016
21
CARIES INDICATOR DYES
bull ROYDENT-TO DYE FOR
bull KURARAY-CARIES DETECTOR
bull ULTRADENT-SEEKSABLE SEEK
bull PROOPTIONS-CARIES INDICATOR
bull DANVILLE-CARIES FINDER
bull PULPDENT-SNOOP
bull VISTA-CARIES INDICATOR
bull RONVIG-SEE IT
bull PATTERSON-
bull HENRY SCHEIN-
bull PEARSON-
CARIES DETECTOR 86 ACCURACY
bull AS NOTED BY SOUTHERN ILLINOIS DENTAL SCHOOL IN-VITRO RESEARCH
bull ldquoCARIES DETECTOR SOLUTION IDENTIFIED 86 OF SUBSEQUENTLY CONFIRMED CARIES
LESIONS AFTER SECTIONINGrdquo
bull REFERENCE CARIES DETECTION ACCURACY BY
MULTIPLE CLINICIANS amp TECHNIQUES THOMAS LAND WILSON amp GREGORY STEWART DDS SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF DENTAL MEDICINE IADR ABSTRACT 3127 1998
CARIES REMOVAL BURSbull SS WHITE
bull SINGLE USE
bull POLYMER
bull HARDNESS
bull 5000-10000 RPMS
bull KOMET
bull MULTI USE
bull CERAMIC
bull HARDNESS
bull 1000-1500 RPMS
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443
Current concepts amp techniques for caries excavation amp adhesion to residual dentin
de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
19
ldquoC-FACTORrdquo DEFINITION
CONFIGURATION FACTOR
ldquoTHE RATIO OF BONDED TO UN-BONDED (FREE) SURFACESrdquo
FEILZER DEGEE DAVIDSON (1987) UNIVERSTIY OF AMSTERDAM ACTA
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
Excellent Flow amp Handling Base Lining
ldquoC-FACTORrdquoRESIN TO DENTIN HYBRID ZONE
PREPARATIONS gt 2MM
bull TRADITIONALLY NUMEROUS INCREMENTS HAVE TO BE PLACED TO DIMINISH POLYMERIZATION
SHRINKAGE AS WELL AS STRESS ON TOOTH STRUCTURE
Technique
05mm Flowable amp Bonding Agent
Composite
Normallyhellip
2mm
2262016
20
Technique
BOND STRENGTHS RELATED TO TYPE OF DENTITION
05
101520253035404550
45 45
30 30 30
10
Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210
Caries Detector
Caries Detector by
Kuraray Dental is the
original caries detecting
stain material It was
developed by Dr
Fusayama amp Kuraray
Dental at the Tokyo
Medical amp Dental School
in 1978
2262016
21
CARIES INDICATOR DYES
bull ROYDENT-TO DYE FOR
bull KURARAY-CARIES DETECTOR
bull ULTRADENT-SEEKSABLE SEEK
bull PROOPTIONS-CARIES INDICATOR
bull DANVILLE-CARIES FINDER
bull PULPDENT-SNOOP
bull VISTA-CARIES INDICATOR
bull RONVIG-SEE IT
bull PATTERSON-
bull HENRY SCHEIN-
bull PEARSON-
CARIES DETECTOR 86 ACCURACY
bull AS NOTED BY SOUTHERN ILLINOIS DENTAL SCHOOL IN-VITRO RESEARCH
bull ldquoCARIES DETECTOR SOLUTION IDENTIFIED 86 OF SUBSEQUENTLY CONFIRMED CARIES
LESIONS AFTER SECTIONINGrdquo
bull REFERENCE CARIES DETECTION ACCURACY BY
MULTIPLE CLINICIANS amp TECHNIQUES THOMAS LAND WILSON amp GREGORY STEWART DDS SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF DENTAL MEDICINE IADR ABSTRACT 3127 1998
CARIES REMOVAL BURSbull SS WHITE
bull SINGLE USE
bull POLYMER
bull HARDNESS
bull 5000-10000 RPMS
bull KOMET
bull MULTI USE
bull CERAMIC
bull HARDNESS
bull 1000-1500 RPMS
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443
Current concepts amp techniques for caries excavation amp adhesion to residual dentin
de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
20
Technique
BOND STRENGTHS RELATED TO TYPE OF DENTITION
05
101520253035404550
45 45
30 30 30
10
Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210
Caries Detector
Caries Detector by
