1 Contemporary Restorative Trends: Separating fact from fiction Daniel H Ward DDS www.drwardhandouts.com Daniel H Ward DDS Graduated 1979 OSU Graduated 1979 OSU Private Practice Private Practice- Columbus, Ohio Columbus, Ohio Assistant Clinical Professor The Assistant Clinical Professor The Ohio State University Ohio State University- 13 years 13 years FACD, FICD, FAGD, FASDA FACD, FICD, FAGD, FASDA “I get by with a little help from my friends…” Dr Harry Albers Dr Harry Albers Dr Paul Belvedere Dr Paul Belvedere Dr John Burgess Dr John Burgess Dr Mark Canon Dr Mark Canon Dr Gordon Christensen Dr Gordon Christensen Dr George Freedman Dr George Freedman Dr Doug Lambert Dr Doug Lambert Dr Karl Leinfelder Dr Karl Leinfelder Dr Graeme Milicich Dr Graeme Milicich Dr Buddy Mopper Dr Buddy Mopper Dr Brian Novy Dr Brian Novy Dr Jorge Perdag Dr Jorge Perdagão ão Dr Robert Seghi Dr Robert Seghi Dr Irwin Smigel Dr Irwin Smigel Dr Byong Suh Dr Byong Suh Dr Ed Swift Dr Ed Swift Company Affiliations AdDent AdDent BISCO BISCO Caulk/Dentsply Caulk/Dentsply Centrix Centrix Clinicians Clinicians’ Choice Choice Coltene/Whaledent Coltene/Whaledent Den Mat Den Mat Doxa Doxa GC GC Heraeus Kulzer Heraeus Kulzer Ivoclar Ivoclar Kerr Kerr Kettenbach Kettenbach 3-M On On Pharma Pharma Pulpdent Pulpdent Shofu Shofu Smile Reminder Smile Reminder SDI SDI SSWhite SSWhite Tokuyama Tokuyama Triodent Triodent Voco Voco Some Images May be: Cropped Rotated Levels adjusted No Images Were: Site adjusted Enhanced to produce a better result Things are not always as they appear You may never have thought about it Maybe it seemed OK at the time If we say it long enough we believe it Perhaps we need to re-examine some of our ideas
Transcript
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Contemporary Restorative Trends:
Separating fact from fiction
Daniel H Ward DDS
www.drwardhandouts.com
Daniel H Ward DDSGraduated 1979 OSUGraduated 1979 OSUPrivate PracticePrivate Practice--Columbus, OhioColumbus, OhioAssistant Clinical Professor The Assistant Clinical Professor The
Ohio State UniversityOhio State University--13 years13 yearsFACD, FICD, FAGD, FASDAFACD, FICD, FAGD, FASDA
“I get by with a little help from my friends…” Dr Harry AlbersDr Harry Albers Dr Paul BelvedereDr Paul Belvedere Dr John BurgessDr John Burgess Dr Mark CanonDr Mark Canon Dr Gordon ChristensenDr Gordon Christensen Dr George FreedmanDr George Freedman Dr Doug LambertDr Doug Lambert Dr Karl LeinfelderDr Karl Leinfelder Dr Graeme MilicichDr Graeme Milicich Dr Buddy MopperDr Buddy Mopper Dr Brian NovyDr Brian Novy Dr Jorge PerdagDr Jorge Perdagãoão Dr Robert SeghiDr Robert Seghi Dr Irwin SmigelDr Irwin Smigel Dr Byong SuhDr Byong Suh Dr Ed SwiftDr Ed Swift
Company Affiliations AdDentAdDent BISCOBISCO Caulk/DentsplyCaulk/Dentsply CentrixCentrix CliniciansClinicians’’ ChoiceChoice Coltene/WhaledentColtene/Whaledent Den MatDen Mat DoxaDoxa GCGC Heraeus KulzerHeraeus Kulzer IvoclarIvoclar KerrKerr KettenbachKettenbach 33--MM On On PharmaPharma PulpdentPulpdent ShofuShofu Smile ReminderSmile Reminder SDISDI SSWhiteSSWhite TokuyamaTokuyama TriodentTriodent VocoVoco
Some Images May be: Cropped
Rotated
Levels adjusted
No Images Were: Site adjusted
Enhanced to produce a better result
Things are not always as they appear
You may never have thought about it
Maybe it seemed OK at the time
If we say it long enough we believe it
Perhaps we need to re-examine some of our ideas
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Health and appearance conscious
The Public has concerns about:
Appearance & Metals
Patients are more knowledgeable than ever
We must listen more to our patients
We must provide alternatives for our patients
…but the rightalternatives
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Composite
The most USED
and ABUSED
Material in Dentistry
Composite
Uncommon, common sense
•What is the most important restoration that determines the long term prognosis of a tooth?
•Are flowable composites always an inferior restoration?
•Does fluoride present within the enamel of an un-prepared tooth margin result in a better bond between resin and tooth?
