patients are more knowledgeable than...

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Daniel H Ward DDS

Uncommon,Common Sense:

What YOU need to know NOW about Restorative Dentistry and Materials

Daniel H Ward DDS

Graduated 1979 OSU

Private Practice‐Columbus, Ohio

Assistant Clinical Professor The Ohio State University‐1996‐2009

Daniel H Ward DDS

Reviewer‐Journal of Prosthetic Dentistry

Reviewer‐Journal of Esthetic and Restorative Dentistry

Member and Evaluator for Catapult

Lecturer and Chief Examiner University of Minnesota Post‐Graduate Program in Esthetic Dentistry‐20 years

“I get by with a little help from my friends…”Dr Harry Albers

Dr Paul Belvedere

Dr John Burgess

Dr Mark Canon

Dr Gordon Christensen

Dr George Freedman

Dr Galip Gürel

Dr Geoff Knight

Dr Doug Lambert

Dr Karl Leinfelder

Dr Graeme Milicich

Dr Buddy Mopper

Dr Jeff Morley

Dr Brian Novy

Dr Jorge Perdagão

Dr Steve Rosenstiel

Dr Robert Seghi

Dr Irwin Smigel

Dr Byong Suh

Dr Ed Swift

Companies I Work With

AdDent

BISCO

Caulk/Dentsply

Centrix

Clinicians’ Choice

Coltene/Whaledent

GC America

Heraeus Kulzer

Ivoclar

Kerr

Pulpdent

Shofu

SDI

SSWhite

Tokuyama

Triodent

3‐M

VOCO

Patients are more knowledgeable than ever

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We must listen more to our patients

We must provide alternatives for our patients

…but the rightalternatives

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?

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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 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?

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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


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)

Intra-oral plaque formation（24 hours W/O Brushing）

Less plaque Full-grown plaque

BEAUTIFIL Ⅱ（Containing S-PRG filler）

Conventional Restorative Material

（Not containing S-PRG filler）

plaque

S PRG FillersSignificantly reduced plaque accumulation

Dispenser Gun

Tray

Compule Tray

Warmer

CALSETThermal Assisted Light Polymerization

WARMER

Improved flowability of composites

Improved marginal adaptation

Improved rate of polymer conversion

Improved surface hardness/durability/polishing.

Decreased curing time and increased depth of cure

Increased sculptability and ease in shaping anatomy

ADVANTAGESADVANTAGESThermal Assisted Light PolymerizationThermal Assisted Light Polymerization

Stansbury JW. Use of near-IR to monitor the influence of external heating on dental composite photopolymerization. Dent Mat 2004; 20(8).

Dispenser Gun TrayComax Dispenser

CALSETCALSETThermal Assisted Light PolymerizationThermal Assisted Light Polymerization

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Low Viscosity Flowable Composite & Warmed Composite

Completed Tooth Restorations“Dentistry begets Dentistry”

“The more dentistry you do for a patient, the more dentistry they will

eventually need.”

“Dentistry begets Dentistry”

Re-Treatment CompleteNotice the lower anterior teeth

15 Year Old

Buildup dentin replacement with opaque darker hybrid –typically A3-A3.5

Buildup remaining form with shade similar to desired final color with hybrid (typically A1-A2)

Add special effects to simulate imperfections within tooth structure

Add translucent incisal hybrid or microfill

Add dentin shade

•Aura

•Miris

Add A-2

•Venus Pearl

•Kalore

•TPH Spectra

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Add A-1

Add Characterization

Important-Junction must be invisible

Add Facial Surface

•Beautifil II

•Aura Enamel

•Kalore GT

•Esthelite Sigma QuickOptrasculpt

Finish and polish restoration

Restore adjacent tooth

Shape, finish and polish restorations

Restore opposite teeth

Pre-Operative

Finished Restorations

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.

Hydrodynamic Theory

Opened, unsealed dentinal tubules causes PAIN

SEM Dr Jorge Perdagão

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DentinDentin


Dentin Bonding

70% inorganic carbonate hydroxyapatite 70% inorganic carbonate hydroxyapatite calcium phosphatecalcium phosphate

30% organic (collagen) and water30% organic (collagen) and water

Dentinal tubules 0.06Dentinal tubules 0.06--3 microns in diameter3 microns in diameter

Most Bonding occurs between dentinal tubulesMost Bonding occurs between dentinal tubules

HydrophilicHydrophilic

Oh NO, not another bonding lecture!