Kuraray Dental is the
original caries detecting
stain material It was
developed by Dr
Fusayama amp Kuraray
Dental at the Tokyo
Medical amp Dental School
in 1978
2262016
21
CARIES INDICATOR DYES
bull ROYDENT-TO DYE FOR
bull KURARAY-CARIES DETECTOR
bull ULTRADENT-SEEKSABLE SEEK
bull PROOPTIONS-CARIES INDICATOR
bull DANVILLE-CARIES FINDER
bull PULPDENT-SNOOP
bull VISTA-CARIES INDICATOR
bull RONVIG-SEE IT
bull PATTERSON-
bull HENRY SCHEIN-
bull PEARSON-
CARIES DETECTOR 86 ACCURACY
bull AS NOTED BY SOUTHERN ILLINOIS DENTAL SCHOOL IN-VITRO RESEARCH
bull ldquoCARIES DETECTOR SOLUTION IDENTIFIED 86 OF SUBSEQUENTLY CONFIRMED CARIES
LESIONS AFTER SECTIONINGrdquo
bull REFERENCE CARIES DETECTION ACCURACY BY
MULTIPLE CLINICIANS amp TECHNIQUES THOMAS LAND WILSON amp GREGORY STEWART DDS SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF DENTAL MEDICINE IADR ABSTRACT 3127 1998
CARIES REMOVAL BURSbull SS WHITE
bull SINGLE USE
bull POLYMER
bull HARDNESS
bull 5000-10000 RPMS
bull KOMET
bull MULTI USE
bull CERAMIC
bull HARDNESS
bull 1000-1500 RPMS
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443
Current concepts amp techniques for caries excavation amp adhesion to residual dentin
de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
21
CARIES INDICATOR DYES
bull ROYDENT-TO DYE FOR
bull KURARAY-CARIES DETECTOR
bull ULTRADENT-SEEKSABLE SEEK
bull PROOPTIONS-CARIES INDICATOR
bull DANVILLE-CARIES FINDER
bull PULPDENT-SNOOP
bull VISTA-CARIES INDICATOR
bull RONVIG-SEE IT
bull PATTERSON-
bull HENRY SCHEIN-
bull PEARSON-
CARIES DETECTOR 86 ACCURACY
bull AS NOTED BY SOUTHERN ILLINOIS DENTAL SCHOOL IN-VITRO RESEARCH
bull ldquoCARIES DETECTOR SOLUTION IDENTIFIED 86 OF SUBSEQUENTLY CONFIRMED CARIES
LESIONS AFTER SECTIONINGrdquo
bull REFERENCE CARIES DETECTION ACCURACY BY
MULTIPLE CLINICIANS amp TECHNIQUES THOMAS LAND WILSON amp GREGORY STEWART DDS SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF DENTAL MEDICINE IADR ABSTRACT 3127 1998
CARIES REMOVAL BURSbull SS WHITE
bull SINGLE USE
bull POLYMER
bull HARDNESS
bull 5000-10000 RPMS
bull KOMET
bull MULTI USE
bull CERAMIC
bull HARDNESS
bull 1000-1500 RPMS
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443
Current concepts amp techniques for caries excavation amp adhesion to residual dentin
de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B
ROUND BURS (6) CARBIDE CERABUR SMARTBURS II (SS WHITE) (KOMET) (SS WHITE)
1000-1500RPM 5-10000RPM
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
22
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
23
POSTERIOR COMPOSITE
PKT 3
Dentin Replacement with Composite Cap
Dentin substitute Composites
Bulkfil Flowables
Flowable Resins
Glass Ionomers
Enamel Replacement Modern NanoHybrid Composite
CR April 2014 NanoHybrid offers best results
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
24
REDUCES INTERNAL STRESS BY 60 COMPARED TO TRADITIONAL RESINS
CURES IN 20 SECONDS4MM SELF LEVELING
LOW POLYMERIZATION STRESS13 OF OFFICE PRODUCTION IS SAID TO COME FROM
DIRECT RESTORATIONS
82 of dentists report
using a flowable as a
liner in Class II
restorations to
increase marginal
adaptation 1
Insight
1Council on Scientific Affairs of the American
Dental Association Spring 20094(2)
LOW STRESS
