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Resin Modified Glass
Ionomer
When one tugs at a single thing in nature, he finds it attached to the rest of the world.
- John Muir
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Injection of RMGI
•Rinse etchant
•Matte finish enamel
•Gloss finish dentin
Fuji II LC
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Physical properties RMGI
• Compressive strength- ( 1 day) 220 MPa
• Depth of cure- 20 seconds (A2)-3.8 mm
• Fluoride release- > 500 ug/cm2/year
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Brush with bonding agent
Bonding agent smoothes RMGI and
leaves adhesive surface for
composite resin
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Bonding
Agents
•Any bonding agent-good way to use up old third generation materials, PLEASE insure no acetone or alcohol is left on brush!
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Apply bonding agent to
RMGI
•Place RMGI increment 1 mm short of margins
•Smooth with bonding agent
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Buccal lingual light
cure
•Sectional matrix
•Ref: Carole Wilson et al
•Dennison et al
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Restorative Care
• IADRPresentation # 3128
Eight different sets of
RMGI/adhesive/composite
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Application of
Occlusal Component
Flowable composite will need to be approximately one mm
thick
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Flowable composites
Microhybrid resin based flowable composites
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Finished restoration
•Sectional matrix removed
•Wedge removed
•Flash removed with carver
•Power cure 600 milliwatts plus
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Restorative Care for Children
• IADRPresentation #3359
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Rubber dam
removed
•Little polishing required
•Adjust occlusion as necessary
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Restorative Care for Children
• Reference:• Journal of
Dentistry for Children
• 2003
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BisCover
• Severe bruxer with low shrink composite
• Note pulp exposure
• Note excellent margins
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BisCover• Same patient,
other side with open sandwich restoration
• Note flowable composite
• Note RMGI and wear
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Vitremer
• RMGI, note wear and staining
• Exposed margins
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Retrieved Molar- occlusal
view
•Beta perhaps even Alfa ranking
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Retrieved molar- distal
view
•Charlie or even Delta gingival ranking
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Are the Margins Sealed?
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Retrieved molar- gingival
margins
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Retrieved molar- 10X
magnification
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Marginal fluoride release
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Sectioned molars 10X
magnification
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Pulp response- reparative
dentin
Fuji II LC
Dentin
Pulp
Reparative Dentin
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Retrieved Molars Study
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Retrieved Molars Study
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“Scout view” of pulp
capping and RMGI
Current Research
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Keith, Andrea, Christopher, Michelle and Ryan Cannon
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Acrylic
Resin
Crowns
Dentistry courtesy of Dr. Elizabeth Ralstrom
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476
Pre-operative photograph
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477
Rubber dam clamp 212
Exposes more tooth
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478
Reduce incisals all atonce
Flame shaped diamond reduces incisal
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479
Interproximal reduction
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480
Round bur in slow speed, gross cariousmaterial removal
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481
Spoon excavator
Final carious substance removal
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482
Curved crown and collarScissors trim crownforms
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483
Crown form tried on, should matchOriginal shape and size-Compare to adjacent teeth
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484
Crown form vented frominside with explorer tine
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485
G Bond application
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LIGHT CURED SELF-ETCHING ONE COMPONENT ADHESIVE
G-BOND
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Application Air Dry Light Cure
G-BOND Technique Chart
Apply G-BOND to the whole cavity and wait for 10 secs.
Dry thoroughly with maximum airpressure 10 secs.from the air syringe.
Light Cure for 10 secs. by visible light irradiation.
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488
Light cure at 600 milliwatts for10 seconds
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489
Crown filled with Gradia andSeated, excess removed withComposite instrument
Pulse cured on buccal, lingual and incisal
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490
Cure 30 seconds per surface
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491
Crown forms seated and light cured
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492
Polishing disks, first reduce incisal
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493
Polish corners
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494
Rubber dam left on forpolishing
96% success rate, 4% failure due to trauma
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495
Rubber dam removed, compositeCrowns on lower lateral incisorsAnd upper central incisors
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496Recall- follow up
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497
Case Two
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498
Case Two
Pre-operative view
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499
Case Two
Bevel fractured edges
Disk does bevel without discomfort
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500
Case Two
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501
Case Two Celluloid crown form trimmed and fitted
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Pay attention to your work
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503
Case Two
Plan shades, see if crown form
allows for layers
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504
Case Two
Pop off and etch!