•What are MMP’s and what agents can affect their effects?

•What is the effect of the width of the hybrid layer and dentin bond strengths?

•What new Self-Etching Primer Dentin Bonding Agent has bond strengths to un-etched enamel greater than 40 MPa ?

Oh NO, not another bonding lecture!

•Is there a relationship between post-operative sensitivity and dentin bond strengths?

•What are the characteristics of alcohol, acetone and water based solvents of dentin bonding agents?

•What are Universal Dentin Bonding Agents?

Etched Dentin


Demineralize surfaceExpose collagen fibersRemove smear layer Increase porosity of intertubular dentinOpen up dentinal tubules Increase surface area

Etched Dentin

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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.

Collapsed collagen fibrils

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Overdrying

SEM Perdigao

Un-collapsed collagen fibrils Collapsed collagen fibrils

Proper Moisture

Moisture Variability

Acetone

Alcohol

Water

Bonding Agent Solvents

Air only syringe Warm air dryer

Air/water syringe Air/water syringe

Evaporating the solvent with dry air

Bond StrengthSensitivity

Variability

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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


Summary

Most technique sensitiveRequires proper attention to detailUse in ideal sized preparations


Materials-4th

Generation

Acetone solvent Alcohol solvent


Materials-5th

Generation

Acetone solvent Alcohol solvent

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•Self Etch Technique Never leave the dentinal tubules open



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 Lohbauer U, Nikolaenko SA, Petschelt A, Frankenberger R.. Resin Tags do not contribute to dentin adhesion in self-etching adhesives. J Adhes Dent. 2008;10(2):97-103 .

Resin Tags do not Contribute to Dentin Adhesion in SE Adhesion

Self-Etch Technique

Challenges

Decreased bond strength to un-etched enamel

Marginal gap formation with un-etched enamel

Bond incompatibility to self-cure and dual-cure resins

More susceptible to hydrolytic degradation resulting in significantly diminished bond strengths over time

Self etching Primer

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37% H3PO4 etched Unprepared enamel surface for 15s. 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



Uncut Enamel 18.7±6.7 31.4±7.1

Cut Enamel 29.0±5.5 35.6±3.6


67% improvement




Uncut Enamel 18.7±6.7 31.4±7.1

Cut Enamel 29.0±5.5 35.6±3.6


22% improvement


•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 (Clearfill SE) following thermocycling•SEM analysis reported marginal gap formationof enamel not etched w phosphoric acid prior to application of a self-etching 6th generation bonding agent (Clearfill SE) following thermocycling

Souza-Junior EJ, Prieto LT, Araújo CT, Paulillo LA. Selective enamel etching: effect on marginal adaptation of self-etch LED-cured bond systems in aged Class I composite restorations. Oper Dent. 2012;37:195-204.

Effect of Enamel Etching-Marginal Gaps

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Solution: “Etching prepared enamel w phosphoric acid promoted better marginal integrity with self-etching bonding agents.”

Souza-Junior EJ, Prieto LT, Araújo CT, Paulillo LA. Selective enamel etching: effect on marginal adaptation of self-etch LED-cured bond systems in aged Class I composite restorations. Oper Dent. 2012;37:195-204.

Effect of Enamel Etching-Marginal Gaps

When the pH of a dentin bonding agent is too low (more acidic), tertiary amines (necessary for the polymerization reaction) are deactivated resulting in bond incompatibility with self and dual cured resins.

Bond Incompatibility with Self and Dual Cured Resins

Suh BI, Feng L, Pashley DH, Tay FR. Factors contributing to the incompatibility between simplified-step adhesives and chemically-cured or dual -cured composites. Part III. Effect of acidic resin monomers. J Adhes Dent 2003;5:267-282.

Solution: Use of a higher pH (>3.0)self-etching dentin bonding agent does not inactivate the tertiary amines and allows for polymerization.

Suh BI, Feng L, Pashley DH, Tay FR. Factors contributing to the incompatibility between simplified-step adhesives and chemically-cured or dual -cured composites. Part III. Effect of acidic resin monomers. J Adhes Dent 2003;5:267-282.


pH=3.2

Solution: Use a dual-cure activator


“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

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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 DegradationSelf 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

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Seventh Generation DBA

BeautibondDual acidic monomersLow film thickness (5 micron)RadiopaqueEasy to use-single application 10 sec

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.