ADAPTATIONbull Marginal Integrity
bull Adaptation at the
most vulnerable
interface
bull Minimal shrinkage
stress
PROTECTS THE MOST VULNERABLE INTERFACE
The 1 reason for
composite failure is
recurrent decay ndash and
the floor of the
proximal box of a Class
II is the most vulnerable
area
3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE
bull EXCELLENT CAVITY ADAPTATION
bull EXCELLENT RADIOPACITY
bull LOW STRESS
INCREASE CLASS II EFFICIENCY
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
25
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW PLUS (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
DENTIN BULK FILL COMPOSITES
What problems are believed to be associated with high-
polymerization stress
Marginal integrity issues
Enamel fracture
Cracked cusps
Failure of the composite-tooth surface
White lines around the restoration
Gaps that cause post-operative sensitivity microleakage
andor secondary caries
bull MATERIAL PLACEMENT TECHNIQUES
bull VARIABLE SUBSTRATE
bull POLYMERIZATION STRESS amp SHRINKAGE
bull WATER ABSORPTION
bull HYDROPHOBIC BONDING AGENTS
bull DECREASED ADHESIVE BOND STRENGTH OVER TIME
bull MMPS AND CATHEPSINS
bull MICROLEAKAGE
DRAWBACKS OF ANY COMPOSITE RESIN DECREASED BOND STRENGTHS DUE TO
bull SUBSTRATE
bull PREPARATION TECHNIQUE
bull BUR SELECTION
bull HAND PIECE OILS
bull BONDING AGENT
bull CURING DEVICE AND POSITION
bull MATERIAL SELECTION
bull LAYERING TECHNIQUE
How are you restoring
these different preparations
DENTIN BULK FILL COMPOSITES
bull BULK FILL COMPOSITES 4MM MAX TYPICALLY
bull MORE TRANSLUCENT
bull TYPICAL SHRINKAGE IS APPROX 31-35
bull SHRINKAGE STRESS IS 16-313MPA
bull VENUS BULK FILL COMPOSITE amp FLOWABLE (KULZER)
bull SUREFIL SDR FLOW (DENTSPLY)
bull TETRIC EVOCERAM BULK FILL (IVOCLAR)
bull XTRA BASE (VOCO)
bull FILTEK BULK FILL (3MESPE)
bull BEAUTIFIL BULK FLOW (SHOFU)
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
26
bull LONG TERM RESEARCH
LIGHT CURED BULK FILL COMPOSITES
bull Dentin amp Enamel Replacement
bull Requires one layer
bull 16-24 vol shrinkage
bull 23-28mpa shrinkage stress
bull Bonding agentbull (2 bottle highly filled system)
bull Self Cured BulkFill
bull Danville
bull Coltene
SONICFILL (KERR)
bull FASTEST GROWING DENTAL MATERIAL CATEGORY IN NORTH AMERICA
bull CONVENIENT TIME SAVINGS
bull REDUCED POLYMERIZATION SHRINKAGE
bull DEPTH OF CURE
bull FLOW OR ADAPTABILITY
bull PHYSICAL PROPERTIES
bull WEAR
bull ESTHETICS
BULK FILL COMPOSITES
These CRA research results agree with
Dr Tagamirsquos results on SonicFill
Tagami stated SonicFill cures to only 70 on bottom at
4 or 5mm depth of cure
EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS
0
10
20
30
40
11176 157 16
198 19
31
MPa
1 Layer (4mm)
2 Layers (2mm)
4 Layers (1mm Each)
Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R
Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
27
Internal (Polymerization) Stresses of Composites
ldquoA Simple Pain-Free Adhesive Restorative System by Minimal Reduction amp
Total-Etching (1993)
Takao Fusayma DDS
Tokyo Medical amp Dental University
Lowest Stress
Low Stress
Medium Stress
High Stress
Highest Stress
ldquoAdhesive dentistry could be expressed as a simple relationship
between bonds and stress If the bonds can withstand the stress the