Uncommon, common sense
•Does the addition of fluoride to a resin result in efficacious fluoride release?
•Should preparations for tooth to be restored with a composite be the same as for a tooth to be restored with amalgam?
•What is the effect of warming composite immediately prior to placement?
Decay Removal
Composite Direct Placement Challenges
Thoroughly remove decay only
Amalgam Preparation
Composite Preparation
“Convenience”Form MID
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Lifetime of tooth often determined by first dentist intervention
15 Year Old
Fissurotomy bur
201.3VF
Conservative Tooth Preparation
169L330
Low Viscosity Flowable Composite
How do you restore?
Low Viscosity Flowable Composite
G-aenial Universal Flo
Homogeneous spherical particles
Better wear resistance
Higher flexural strength (167 MPa)
Filled 50% by volume
Good polishability
Visibly blends in well Mean particle size 200 nm
Low Viscosity Flowable Composite
Beautifil Flow 00
Unique glass ionomer filler particles
Releases fluoride and other ions
Neutralizes pH-Antibacterial
Reduced plaque accumulation
Good polishability
Visibly blends in well S-PRG (Surface pre-treated Glass Ionomer)
4% organic (tyrosine rich amelogenin 4% organic (tyrosine rich amelogenin protein) and waterprotein) and water
Enamel rods 4Enamel rods 4--8 microns in diameter8 microns in diameter Bonding occurs within enamel rodsBonding occurs within enamel rods HydrophobicHydrophobic
Sheared enamel Sheared enamel rodsrods
White Lines
Unprepared MarginsExpose fresh ends of the enamel rods
with a very fine diamond
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Koase K, Inoue S, Noda M, Tanaka T et al. Effect of burKoase K, Inoue S, Noda M, Tanaka T et al. Effect of bur--cut dentin on bond strength cut dentin on bond strength using two allusing two all--inin--one and one twoone and one two--step adhesive systems. step adhesive systems. J Adhes DentJ Adhes Dent. 2004;6:97. 2004;6:97--104.104.
Hosoya Y, Shinkawa H, Suefiji C, Nozaka Ket al. Effects of diamHosoya Y, Shinkawa H, Suefiji C, Nozaka Ket al. Effects of diamond bur particle ond bur particle size on dentin bond strength. size on dentin bond strength. Am J DentAm J Dent. 2004;17:359. 2004;17:359--364.364.
Use a fine 25 micron diamond when using self-etching primers
Greater angle than direction of enamel rods
Class II Interproximal Margin Preparation
Expose the ends of the enamel rods to avoid tooth fracture at margins
Class II Interproximal Margin Preparation
Composite Composite PreparationPreparation
Amalgam Amalgam PreparationPreparation
Bevel Interproximal Enamel for better bonding and less shearing of enamel rods
Class II Interproximal Margin Preparation
Importance of flaring Class II Interproximals
Fractured tooth structure
Importance of flaring Class II Interproximals
Parallel preparation
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Importance of flaring Class II Interproximals
Result
Post-Operative Sensitivity
Composite Direct Placement Challenges
Hydrodynamic Theory
Hydrodynamic Theory
Fluid flow within dentinal tubules causes PAINBrannstrom M. The Cause of post restorative sensitivity and its prevention. J Endod 1986;12:475-481.
30% organic (collagen) and water30% organic (collagen) and water
Dentinal tubules 0.06Dentinal tubules 0.06--3 microns in diameter3 microns in diameter
Most Bonding occurs between dentinal tubulesMost Bonding occurs between dentinal tubules
HydrophilicHydrophilic
FIVE Pillars for Successful Dentin Bonding
Dental bonding is a critical step for the success of both direct and indirect restorations.
A dental bonding agent is a functional component for any dental restoration—providing adhesion, sealing and maintaining structural integrity for lasting restorations.
Not all bonding agents are equal-due to the different chemistries and the application techniques employed.
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In the case of bond failures, the bonding agent may not be the sole culprit, but rather the failure of the clinician to understand the fundamentals of bonding or the specific techniques for a particular dental bonding system.
Not all "advances" have resulted in improved clinical performance. Fewer steps, fewer bottles of agents, or increased speed may not always equate to increased long term bond strengths.
FIVE Pillars for Successful Dentin Bonding
Dentists often employ protocols which stray from the actual recommended or ideal methods for using a particular bonding agent, picking and choosing techniques from different systems which may or may not be applicable to their particular bonding system.
As a result, there has been—and continues to be a lack of general, objective guidance regarding the use of bonding agents.
FIVE Pillars for Successful Dentin Bonding
1. In-Vivo Efficacy Without Post-Operative Pain
2. Marginal Integrity
3. Bond Compatibility
4. Long-term Durability
5. Consistency of Strength and Adhesion Performance
FIVE Pillars for Successful Dentin BondingSelection Criteria
Oh NO, not another bonding lecture!
•What are MMP’s and what agents can affect their effects?
•What is the effect of the width of the hybrid layer and dentin bond strengths?