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505
Case Two
Etch all surfaces of
enamel for 30 seconds
Etch dentin for a few seconds
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506
Case Two
Apply two coats of adhesive resin!
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507
Case Two
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508
Case Two
Primed surface should not be air sensitive
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509
Case Two
1. Roll ball of incisal or transluscent
composite2. Place in crown form
3. Roll ball of Inside Shade4. Place on palatal
5. Roll ball of Body Shade or use enamel
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GRADIA DIRECT
• Reflection similar to tooth structure
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GRADIA DIRECT in
comparison
• Polishability ( µm )0 0.2 0.4 0.6 0.8 1
GRADIA Posterior
GRADIA Anterior
A110
Heliomolar
Miris
Herculite XRV
EsthetX
PrismaTPH
Tetric Ceram
Supreme Trans
Supreme Body
Z 100
• Cured against a mylar strip
• Diamond bur,GC
• Silicone polisher,
Compomaster,Shofu
• Soflex Superfine,3M
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• Shade range
P-NT
GRADIA DIRECT – Outside
special shades
NT DT WT GT CVT
P-WT
ANTERIOR
POSTERIOR
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GRADIA DIRECT
• Anterior and Posterior version
Prepolymerized filler
Silica*
Prepolymerized filler
FAl – silicate glass*
ANTERIOR POSTERIOR
Silica*
* Mean particle size 0.85 µm
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35
38
27
Monomer
Silica
Prepoly filler
GRADIA DIRECT
• Composition (weight %)
ANTERIOR
38
20
19
23
Monomer
Silica
Prepoly filler
FAlSiglass
POSTERIOR
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515
Case Two
Remove excess composite only- leave a thin margin to reduce
polishing
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516
Case Two
Light cure for 30 secondsFrom buccal, lingual
And incisal
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517
Case Two
Light cure for 30 secondsFrom buccal, lingual
And incisal
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518
Case Two
Remove crown form and polish with EC Moore’s disks, mainly incisal corners and gingival margins
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519
Case Two
32 flute carbide finishing bur, football shaped
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Newest Real
TV
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521
Case Two
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522
Case Two
Palatal view
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Mark Cannon DDS MS, Associate Professor
Northwestern UniversityAttending Physician
Children’s Memorial HospitalChicago, Illinois
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Pulpotomy therapy is one of the most important treatment techniques necessary for preservation of the primary dentition. Laser treatment of pulpal tissue is now
rapidly becoming commonplace. This presentation discusses the current
research, including animal studies performed at UNESP (Aracatuba, Brazil) and Northwestern University in addition
to the clinical techniques and applications of the dental diode lasers.
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Animal Studies
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Animal Studies
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Laser Studies
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Laser Studies
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Our Purpose
• The purpose of this animal study was to compare the effectiveness of an experimental antibacterial and hemostatic formulation to that of diode laser irradiation by histological examination in the healing of porcine pulpotomized molars.
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Study Design:
• The experiment required three young swine (Sus scrofa domestica, Yorkshire) with 36 teeth prepared with occlusal penetrations into the pulpal tissues. The preparations were performed under general anesthesia and the exposed pulps were exposed using high speed instrumentation with rubber dam isolation and a disinfected field.
• Following instrumentation, the coronal pulpal tissue was amputated and immediately treated with either:
• ferric sulfate and chlorhexidine semi-gel (12) for approximately 2 minutes
• diluted Buckley formocresol solution (12) for 5 minutes • laser irradiation with a diode laser (12) for approximately 2
minutes• Hemostasis was obtained and a IRM base applied to the treated pulps
(36). The pulpal bases were all covered with a RMGI (Fuji II LC).
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Treatment Groups
• Buckley’s Solution – Formocresoldiluted and 5 minute
application on cotton pellet• Kavo Gentleray Diode Laser
3 watt pulsed 100ms 2 mins.• 20% Ferric Sulfate/1.2%
Chlorhexidine Mix-(experimental) for 2 minutes
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Treatment under General Anesthesia at Northwestern University :
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Study Design, cont.
• The tissue samples were collected at 4 weeks (28 days) via animal sacrifice.