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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


Disinfect to prevent MMPs

MDPB (12-methacryloxydodecalpyridinium bromide)


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

• SE 1-step adhesives are too hydrophilic and permeable even after polymerization

• The best way to minimize these weaknesses is to apply a neutral-pH, hydrophobic adhesive resin layer in a separate step

• Acidic components cause incompatibility with self-cured composites.

• 3-step, etch-and-rinse adhesives remain the “gold standard” in terms of adhesive durability.

Dentin Bonding Solutions

De Munck J, Van Landuyt K, Peumans M, Poitevin A, Lambrechts P, Broem M, Van Meerbeek B. A Critical Review of the Durability of Adhesion to Tooth Tissue: Methods and Results. J Dent Res. 2005;84(2):118-132.

Selective Etch TechniqueApply etch to enamel only for 15 secondsWash thoroughlyPlace self-etching primer

Frankerger R, Lohbauer U, Roggendorf MJ, Naumann M, Taschner M. Selective enamel etching reconsidered:better than etch-and-rinse and self etch? J. Adhes Dent. 2008;10:339-344.

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Selective Etch TechniqueHigh Viscosity allows precise placementContains BAC

Selective Etch TechniqueAllows total etch or self etch of enamel

and/or dentin

G-aenial Bond

Selective Etch TechniquePrecursor to “Universal” Bonding agentsBond strength same to total vs self etch

Dentin Bond Strength

Self-Etch Total Etch Moist

Total Etch Wet

Total, Self or Selective Etch Universal Bonding

Materials

Total-etch, self-etch or selective-etch technique

Can be used for direct and indirect restorations

Bond to all indirect substrates-metal, ceramics, zirconia, porcelain and lithium disilicate.

Compatible with light-cured, self-cured and dual-cured composite and luting cements.

Universal Bonding Materials

Total, Self or Selective Etch All-Bond UniversalTotal-etch, self-etch or selective-etch

Single bottle for direct and indirectrestorations

High bond strengths to metal, ceramics, zirconia, porcelain & lithium disilicate.

Compatible with light-cured, self-cured and dual-cured composite and luting cements since pH is 3.2

Becomes hydrophobic upon setting

Total, Self or Selective Etch

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Total Etch vs. Self EtchShear bond strength of Universal Adhesives on Tooth Structures MPa*

*Manufacturer supplied data




Total, Self or Selective Etch Universal Bonding

Materials


Light Cured Dual Cured

•Total Etch Technique Never open the dentinal tubules



Resin-Modified Glass Ionomer

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RMGI Liner

No dentin conditionerneeded due to self-etch

primer component

RMGI BaseReprepare

Dentin conditionerpreferred to achieve optional dentin bond

10. It’s not necessary

9. It takes more time

8. It costs more money

7. I don’t understand which product to use

6. Not necessary with today’s Hundredth generation bonding agents

TOP TEN REASONS:GI isn’t used under every restoration

5. I don’t know how to use

4. Not as strong: I “bond” everything-holding tooth together and making it stronger

3. It doesn’t bond as well to dentin as resin

2. Fluoride release is transient

1. Old fashioned: used before better bonding agents were available

TOP TEN REASONS:GI isn’t used under every restoration

••Make initial access opening w small burMake initial access opening w small bur

••Use slow speed to remove decayUse slow speed to remove decay

Clinical Class I Restoration

••Use high speed to refine preparationUse high speed to refine preparation

••Smooth margins with a football diamond.Smooth margins with a football diamond.


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••Completed PreparationsCompleted Preparations


••Glass ionomer base/linerGlass ionomer base/liner

••Etch enamel then dentin, wash and dryEtch enamel then dentin, wash and dry


••Place & scrub multiple coats bonding Place & scrub multiple coats bonding agent, wait, evaporate solvent and cureagent, wait, evaporate solvent and cure