•What new Self-Etching Primer Dentin Bonding Agent has bond strengths to un-etched enamel greater than 40 MPa ?
Oh NO, not another bonding lecture!
•Is there a relationship between post-operative sensitivity and dentin bond strengths?
•What are the characteristics of alcohol, acetone and water based solvents of dentin bonding agents?
•What are Universal Dentin Bonding Agents?
Demineralize surfaceExpose collagen fibersRemove smear layer Increase porosity of intertubular dentinOpen up dentinal tubules Increase surface area
Etched Dentin
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•Total Etch Technique Fill and Occlude open dentinal tubules
Bonding agent should not leave the dentinal tubules open
Method #1-Reducing Post-Op Sensitivity
Placement of Etchant
Total Etch Technique
“Moist” Dentin”
Rinsing of Etchant Placement of Resin Primer
Apply multiple coats
Moist Moist
Placement of Resin Primer
“Overwet” Phenomenon
Tay FR, Gwinnett AJ, Wei Sh. The overwet phenomenon: a scanning electron microscopic study of surface moisture in the acid-conditioned, resin-dentin interface. Am J Dent. 1996;9(3):109-114.
Overdrying
Gwinnett AJ. Dentin bond strength after air drying and rewetting. Am J Dent. 1994;7(3):144-148.
Lopez CL, Perdigao J, Lopes M et al. Dentin Bond Strengths of Simplified Adhesives:Effect of Dentin Depth. Compendium. 2006;27(6):340-345.
17.6(+/-5.9)
18.4(+/-4.8)
14.2(+/-7.0)
Deep
Dentin
21.0(+/-7.4)
18.9(+/-4.1)
22.1(+/-2.8)
Superficial
Dentin
Clearfil
Liner
Bond
Optibond
Solo
Single Bond
Adhesive
System
Mean shear bond strength in MPa
Effect of Dentin Depth on Bond Strengths
•Occludes tubules
•Anti-bacterial
GLUMA
•Occlusions
Total Etch Technique
Summary
Most technique sensitiveRequires proper attention to detailUse in ideal sized preparations
Total Etch Technique
Materials-4th
Generation
Acetone solvent Alcohol solvent
Total Etch Technique
Materials-5th
Generation
Acetone solvent Alcohol solvent
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•Self Etch Technique Never leave the dentinal tubules open
Bonding agent should not leave the dentinal tubules open
Method #2-Reducing Post-Op Sensitivity
Acid-groupsHydrophilic end
etches tooth structure (self
limiting)
Spacer-chainlink between
functional groups
Methacrylate-groupHydrophobic end
connects to polymer-network
COOH
COOH
CH 2
CH 2
O
OO
O
Self-Etching Primer
“Self Etching” PrimerAcidifying Primer accompanies etch
Acid reaction is self-limiting
Self-Etch Technique
Challenges
Decreased bond strength to un-etched enamel
Marginal gap formation with un-etched enamel
Bond incompatibility to self-cure and dual-cure resins
More susceptible to hydrolytic degradation resulting in significantly diminished bond strengths over time
Self etching Primer
37% H3PO4 etched Unprepared enamel surface for 15s.
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Popular SE primer etched Unprepared enamel surface
•Tests confirm that preparing the enamel margin improves bond strength especially with self-etch dentin bonding agents
Substrate All-Bond UniversalSelf-Etch
All-Bond UniversalTotal-Etch
Uncut Enamel 18.7±6.7 31.4±7.1
Cut Enamel 29.0±5.5 35.6±3.6
Bisco in-house data.. Lee IS, Son SA, Hur B, Kwon YH, Park JK. The effect of additional etching and curing mechanism of composite resin on the dentin bond strength. J Adv Prosthodont. 2013;5:467-484.
55% improvement
Effect of Enamel Etching-Bond Strength
•Tests show that etching uncut enamel with phosphoric acid increases bond strength to enamel with 1- bottle dentin bonding agents
Substrate All-Bond UniversalSelf-Etch
All-Bond UniversalTotal-Etch
Uncut Enamel 18.7±6.7 31.4±7.1
Cut Enamel 29.0±5.5 35.6±3.6
Bisco in-house data.. Lee IS, Son SA, Hur B, Kwon YH, Park JK. The effect of additional etching and curing mechanism of composite resin on the dentin bond strength. J Adv Prosthodont. 2013;5:467-484.
67% improvement
Effect of Enamel Etching-Bond Strength
Substrate All-Bond UniversalSelf-Etch
All-Bond UniversalTotal-Etch
Uncut Enamel 18.7±6.7 31.4±7.1
Cut Enamel 29.0±5.5 35.6±3.6
Bisco in-house data.. Lee IS, Son SA, Hur B, Kwon YH, Park JK. The effect of additional etching and curing mechanism of composite resin on the dentin bond strength. J Adv Prosthodont. 2013;5:467-484.