restorative technique will be successfulrdquo
Unterbrink and Liebenberg (1999)
BULK FILL SELF CURE MATERIAL
Releasesrecharges calcium phosphate and fluorideChemically bonds and seals tooth
bull NO BONDING AGENT NECESSARY
bull NO LAYERING BULK FILL
bull NO POLYMERIZATION STRESS
bull BIOACTIVE
bull BIOAVAILABLE
bull NO SENSITIVITY
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
28
ACTIVA incorporates reactive ionomer glasssbquo a patented ionic
resin and a patentedsbquo shock-absorbing synthetic rubber molecule
to deliver excellent esthetics with high compressive and flexural
strengths thatrsquo mimic the physical and chemical properties of
natural teeth
ACTIVA materials are tougher more durable more impact
resistant have much higher flexural strength and are more
cohesive elastic and esthetic than traditional glass ionomers and
RMGIssbquo without sacrificing their bioactive properties
These properties position ACTIVA as a bioactive dentin and tooth
replacement material with the strength and esthetics of
restorative composites
DO Restoration
Tooth 29
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
29
MOD RESTORATION TOOTH 3
CLASS V AND CLASS II TOOTH 31
OTHERS TO FOLLOWhellip
bull DANVILLE-BULKEZ
bull COLTENE-FILL-UP
bull BIOACTIVE MATERIAL
bull AFFINITY TO TOOTH STRUCTURE WHEN PLACING A GLASS IONOMER A WEAK
ACID OR CONDITIONER IS USED TO AID IN RELEASING CALCIUM AND PHOSPHATE
IONS FROM THE TOOTH STRUCTURE THESE CALCIUM AND PHOSPHATE IONS
COMBINE INTO THE SURFACE LAYER OF THE GLASS IONOMER AND FORM AN
INTERMEDIATE LAYER CALLED THE INTERDIFFUSION ZONE THIS BOND LAYER CAN BE
VERY STRONG AND SIGNIFICANTLY REDUCE THE MICROLEAKAGE THAT WOULD
OCCUR AT THE MARGINS OF THE RESTORATION
bull VERY GOOD FLUORIDE AND ION RELEASE HELPS REMINERALIZE TOOTH STRUCTURE IN
THE REMINERALIZATIONndashDEMINERALIZATION PROCESS THAT NATURALLY OCCURS IN
THE ORAL CAVITY
bull THEY BOND TO ENAMEL DENTIN AND METALS
Why Glass Ionomersbull THEY PRODUCE GOOD MARGINAL INTEGRITY
bull THEY SHRINK ONLY ONE NINTH THE AMOUNT OF COMPOSITE
MATERIAL
bull THEY ARE FLUORIDE-RECHARGEABLE
bull THERE ARE NO FREE MONOMERS IN THE MATERIAL
bull THE CAVITY PREPARATION CAN BE BULK-FILLED MAKING THE
MATERIALS EASY TO PLACE
bull THEY EXHIBIT EXCELLENT BIOCOMPATIBILITY
Why Glass Ionomers
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
30
Deep Preparations Bonding Agent amp Flowable composite
Conventional Glass Ionomer or RMGI then Composite
Fluoride Release
High compressive strength
Hydrophillic
Insoluble
True chemical adhesion
Minimizes microleakage
No sensitivity
Acid Base Resistant Zone
Decreased gap formation amp C Factor
Coefficient thermal expansion similar to dentin
LARGE SIZED LESIONS (gt2MM)bull MOSTLY DENTIN
bull DENTIN HAS MORE MOISTURE AND LESS SUBSTANCE
bull OPEN AND CLOSED DEFECTS
bull COMPLICATIONS amp RISKS ARE HIGHER
bull POROUS WET DENTIN AVAILABLE
bull INTERPROXIMAL CONCERNS
bull INCREASED OCCLUSAL LOADING
bull REMAINING TOOTH STRUCTURE
Pulpal Proximity
Seals amp Protects the Pulpbull For Direct amp Indirect Pulp Capping
bull Light-curable Radiopaque Liner
bull Significant Calcium Release
bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation
Resin-Modified Calcium Silicate Pulp ProtectantLiner