• This was a No Loss study done in conjunction with the Northwestern Medical School Department of Surgery.
• Northwestern Center for Advanced Surgical Education• The tissue samples were collected during animal sacrifice.
The animals were given an overdose of general anesthesia after N-CASE procedures and the teeth removal. The teeth were then placed in 10% formalin for 48 hours. Decalcification of the tissue blocks was done by placing the samples into formic acid-sodium citrate solution.
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Histology:• The 36 samples were received by Northwestern
University Department of Pathology for an independent histological evaluation utilizing Leitz Dialux 20 microscopes. The evaluators were unaware of the materials and technique utilized as all the samples were assigned identification by number only. The samples were evaluated at both 63X magnification and at 160X magnification.
• The histological analysis consisted of the following parameters: necrosis, hyperemia, quantity and quality of hard tissue bridging, presence of odontoblastic-like cells, other calcifications, presence of giant cells, particles of capping agent, and a ranking of the inflammation.
• The data was statistically analyzed with the assistance of a statistician unaware of the sample groups constituents.
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Ranking for Inflammation:
• Inflammation– 0- none or few inflammatory cells
present– 1- slight amount of inflammation– 2- moderate inflammation– 3- severe inflammation, micro-
abscesses– 4- necrosis or abscess formation
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Ranking for Inflammation:
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Ranking for Inflammation:
Severe inflammation
Ferric sulfate and chlorhexidine
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Ranking for Inflammation:
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Results: Non-parametricIndependent – Kruskall-Wallis Test
Group N Rank Sum Mean Rank
Laser 12 136.5 11.38
Formo 12 235.0 19.58
Ferric 12 294.5 24.54
p= 0.0072
The treatment groups were statistically
significant.
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Discussion
• The mixture of 20% ferric sulfate and 1.2% chlorhexidine did not perform as well in pulpal application as was hypothesized.
• Perhaps there is an un-expected chemical reaction between the ferric sulfate and the chlorhexidine. It is possible that another anti-microbial medicament, such as, benzyl ammonium chloride would be an acceptable additive to ferric sulfate to provide anti-bacterial effectiveness and maintain the hemostatic feature.
Ferric sulfate and chlorhexidine group
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Discussion
Ferric Sulfate and Chlorhexidine
Of great concern should be the apparent ferric sulfate compound deposits found by the pathologists in the radicular pulpal tissues. These deposits may or may not contribute to pulpotomy failure or success but the end result of less than acceptable healing would more or less indicate that the deposits do not contribute to healing but may be the result of increased inflammation or result in increased inflammation. Further studies are definitely indicated to determine the nature of the deposits, and their contribution, if any, to inflammation of the treated pulps.
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Discussion
• Laser treatment of pulpal tissue is rapidly becoming commonplace as the diode laser units are now extremely economical and found in many dental offices. The diode laser has been advocated for treatment of anything from apthous ulcers to periodontal disease. It is now utilized by dental hygienists rather routinely and for soft tissue surgery by dentists, both specialists and general dentists. All of the diode laser units have a pulpotomy setting, but the rationale for these settings is unclear. The setting advocated for the KaVo Gentle Ray was apparently sufficiently correct to allow for successful pulpal treatment. Ideally, animal and clinical studies should be performed to determine the exact settings for achieving the most histologically kind treatment of the involved pulp.
Diode Laser Group
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Discussion
• As with all treatment modalities, the pulpotomy technique will progress through an un-ending state of evolution, with slow and inevitable improvement. Animal studies with more biologic medicaments, and pulp capping materials may provide significant advancements, provided that the results are replicated in large, well designed and controlled, clinical studies.
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Effects of Alternative Pulpotomy Techniques on Swine Pulps
Mark Cannon DDS, John Z Thobaben DMD*, Cameron Wagner DMD*, Ray Jurado DDS Northwestern University, Children’s Medical Center, Chicago USA
\
The Diode Laser Group demonstrated significantly better pulpal healing and less inflammation than the other two groups. The Ferric Sulfate Group also presented with “Black Granules”, apparently precipitates, from the Ferric Sulfate in the radicular pulpal tissues. The Formocresol Group had moderate inflammation consistent with previously published research.
Conclusion:
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Laser Clinical Pulpotomy Technique
Pulpal ExtirpationHemostasisDebridementDecontamination