22% improvement
Effect of Enamel Etching-Bond Strength
•Tests show that etching cut enamel with phosphoric acid increases bond strength to enamel with 1- bottle dentin bonding agents
•SEM analysis found no marginal gapformation of enamel etched w phosphoric acid prior to application of a self-etching 6th
generation bonding agent following thermocycling•SEM analysis reported marginal gap formationof enamel not etched w phosphoric acid prior to application of a self-etching 6th generation bonding agent following thermocycling
Souza-Junior EJ, Prieto LT, Araújo CT, Paulillo LA. Selective enamel etching: effect on marginal adaptation of self-etch LED-cured bond systems in aged Class I composite restorations. Oper Dent. 2012;37:195-204.
Effect of Enamel Etching-Marginal Gaps
Solution: “Etching prepared enamel w phosphoric acid promoted better marginal integrity with self-etching bonding agents.”
Souza-Junior EJ, Prieto LT, Araújo CT, Paulillo LA. Selective enamel etching: effect on marginal adaptation of self-etch LED-cured bond systems in aged Class I composite restorations. Oper Dent. 2012;37:195-204.
Effect of Enamel Etching-Marginal Gaps
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When the pH of a dentin bonding agent is too low (more acidic), tertiary amines (necessary for the polymerization reaction) are deactivated resulting in bond incompatibility with self and dual cured resins.
Bond Incompatibility with Self and Dual Cured Resins
Suh BI, Feng L, Pashley DH, Tay FR. Factors contributing to the incompatibility between simplified-step adhesives and chemically-cured or dual -cured composites. Part III. Effect of acidic resin monomers. J Adhes Dent 2003;5:267-282.
Solution: Use of a higher pH (>3.0)self-etching dentin bonding agent does not inactivate the tertiary amines and allows for polymerization.
Suh BI, Feng L, Pashley DH, Tay FR. Factors contributing to the incompatibility between simplified-step adhesives and chemically-cured or dual -cured composites. Part III. Effect of acidic resin monomers. J Adhes Dent 2003;5:267-282.
Bond Incompatibility with Self and Dual Cured Resins
pH=3.2
Solution: Use a dual-cure activator
Bond Incompatibility with Self and Dual Cured Resins
“The cured layer of 1-step self-etching adhesives is hydrophilic and a permeable membrane.”
Tay F, Suh B, Pahsley D, Carvalho R. Single Layer Adhesives are Permeable membranes. J Dent 2002;30:371-382.
Hydrolytic Degradation
Solution: Use 2 layers-a hydrophilic layer covered with a hydrophobic layer
Yoshida Y, Yoshihara K, Nagaoka N, Hayakawa S, Tori Y, Ogawa T, Osaka A, Van Meerbeek B. Self-assembled nano-kayering at the adhesive interface. J Dent Res 2012;9:376-381.
Hydrolytic Degradation
Solution: Use MDP containing bonding agents which become hydrophobic upon polymerization due to high amount of cross-linkage.“MDP-containing adhesives form nano-layering at the adhesive interface. Stable MDP-Ca salt deposition along with nano-layering may explain the high stability of MDP-based bonding.”
Yoshida Y, Yoshihara K, Nagaoka N, Hayakawa S, Tori Y, Ogawa T, Osaka A, Van Meerbeek B. Self-assembled nano-kayering at the adhesive interface. J Dent Res 2012;9:376-381.
Hydrolytic Degradation
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Self Etch Technique
OptiBond XTR
6th generation DBA that effectively etches enamel
Unprepared enamel surface
Etched with 37% Phosphoric Acid OptiBond XTR 6th Generation DBA
Popular 6th Generation DBA Popular 7th Generation DBA
Swift E, et al. J Esthet Restor Dent. 2011;23(6):390-398.
Self Etch Technique
OptiBond XTR
Self Etch Technique
OptiBond XTR
2 component self-etch 15% filled by volumeHydrophilic acidic self-etching primer with
enhanced etching capabilitiesHydrophobic adhesive to maximize
material compatibility, increase strength and promote bond durability
Self Etch Technique
OptiBond XTR
Primer contain acetone, alcohol and water solvents
Low film thickness (5 micron)Bonds to gold, non-precious metal,
zirconia, porcelain Direct and indirect restorative procedures
Seventh Generation DBA
BeautibondDual acidic monomersLow film thickness (5 micron)RadiopaqueEasy to use-single application 10 sec
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Self Etch Technique
Materials 6th & 7th
Generation
Sixth Generation Seventh Generation
All-Bond SE Clearfil SE Protect
BeautiBond G-BondOptibondXTR
Long Term Dentin Bond StabilityMMP-Matrix MetalloproteasesMMPs are naturally occurring proteases
involved in dentin formation and trapped during odontogenesis
Not bacteria but proteolytic enzymes found within dentin capable of degrading collagen within newly created adhesive hybrid layers
Low pH causes dentin to release these inherent MMPs which attack exposed collagen fibrils
Osorio R, Yamauti M. Osorio E., et al. Effect of dentin etching on metalloproteinase-mediated collagen degradation. Eur J Oral Sci 2011;119:79-85.