THERACAL LC (BISCO)
CONVENTIONAL GLASS IONOMERGLASS IONOMER SANDWICH
bullClass I II III amp V posterior restorations
bullOpen amp Closed Sandwich techniques
bullComposite replacement
bullAmalgam replacement
bullHigh caries risk patients
bullPediatric patients
bullGeriatric patients
bullSpecial needs patients
bullLong term resistance to microleakage
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
31
GLASS IONOMER MATERIALSbull DENTSPLY-CHEMFIL ROCK RESTORATIVE
bull SDI-RIVA LC LIGHT CURE HV RIVA SC SELF CURE HV
bull GC AMERICA-FUJI II LC EQUIA FIL (FUJI IX)
bull VOCO-IONOLUX IONOFIL MOLAR AC
bull 3MESPE-KETAC NANO PHOTAC FIL QUICK VITREMER KETAC MOLAR QUICK KETAC FIL
PLUS
bull SHOFU- FX II
COMPRESSIVE STRENGTHSbull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR
CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
MINIMALLY INVASIVE PREPARATIONS
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
32
GLASS IONOMER INTERFACEInte
rface
Ana
lysis (TEM
)
CARDOSO et al J Dent 2010
RESIN TO DENTIN HYBRID ZONE
Open sandwich glass ionomer amp nanohybrid composite
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
33
GLASS IONOMER VS OPEN SANDWICH
GLASS IONOMER VS OPEN SANDWICH
bull 7 YEARS LATER
A35 A3 A2
Glass Ionomer Bulk Fill
COMPRESSIVE STRENGTHS
bull GC EQUIAFIL COMPRESSIVE STRENGTH 255MPA
bull RIVA SC COMPRESSIVE STRENGTH 271MPA
bull CHEMFIL ROCK COMPRESSIVE 200MPA
bull VOCO IONOLUX HAD HIGHER COMPRESSIVE STRENGTH THAN EQUIA FIL OR CHEMFIL ROCK
bull SUREFIL SDR COMPRESSIVE STRENGTH 220MPA
bull DENTIN 280MPA-297MPA
bull ENAMEL 384MPA
bull GRANDIO SO HF HAS COMPRESSIVE 417MPA
bull FUJI II LC 170MPA (RMGI) COMPRESSIVE STRENGTH
CHEMFIL ROCK VS CONVENTIONAL GI
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
34
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
35
ENDODONTIC SANDWICH TECHNIQUE ENDODONTIC SANDWICH TECHNIQUE
ENDODONTIC SANDWICH TECHNIQUE
DIRECT RESTORATION LAYERING REVIEWbull BONDING AGENT + COMPOSITE LAYERING (THIN FLOWABLE
INITIALLY)
bull ENAMEL IS PRESENT AROUND CAVOSURFACE MARGINS
bull IN SUPERFICIAL DENTIN
bull MOISTURE CONTROL IS ACHIEVABLE
bull NO PULPAL PROXIMITY
bull BONDING AGENT + DUAL CURED BULK-FILL COMPOSITE
bull LACK OF TIME NEEDING FAST OR EASIER ALTERNATIVE
bull LESS TECHNIQUE SENSITIVITY
bull DEEP PREP
bull BIOACTIVITY WITH A RESIN (ACTIVA)
DIRECT RESTORATION LAYERING REVIEW
bull GLASS IONOMER + BONDING AGENT + COMPOSITE
bull LACK OF ENAMEL DEEP PREP OR IF PREPARATION IS ON
DENTIN amp CEMENTUM INTERPROXIMALLY
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull GLASS IONOMER BULK FILL
bull ENAMEL OR DENTIN PRESENT
bull CLOSE PROXIMITY TO GINGIVA
bull SUBGINGIVAL
bull MOISTURE CONTROL POSES AN ISSUE
bull CLOSE PULPAL PROXIMITY
bull LESS THAN HALF THE OCCLUSAL ISTHMUS WIDTH
DIRECT RESTORATION LAYERING REVIEW
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
36
Lots of options
What works best for your practice and skills
How much time do you have
Bond Strengths
Risks and Longevity
ABFRACTION LESIONS
bull SOMETIMES IT PRESENTS AS SINGLE TEETH DUE TO EXCURSIVE INTERFERENCES OR AS A PIVOT FULCRUM OR
ldquoTEETER TOTTERrdquo TOOTH
bull OTHER TIMES THERE ARE MORE IN A QUADRANT AND THERE IS SEVERE WEAR TO THE OCCLUSION