••Place composite and adapt to sidesPlace composite and adapt to sides

Ivoclar P-1

•Cure thoroughly


Posterior Finishing Burs

Occlusal Anatomy OcclusalSecondary Anatomy

Buccal/ lingual gingival-IP

12 fluted carbide burs

ProcedureProcedure Trim and shape composite

Adjust occlusion

Blend margin between tooth and composite

Define secondary anatomy

Restore occlusal fissures

Restore buccal/ lingual contour

Reduce and smooth composite surface

Interproximal shaping at gingiva and above contact

Popular InstrumentsPopular Instruments Football or egg-shaped

7406

H379

15106-5

Flame-shape

H-274

5379-5

Needle shape

Safe-end SE6

7901

15121-5

Ivoclar

Astropol

SS White

Jazz

Caulk Enhance/POGO

••Blend margins with finishing carbidesBlend margins with finishing carbides

••Adjust occlusionAdjust occlusion

••Finish and polishFinish and polish

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••No metal in the centerNo metal in the center

••Very FlexibleVery Flexible--now more durablenow more durable

••Double SidedDouble Sided

••Available in Unit Dose Available in Unit Dose ••Etch, wash/dry and apply surface sealantEtch, wash/dry and apply surface sealant


Summary

Best reduction of post-operative sensitivity

Insurance of fluoride releaseBest bond to enamelLong term stable bond to dentinUse in majority of posterior preparations

Total Etch with RMGI Liner/Base

•What’s new in composite technology?

•What’s all the buzz about bulk fill composites?

•To achieve good Class II interproximal contacts with composite, you just use the same armementarium as amalgam?

““Fill meFill me”” in on the latest in Direct in on the latest in Direct Restoratives!Restoratives!

New Filler TechnologyNew Filler TechnologyGiomer FillersGiomer Fillers

Unique Filler particles made of set glass ionomer with special surface coating

Set Glass Ionomer Material Surface Modified Pre-Reactive Glass Ionomer Filler

Surface modified layer

Glass Ionomer phase

Glass Core

New Filler TechnologyNew Filler TechnologyGiomer FillersGiomer Fillers

BeautiSealant BeautiBond

Beautifil IIBeautifil Flow Plus

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16 of 26 Class I, and 25 of 35 Class II restorations were observed.No failures

No secondary caries

Alpha or Bravo aesthetics

No post-op sensitivity noted

Gordan VV, Mondragon E, Watson RE, Garvan C, Mjör IA. A clinical evaluation of a self-etching primer and a giomer restorative material: results at eight years. J Am Dent Assoc. 2007;138(5):621-7

GiomerGiomer TechnologyTechnology8 Year Results8 Year Results

19 of 26 Class I, and 22 of 35 restorations were observed.Retention rate 66% (27 of 41)

– 52% of retained noted as excellent – 41% of retained noted minor changes

Secondary caries rate 3.27% (2 of 61) Overall positive results and low secondary caries attributable to Giomer technology

Gordan VV, Blaser PK, Mjor IA, Sensi L, Watson R, McEdward DL, Riley III J. Clinical Evaluation of a GiomerRestorative System: Thirteen-Year Recall 2013 IADR #3104:University of Florida

GiomerGiomer TechnologyTechnology13 Year Results13 Year Results

Agl MicrofillAgl MicrofillHeliomolarHeliomolar

MicroMicro--HybridHybridMiris, Point4, Miris, Point4, EsthetX, Venus EsthetX, Venus

NanoclusterNanoclusterFiltek SupremeFiltek Supreme

NanoNano--HybridHybridVenus Diamond, Venus Diamond, Tetric EvoTetric Evo--Ceram, Ceram, Kalore, Esthelite QKalore, Esthelite Q

New Filler TechnologyNew Filler TechnologyLow Shrinkage CompositesLow Shrinkage Composites

Nano/Hybrids in green

Open Margin Cracked Enamel

(white line)

Effects of polymerization shrinkage STRESS

Fractured Cusp

Prepolymerized Filler

Average Size 17 µm400 nm Strontium Glass

100 nm Lanthanoid fluoride

Glass Fillers

700 nm Strontium Glass700 nm Fluoroaluminum Silicate Glass

Non-aggregated nano silica filler

16 nm Silica filler

KaloreKalore

New Filler TechnologyNew Filler TechnologyNanofill/HybridNanofill/Hybrid

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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 Pre-Operative

Completed Preparation

KaloreKalore--Clinical CaseClinical Case

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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

Surefill SDRSurefill SDR

•Reduced polymerization shrinkage stress• Bulk fill to 4mm•Increased sensitivity to lightGreat placement with metal tips•Self-leveling•A1, A2, A3 Universal shades

Roggendorf MJ1, Krämer N, Appelt A, Naumann M, Frankenberger R. Marginal quality of flowable 4-mm base vs. conventionally layered resin composite. J Dent. 2011;39:643-647.