Long Term Dentin Bond StabilityCysteine Proteases (Cathepsins)
Lysosomal enzymes that become activated in lysosomes by a low pH
Secreted by osteoclasts in bone resorption
Regulated by chondroitin
Collagenase activity breaks down collagen and hydrolyzes collagen into small peptides
Terasariol Il, Geraldeli S., ,Minciotti Cl., et al., Cysteine catepsins in human dentin pulp complex. J Dent Res 2011; 90:506-11.
MMP-Matrix Metalloproteases
Carrilho et al., JDR 2007; 86; 529Brackett et al.,Operative Dentistry; 2009;34(4):381-385
In-vivo 12 m w/PBNT (Acetone)
Immediate (MPa)Control 29.3 (9.2)CHX 32.7 (7.6)
w/CHX in 12 m
14 mo (MPa)Control 19.0 (5.2)CHX 32.2 (7.2)
Potential MMP Inhibitors
Long Term Dentin Bond Stability
Chlorhexidine (CHX)
Benzalkonium Chloride
MDPB ((12-methacryloxydodecalpyridinium bromide)
Galardin (mimics MMP-binds Zn atom) (inhibits tumor growth and metastasis)
Epigallocatechin-3-gallate (green tea polyphenol)
Perdigao J, Resi A, Loguercio AD. Dentin Adhesion and MMPs: A Comprehensive Review. J Esthet Restor Dent 2012: 25:219-241.
Disinfect to prevent MMPs
Use Etchant containing 1% Benzalkonium Chloride
TE-Apply 2% Chlorhexidine after acid etching for 30 sec
SE-Apply 2 coats 2% Chlorhexidine prior to application of primer
OR
Long Term Dentin Bond Stability
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Disinfect to prevent MMPs
MDPB (12-methacryloxydodecalpyridinium bromide)
Long Term Dentin Bond Stability
Pashley DH, Tay FR, Imazato S. Hot to Increase the durability of Resin-Dentin Bonds. Compend. 2010;32(7):60-64.
Pashley DH, Tay FR, Imazato S. Hot to Increase the durability of Resin-Dentin Bonds. Compend. 2010;32(7):60-64.
Breschi L, Mazzoni A, Ruggeri A, Cadenaro M, Di Lenarda R, De Stefano Dorigo E. Dental adhesion review: aging and stability of the bonded interface. Dent Mater. 2008 Jan;24(1):90-101.
Most simplified one-step adhesives were shown to be the least durable, while three-step etch-and-rinse and two-step self-etch adhesives continue to show the highest performances, as reportedin the overwhelming majority of studies. In other words, a simplification of clinical application procedures is done to thedetriment of bonding efficacy. Among the different aging phenomena occurring at the dentin bonded interfaces, some are considered pivotal in degrading the hybrid layer, particularly if simplified adhesives are used. Insufficient resin impregnation of dentin, high permeability of the bonded interface, sub-optimal polymerization, phase separation and activation of endogenous collagenolytic enzymes are some of the recently reported factorsthat reduce the longevity of the bonded interface.
Dentin Bonding Challenges
Breschi L, Mazzoni A, Ruggeri A, Cadenaro M, Di Lenarda R, De Stefano Dorigo E. Dental adhesion review: aging and stability of the bonded interface. Dent Mater. 2008 Jan;24(1):90-101.
In order to overcome these problems, recent studies indicated that (1) resin impregnation techniques should be improved, particularly for two-step etch-and-rinse adhesives; (2) the use of conventional multi-step adhesives is recommended, since they involve the use of a hydrophobic coating of nonsolvated resin; (3) extended curing time should be considered to reduce permeability and allow a better polymerization of the adhesive film; (4) proteases inhibitors as additional primer should be used to increase the stability of the collagens fibrils within the hybrid layer inhibiting the intrinsic collagenolytic activity of human dentin.
Dentin Bonding Solutions
De Munck J, Van Landuyt K, Peumans M, Poitevin A, Lambrechts P, Broem M, Van Meerbeek B. A Critical Review of the Durability of Adhesion to Tooth Tissue: Methods and Results. J Dent Res. 2005;84(2):118-132.
Dentin Bonding Challenges
• SE 1-step adhesives are too hydrophilic and permeable even after polymerization
• The best way to minimize these weaknesses is to apply a neutral-pH, hydrophobic adhesive resin layer in a separate step
• Acidic components cause incompatibility with self-cured composites.
• 3-step, etch-and-rinse adhesives remain the “gold standard” in terms of adhesive durability.
Dentin Bonding Solutions
De Munck J, Van Landuyt K, Peumans M, Poitevin A, Lambrechts P, Broem M, Van Meerbeek B. A Critical Review of the Durability of Adhesion to Tooth Tissue: Methods and Results. J Dent Res. 2005;84(2):118-132.