bull OTHER TIMES IT MAYBE ON THE FACIALS OF ANTERIOR TEETH WHERE THERE IS WEAR ON THE INCISAL EDGES OR
WEAR FACETS ON THE LINGUALS HOWEVER LITTLE TO NO WEAR ON POSTERIORS
bull OCCLUSAL GUARDS SHOULD BE FABRICATED ALONG WITH AN OCCLUSAL ANALYSIS IN CR ON MODELS
FLOWABLES
bull MICROLEAKAGE AND MISSING FILLINGS FROM HIGH OCCLUSAL LOADS ON TEETH CAN
CAUSE LARGE CERVICAL STRESS CONCENTRATIONS RESULTING IN DISRUPTION OF THE BONDS
BETWEEN THE HYDROXYAPATITE CRYSTALS AND THE EVENTUAL LOSS OF CERVICAL ENAMEL
DENTIN AND RESTORATION
bull SDI-RIVA LC LIGHT CURE HV
bull GC AMERICA-FUJI II LC
bull VOCO-IONOLUX AC
bull 3MESPE-KETAC NANO
bull SHOFU ndash FX II
RESIN MODIFIED GLASS IONOMER
Fig 15 ndash Graph representing the mean annual failure ratesper adhesive class determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998ndash2004 [2]
Van Meerbeek B et al Relationship between bond-strength tests and clinical outcomes Dent Mater (2009) doi101016jdental200911148
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
37
ABFRACTION LESIONS amp CLASS V RESTORATIONSLATIN WORDS AB ndash ldquoAWAYrdquo FRACTION ndash ldquoBREAKINGrdquo
bull PATHOLOGICAL LOSS OF TOOTH STRUCTURE CAUSED BY BIOMECHANICAL LOADING FORCES
bull STATIC AND CYCLIC FLEXURAL OVERLOADING OF TOOTH STRUCTURE ULTIMATELY LEADING TO FATIGUE AND
FAILURE OF TOOTH STRUCTURE AWAY FROM THE POINT OF LOADING
RESIN MODIFIED GLASS IONOMER RESTORATION
POST-OP PHOTO ndash NOTICE UNLIKE TYPICAL CLASS V COMPOSITE RMGI RESTORATIVE
MATERIAL
RESIN MODIFIED GLASS IONOMERbull LIGHT CURED
bull DUAL CURED
bull HIGH FLEXURAL STRENGTH
bull GOOD POLISHABILITY
bull EXCELLENT WEAR
bull HYDROPHILLIC
bull FLUORIDE RELEASE
bull NO MICROLEAKAGE
bull NO ADHESIVES
bull ACID RESISTANT LAYER
bull REDUCES SENSITIVITY
bull TRUE CHEMICAL ADHESION
ABFRACTION LESIONS
bull DENTIN 109-160MPA FLEXURAL STRENGTH
bull COMPOSITES CAN HAVE FLEXURAL STRENGTHS OF 65MPA -159MPA
bull CHEMFIL ROCK HIGHEST FLEXURAL STRENGTH 63MPA FOR A CONVENTIONAL GI
bull FUJI II LC BOND STRENGTH 218MPA FLEXURAL STRENGTH 64-68MPA
TYPICAL TREATMENT INVOLVES THE PLACEMENT OF A 00 RETRACTION CORD ON EACH
TOOTH FOLLOWED BY A SHADE SELECTION ROUGHEN TOOTH STRUCTURE WITH AIR
ABRASION PLACE CAVITY CONDITIONER ON ALL AREAS TO BE RESTORED FOR 10
SECONDS THEN WASH AND DRY
MIX RMGI AND SYRINGE INTO PLACE UTILIZE HAND INSTRUMENTS TO SHAPE AND
REMOVE GROSS EXCESS CURE EACH TOOTH FOR 20 SECONDS REMOVE EXCESS AND
CONTOUR USING A HANDPIECE WITH FINE DIAMOND BURS TEETH SHOULD BE ISOLATED
FROM SALIVA
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
38
AFTER CONTOURING THE RESTORATIONS CAN BE COATED WITH A SELF ETCH ADHESIVE
COATING AND CURE FOR 10 SECONDS
Eight year post-op photos show the integrity of the material is still excellent Note the lack of
marginal microleakage stain often present with composite restorations
HOW DO WE CREATE THEM
INTERPROXIMAL CONTACTSINTERPROXIMAL CONCERNS amp ISSUES
bull VOIDS
bull SENSITIVITY
bull CONDENSING
bull SHAPE
bull FLASH
bull CONTACT
bull POSITION
bull TIGHTNESS
PROBLEM amp SOLUTION
TOFFLEMIRE VS SECTIONAL MATRICES
PROBLEM amp SOLUTION
TOFFLEMIRE
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
39
Direct Class II PosteriorComposite(conservative preps)
(tight contacts)