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Polymerization Shrinkage Polymerization Shrinkage StressStress(MPa)(MPa)

Bulk Fill Posterior CompositesBulk Fill Posterior CompositesLow Shrinkage StressStress

• Voco Xtra Fill•Beautifil Bulk Flow•Aura Bulk Fill•Tetric Evo-Ceram Bulk Fill•Sonic Fill

Sonic Energy Assisted Light Sonic Energy Assisted Light PolymerizationPolymerization

Sonic FillSonic Fill

Improved flowability of composites

Improved marginal adaptation

5mm depth of cure

Increased sculptability and ease in shaping anatomy

Composite designed specifically for use

ADVANTAGESADVANTAGESSonic Energy Assisted Light Sonic Energy Assisted Light

PolymerizationPolymerization





26

Interproximal Contacts

Composite Direct Placement Composite Direct Placement ChallengesChallenges

Christensen JJ. Duplicating the form and function of posterior teeth with Class II resin-based composite. Gen Dent. 2012;60:104-108.

Microband Focu-tip Trimax

Interproximal ContactsInterproximal ContactsOriginal Attempted SolutionsOriginal Attempted Solutions

Not enough pressure to separate teeth

Fly off

Wedge in the way

Interproximal ContactsInterproximal ContactsSectional Matrix ChallengesSectional Matrix Challenges

Interproximal ContactInterproximal Contact

SolutionSolution

Contact Perfect


SolutionSolution

Contact Perfect

TofflemireTofflemire vs. Sectional vs. Sectional MatricesMatrices

Tofflemire System

Thin contact at the marginal ridge

Non‐anatomical Foodtrapbelowcontact

Increasedlikelihoodof:fracture,recurrentcariesandperiodontaldisease.

SectionalMatrices

Broad contacts at the proper height of contour

Anatomicallyshapedcontacts

TightContactsPropercontactsthatflossproperlyandpromotegingivalhealth

27


RetainersRetainers

TrioDent/Palodent

Universal V3 Ring Narrow V3 Ring


Also Available as:Also Available as:

Palodent Plus

Universal Ring Narrow Ring


BandsBands

TrioDent/Palodent Plus

Bendable tab

Side holes for easy removal

Holes allow grip with Pin-Tweezers

Marginal Ridge Contour

Pin Tweezers


BandsBands


Bicuspid

Molar

Sub-gingival Molar


Anatomical WedgesAnatomical Wedges

Wave Wedges

Pin Tweezers


28

Challenge:

Adjacent Class II Composite Restorations

Prepare enamel margins

Place contoured

band, wedge & V-Ring

Selective etching

Wash thoroughly

Apply bonding agent

Fill box 2/3’s full

Compress w 1P

Cure

Finish buildup

Cure

Sonicfill

Remove wedge peel band back

Cure IP

Remove band & cure ContacEZ

Re-contour diamond/finishing

carbides

Finishing strips

Place V-Ring on adjacent tooth

Burnish desired contact area

Selective etching

Place Universal bonding agent

Light Cure

Peel back band

Cure from both sides at

gingiva

Place Composite as before

Light Cure

29

Finish and polish

Adjust occlusion

V4 Clear‐Metal Matrix System

•Transparent ring tines, wedge and matrix band to allow cure –through – great with bulk fill and deep cavities

•Very versatile – can be used on missing cusps, large boxes and where little tooth structure remains

•Superior grip, even on severely compromised teeth

V4 Ring

Clear tinesLight passes through the tines

New tine shapeIncreased grip and stability

VersatileCan be used:

•where little tooth structure remains•on large boxes •misaligned/malpositionedteeth •missing cusps•more compatible with circumferential bands

Easier to clean and more durable tines

ClearMetal Matrix

Resin filled Micro‐Windows for optimum curing

•Hundreds of cure‐through micro‐windows•Similar curing to plastic matricesHighly anatomical