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Selective Etch TechniqueApply etch to enamel only for 15 secondsWash thoroughlyPlace self-etching primer
Frankerger R, Lohbauer U, Roggendorf MJ, Naumann M, Taschner M. Selective enamel etching reconsidered:better than etch-and-rinse and self etch? J. Adhes Dent. 2008;10:339-344.
Often need more treatmentOften need more treatment
Refer new patientsRefer new patients
Say Thank You!Say Thank You!
60+ Patients are Wonderful
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Multiple Medications
Oral Environment Challenges-Xerostomia
Oral Environment Challenges-Xerostomia
“40% of all prescription drugs have dry mouth listed in the PDR as a possible side effect”
Chalmers J. Personal Communication. 2006.Chalmers J. Personal Communication. 2006.
Oral Environment Challenges-Xerostomia
In a published study of 131 different prescribed medications the most common side effect cited was xerostomia.
Smith RG, Smith RG, BurtnerBurtner AP. Oral sideAP. Oral side--effects of the most frequently prescribed drugs. effects of the most frequently prescribed drugs. Spec Spec Care Dent.Care Dent. 1994;14:961994;14:96--102. 102.
Oral Environment Challenges-Xerostomia
• Incidence increases with # of drugs taken
• 50% of patients taking 4 or more medications had Dry Mouth
Oral Environment Challenges-Carbohydrates
Nutrition Facts: Serving Size: 8.3 fl. oz Calories: 140 Total Fat: 0g Sodium: 200mg Protein: 0g Total Carbohydrates: 28g Sugars: 28g
Nutrition Facts:16 fl oz; calories 140; total fat 0g; sodium 220mg; potassium 60mg; total carbs 28g; sugars 28g
Brackett WW, Dib A, Brackett MG, Reyes AA, Estrada BE. Two-year clinical performance of Class V resin-modified glass-lonomer and resin composite restorations. Oper Dent. 2003;28:477-81
37 pairs of caries-free unprepared abfraction lesions were treated with resin modified and resin composite restorations (single bottle total etch dba). Retention of the composite restorations at six months was below the minimum specified in the ADA Acceptance Program for Dentin and Enamel Adhesives. At two years retention was 96% for the resin-modified glass ionomer and 81% for the resin composite. The resin composite restorations generally had a better appearance, with a 100% alpha rating in color match, versus 85% for the resin-modified glass ionomer.
•Better retention
Resin-Modified Glass Ionomer Base/Restorative
Capsule
Fuji II LC RIVA LC
Fuji Filling LC
Resin-Modified Glass Ionomer Base/Restorative
Ketac Nano
Paste-Paste
Class V Restoration
Restoration Under Crown Quick Temporary prior to Crown
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Temporary placed 5 years ago Sandwich Technique
Sandwich TechniqueTelio – Temporary Concept, Team IV Spain, Madrid, November 2009
Resin-modified Bonding Agent–Triturated
–Reduces polymerization shrinkage
stress
–Novel concept
Riva Bond LC
•Exposed to occlusion
•Able to control moisture
•Not acid etching
•No shrinkage stress
•Highest fluoride release
•Out of occlusion
•Need quickness
•Need to acid etch
•Need to bond
•↑translucence/esthetic
Resin-Modified Glass Ionomer
Glass Ionomer
•Core-Cemented posterior crowns
•Entire Class I or II (Long Term Interim)
•Class V-high caries
•All deciduous posteriors
•Sandwich technique-Co Cure
Glass Ionomer Preferred Uses
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•Core-all crowns
•Base Class I or II-re-prepared sandwich
•Class V-more esthetic
•Quickly placed short-term interim restorations
Resin-Modified Glass Ionomer
Preferred Uses
Calcium Aluminate/RMGI cement– Hybrid cement
– Forms apatite crystals
– Excellent physical properties
– Low film thickness-easy to use
– Virtually no sensitivity
Ceramir
GI Initial setting and early strength Fluoride release
Calcium Aluminate Long term-increased strength and retentionApatite formation Sealing at marginal interface Sustained long term properties w/o degradingHigher pH (not acidic)-virtually no sensitivity
Ceramir
Telio – Temporary Concept, Team IV Spain, Madrid, November 2009
Ceramir
Forms apatite crystals(a group of phosphate minerals, usually referring to hydroxyapatite, fluorapatite and chlorapatite, named for high concentrations of OH−, F−, Cl− or ions, respectively, in the crystal. The formula of the admixture of the four most common end members is written as Ca10(PO4)6(OH,F,Cl)2, and the crystal unit cell formulae of the individual minerals are written as Ca10(PO4)6(OH)2, Ca10(PO4)6(F)2 and Ca10(PO4)6(Cl)2.)