Class II Direct Composite
QUICKMAT DELUXPolydentia SA
QUICK RINGS amp SILICONE RUBBER ADAPTERS
MICROTHIN MATRICES 0025MM (0001 IN)
WOODEN WEDGES
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
40
NiTi only spring
V-Shaped glass reinforced autoclavable plastic tines
(leaves room for the wedge)
Built in lip for increased
stability in forceps
Anatomically shaped
tines
Universal V3 Ring Narrow V3 Ring
TrioDent has developed Narrow V3 Ring in addition to the Universal
V3 Ring to ensure ideal separation on smaller teethNote how the anatomical shape of the V3 Ring matches the lingual
contour of the molar while engaging the gingival undercut
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
41
Wave Wedge
Hole to fit with positive
grip Pin-Tweezers Inter-proximal contour for a
better gingival seal and V-
shaped concavity to protect
the papillae
45mm
55mm
65mm
Tab can be bent 90˚ for
contra-angle placement
Holes designed to fit with
positive grip Pin-Tweezers
by TrioDent
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
42
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
43
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
44
Garrison Dental 3D Ring System
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
45
Garrison Dental
XR = Extra Retention
FENDER WEDGES amp SLICK BANDS
by TrioDent
bullINTERPROXIMAL CONTACTSbull CONSISTENTLY TIGHT CONTACTS REGARDLESS OF PREPARATION SIZE
bull HEIGHT OF CONTOUR
bull STACKABLE
bull EASY PRE- OR POST- WEDGING
bull BAND SIZE OPTIONS
bull COATING OPTIONS
bull ANATOMICALLY SHAPED CONTACT
HOW DO WE ELIMINATE IT
POST OPERATIVE PROBLEMS
CORRECTING COMMON PROBLEMS
bull HYPER OCCLUSION
bull SYMPTOMS-SENSITIVE TO PRESSURE TEMPERATURE SENSITIVE
bull TREATMENT-CHECK BITE IN CO amp CR CHECK PATIENT SITTING UPRIGHT AS WELL AS
LYING IN CHAIR BEFORE AND AFTER APPOINTMENT
bull WEAK INTERPROXIMAL CONTACTS
bull SYMPTOMS-FOOD TRAP NO FLOSS PRESSURE FROM ADJACENT TOOTH
bull TREAMENT ndash PLACE NEW RESTORATION OR SLOT PREP TO CREATE NEW CONTACT
bull SHARP POST OPERATIVE PAIN UPON BITING (ADHESION PROBLEM)
bull SYMPTOMS- TOOTH IS PERFECTLY NORMAL BUT ON BITING PRESSURE IT HAS
SHARP PAIN
bull TREATMENT- WAIT AND DO NOTHING TAKE OUT MATERIAL AND PLACE RMGI
FILLING
bull PAIN IN TOOTH
bull POSSIBLE NECROTIC TOOTH THAT HAS PRESSURE BUILDING UP
bull UNCURED RESIN IN TOOTH
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
2262016
46
CORRECTING COMMON PROBLEMS
bull WHITE LINES
bull SYMPTOMS-WHITE DISCOLORATION ALONG CAVOSURFACE MARGIN
bull TREATMENT-
bull ETCH ENAMEL MARGIN
bull CURE PROPERLY
bull ADJUST MARGINS WITH CARBIDE BUR UNDER WATER SPRAY FROM TOOTH TO
COMPOSITE
bull C-FACTOR
bull INCREMENTAL LAYERING
bull NO FAST CURING
bull FOLLOW MANUFACTURERrsquoS DIRECTIONS
bull GLASS IONOMER BASE
CORRECTING COMMON PROBLEMS
bull ADHESIVE FATIGUEFAILURE
bull USE ANTIMICROBIAL RINSE PRIOR TO ADHESIVE TO MINIMIZE MMP
RELEASE
bull MICROLEAKAGEMOISTURE CONTROL
bull GLASS IONOMERRMGI OPEN SANDWICH
bull CONTAMINANTS
Water
Saliva
Blood
Crevicular fluids
Oil
Alcohol
Eugenol
Oxygen
Copal varnish
IRM
Bleach amp Superoxol
Chemical coagulants
LECTURE HANDOUT FREE DRAWING amp SPECIAL OFFERS AVAILABLE
wwwDENTOOLZcom
Todd Snyder DDS AAACDdoctcsdentalcom
Handout at
wwwdentoolzcom