Telio – Temporary Concept, Team IV Spain, Madrid, November 2009
Ceramir
Forms apatite crystals Powder and water are mixed Dissolution results in nano-crystal formation Gibbsite and Katoite forms
Gibbsite
Tooth apatite
Mixed zoneChemically formed apatiteGibbsite(Calcite)
Katoite
Telio – Temporary Concept, Team IV Spain, Madrid, November 2009
Ceramir
Forms apatite crystals Powder and water are mixed Dissolution results in nano-crystal formation Gibbsite and Katoite forms Crystals form on tooth and restoration Long-term stable bond Ceramir Dentin
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Physical Properties– Creates Apatite when in contact with phosphates– No shrinkage– Hydrophilic system with Alkaline pH– Thermal properties similar to tooth structure– Low film thickness -15 microns– 160 Mpa compressive strength– Anti-bacterial-inhibits caries– Gets stronger over time– Acid resistant– Bonds well to metal, porcelain, ceramics, zirconium
Ceramir
0:00
Ceramir
2:00
Ceramir
4:00
Ceramir
Glass IonomersThe “missing link” of esthetic
restorative materials
We must communicate better with our patients
– Patients are more informed
– Patients are more demanding
– Patients want choices
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•I’m too old to change to Digital Radiography
•I don’t take intra-oral photographs because I don’t know how
•Where should I buy a camera for my office?
Trust me, ITrust me, I’’m the doctor and I know m the doctor and I know what is best for you!what is best for you!
•How do patients often judge their dentists?
•What about using text messaging and email to communicate?
Trust me, ITrust me, I’’m the doctor and I know m the doctor and I know what is best for you!what is best for you!
We must communicate better with our patients
Digital RadiographyDigital Radiography
Digital Radiography
Advantages– Instant Viewing
– Able to manipulate contrast-magnification
– WOW factor to patients
– More environmentally friendly
– Email to insurance companies-films not lost
– Able to access remotely
– Adds value and higher perception if selling practice
Disadvantages– Sensor can be bulky for some patients
How many of you have How many of you have problems with Mandibular Nerve problems with Mandibular Nerve
Blocks?Blocks?
30-Minute Time Course for Pulpal Analgesia - Lidocaine IANBsData from 30 PRP Studies (1991 - 2008), n = 1162 Subjects, Lidocaine/Epi IANB
How many of you have How many of you have problems with Mandibular Nerve problems with Mandibular Nerve
Blocks?Blocks?
Mean 30-Minute Time Course for Pulpal Analgesia - Lidocaine IANBsData from 30 PRP Studies (1991 - 2008), n = 1162 Subjects, Lidocaine/Epi IANB
How many of you have How many of you have problems with Mandibular Nerve problems with Mandibular Nerve
Blocks?Blocks?
Mean 30-Minute Time Course for Pulpal Analgesia - Lidocaine IANBsData from 30 PRP Studies (1991 - 2008), n = 1162 Subjects, Lidocaine/Epi IANB
The knee in the curve is at about 10 minutes (60%)
How many of you have How many of you have problems with Mandibular Nerve problems with Mandibular Nerve
Blocks?Blocks?
30-Minute Time Course for Pulpal Analgesia - Articaine IANBsData from 5 PRP Studies - 222 Subjects (1990 - 2008)
51
How many of you have How many of you have problems with Mandibular Nerve problems with Mandibular Nerve
Blocks?Blocks?
Mean 30-Minute Time Course for Pulpal Analgesia - Articaine IANBsData from 5 PRP Studies - 222 Subjects (1990 - 2008)
How many of you have How many of you have problems with Mandibular Nerve problems with Mandibular Nerve
Blocks?Blocks?
Mean 30-Minute Time Course for Pulpal Analgesia - Articaine IANBsData from 5 PRP Studies - 222 Subjects (1990 - 2008)
Pharmacology of Local Pharmacology of Local AnestheticsAnesthetics
Each patient has unique physiology and chemistry that
Standard Dental Anesthetic2% Lidocaine w/ epinephrineStandard Dental Anesthetic
2% Lidocaine w/ epinephrine
Often require 2nd or 3rd injection
Failures disrupt schedule and adds stress
Inactive versus Active Form of Anesthetic 25,000:1*
* Calculated values based on Henderson-Hasselbach equation
Body tissues & fluids must buffer anesthetic toward
physiologic pH before it works
Body tissues & fluids must buffer anesthetic toward
physiologic pH before it works
creates uncertainty in the buffering process
Has almost no active anesthetic
Packaged at the pH of 3.5– as a preservative to extend shelf life
Acidity
Pharmacology of Local Pharmacology of Local AnestheticsAnesthetics
Increased predictability and decreased stress
Know sooner if additional injection is needed
Less likely to need additional injection
* Calculated values based on Henderson-Hasselbach equation
Increase in active anesthetic when
pH approaches 7.4 *
Increase in active anesthetic when
pH approaches 7.4 *
Inactive versus Active Form of Anesthetic 3:1*
Onset Precision Buffered Anesthetic
3:1 means 8,000% increase in immediate active form
Less Injection pain due to neutral pH
Rapid onset of analgesiaRapid onset of analgesia
Buffered and nonBuffered and non--buffered buffered anestheticanesthetic--time vs. efficacy of time vs. efficacy of
IANBIANB
Mean 30-Minute Time Course for Pulpal Analgesia – Lidocaine, Articaine , Buffered Lidocaine IANBsData from published and company Studies
2 minute Buffered as effective 2 minute Buffered as effective as 10 minute nonas 10 minute non--buffered buffered anestheticanesthetic--efficacy of IANBefficacy of IANB
Mean 30-Minute Time Course for Pulpal Analgesia – Lidocaine, Articaine , Buffered Lidocaine IANBsData from published and company Studies
67%
52
8 minute Buffered anesthetic 8 minute Buffered anesthetic gives 90+% efficacy of IANBgives 90+% efficacy of IANB
Mean 30-Minute Time Course for Pulpal Analgesia – Lidocaine, Articaine , Buffered Lidocaine IANBsData from published and company Studies
“Contact with acid and pulp tissue started the bleeding process thus damaging the bonding technique resulting in no cellular differentiation and new dentin formation. The use of dentin bonding agents should be avoided for vital pulp therapy.”
Silva GA, Lanza LD, Lopes-Junior N, MoreiraA, Alves JB. Direct pulp capping with a dentin bonding system in human teeth: a clinical and histological evaluation. Oper dent. 2006;31:291-307.
“Poly Acrylic Acid (PAA) inhibits apatite formation in the body environment. PAA released from the glass-ionomer cements inhibits the apatite formation on tooth surfaces. It might be considered difficult to obtain bioactive glass-ionomer cements”
Kawashita M, Kokubo T, Nakamura T. Effect of polyacrylic acid on the apatite formation of a bioactive ceramic in a simulated body fluid: fundamental examination of the possibility of obtaining bioactive glass-ionomer cements for orthopaedic use. Biomaterials. 2001;22:3191-6.
New Filler TechnologyNew Filler TechnologyNanofill/HybridNanofill/Hybrid
New Filler TechnologyNew Filler TechnologySpheroidal FillersSpheroidal Fillers
Easy polishing and retention
Blends well into tooth structure
Esthelite Sigma Quick-1 layer
Omega-2-3 layers
Estelite Sigma Quick
1μm
New Filler TechnologyNew Filler TechnologySpheroidal FillersSpheroidal Fillers
1μm
Estelite Sigma Quick
4 Seasons
Venus
Filtek Supreme Premise
Nano Clusters
(5,000 Magnification)
Tetric Evo-Ceram
1μm
DX-511
MW 895
BIS-GMA
MW 512
UDMA
MW 470
TEGMA
MW 286MW=Molecular Weight
New Resin TechnologyNew Resin TechnologyNanofill/HybridNanofill/Hybrid
Concern about bis-GMA
Shrinkage of bis-GMA,TEGMA
Higher molecular weight-less shrinkage
New advances possible through resin technology
DX-511
New Resin TechnologyNew Resin TechnologyNanofill/HybridNanofill/Hybrid
Increasing the size and molecular weight of monomers reduces overall shrinkage
Low Molecular weight
Shrinkage
High Molecular weight
Polymerization
Less Shrinkage
New Resin TechnologyNew Resin TechnologyNanofill/HybridNanofill/Hybrid
57
Pre-Operative
Completed Preparation
KaloreKalore--Clinical CaseClinical Case
Fuji II LC Resin Modified Glass Ionomer Base
Kalore
Kalore
Kerr products
Venus Pearl
New Resin TechnologyNew Resin TechnologyNon Non bisbis--GMA CompositesGMA Composites Bulk Fill CompositesBulk Fill Composites
Allow many posterior restorations to be built up in 1 segment
Descriptions– “Stick the stuff in the hole and cure”– Evolutionary– Monolithic
Physical Advantages– Deeper depth of cure– Less Polymerization Shrinkage– Less Polymerization Shrinkage Stress– Reduced likelihood of air voids between layers
Bulk Fill CompositesBulk Fill Composites
Modes of Action– Improved initiators– Greater translucency allows better light transmission– Delayed gel state formation– Increased elasticity
Materials– Flowable– Conventional
Advantages– Quicker, easier– Less chance of enamel and cusp fractures– Increased likelihood of adequate resin polymerization
Bulk Fill Flowable CompositesBulk Fill Flowable CompositesLow Shrinkage StressStress
•Surefill SDR
• Voco Xtra
•Beautifil Bulk Flowable
•Venus Bulk Fill
58
Surefill SDRSurefill SDR
•Reduced polymerization shrinkage stress
• Bulk fill to 4mm
•Increased sensitivity to light
Great placement with metal tips
•Self-leveling
•A1, A2, A3 Universal shades
Roggendorf MJ1, Krämer N, Appelt A, Naumann M, Frankenberger R. Marginal quality of flowable 4-mm base vs. conventionally layered resin composite. J Dent. 2011;39:643-647.