•SuperCurveMatrix•Malleable• Burnishale

Non‐stick•Transparent, non‐stick coating•Leaves no marks on restoration

ClearMetal Matrix

Resin filled Micro‐Windows for optimum curing

•Hundreds of cure‐through micro‐windows•Similar curing to plastic matricesHighly anatomical

•SuperCurveMatrix•Malleable• Burnishale

Non‐stick•Transparent, non‐stick coating•Leaves no marks on restoration

ClearMetal Matrix

Small tip light output Small tip light output through band

30

V4 Wedge

•Notches split the wedge into 3 sections

•Sections compress and expand independently allowing for more interproximal anatomical variations

•Transparent, to allow cure‐through

•Great sealing on the gingival margin whatever the interproximal anatomy

Population 60+ by Age: 1900-2050Source: U.S. Bureau of the Census

0

20,000,000

40,000,000

60,000,000

80,000,000

100,000,000

120,000,000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Num

ber o

f Per

sons

60+

Age60-64

Age65-74

Age75-84

Age85+

Number of people aged 60+

28 M42 M

57 M

92 M

US Population is Aging

Percentage 60+ by Age: 1900-2050Source: U.S. Bureau of the Census

0

0

0

0

0

0

0

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Perc

enta

ge 6

0+

Age60-64

Age65-74

Age75-84

Age85+

Percentage of people aged 60+

14%17%

18%

25%

10

5

15

20

25

30


• Xerostomia

• Difficulty maintaining oral hygiene

• Root exposures

• Some unable to tolerate long appointments

• Difficulty coming to office

• Fixed Income



DonDon’’t miss appointmentst miss appointments

AppreciativeAppreciative

Pay billPay bill

Often need more treatmentOften need more treatment

Refer new patientsRefer new patients

Say Thank You!Say Thank You!

60+ Patients are Wonderful Multiple Medications

Oral Environment Challenges-Xerostomia

31


“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.


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.


• 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

Oral Environment Challenges-Antacids

Ingredients:Calcium carbonate, adipic acid, corn starch, crospovidone, dextrose, flavors, malodextrin, sucrose, talc, colors.

Oral Environment Challenges-Bottled Water

Fluoride-less water Fluoridated water

32

Oral Environment Challenges-Illegal Drugs

“Meth mouth” or chronic marijuana use

Xerostomia patients

High carbohydrate users

Non-fluoridated water users

Drug abusers

Need TherapeuticRestorations

Composite Challenges

•Post-operative sensitivity

•Recurrent decay

•Achieving proper moisture

•Polymerization shrinkage

•Increased time-layering

•Technique sensitivity

Low post-op sensitivity

Fluoride Release

Moisture variability

No shrinkage

Bulk placement

Simple-more forgiving

Glass Ionomer

Look, we all know that Glass Ionomers are weak!

•Which wears more resin modified glass ionomers or pure glass ionomers?

•According to research what is the average 10 year survival rate of posterior single surface glass ionomers?

Look, we all know that Glass Ionomers are weak!

•Which form(s) of glass ionomer can be used as an RUC under bonded crowns? Under conventionally cemented crowns?

•Will placement of large glass ionomers always result in less total tooth and restored surface than placement of composites?

Fuji IX Self Cure Glass Ionomer

Glass IonomerBase/Restorative

SDI Self Cure Glass Ionomer

33

•More highly filled-reduced wear•Self-curing in 2.5-5 minutes•No polymerization (setting) shrinkage stress•Expansion/contraction similar to tooth•High fluoride release•Bioactive

Glass IonomerCharacteristics •Multiple cervical carious lesions

•Pediatric Patients•Sealants•Class V restorations•Sandwich Technique•Crown buildups•Long term interim restorations•Cements

Glass Ionomer Uses

High caries rate individuals

Glass Ionomer RestorationsGlass Ionomer Restorations

Remove decay and place matrices


Treat dentin with PAA


Place, shape and wait 2:30


34

Shape with diamonds w/ water


Dry and place Surface Sealant

No phosphoric acid




Spoon out decay and refine prep


Place and rinse Poly-acrylic acid


Mix Gi and quickly place and push out


35

Allow to set 2:30


Hold down gingiva and shape


Dry and place surface sealant




Pediatric Patients


Pediatric Patients


36

Class V root caries


Class V root caries


Repair around crown margins


Repair around crown margins


Long term interim restoration




37





Decalcified areas in partially erupted tooth

Treat with phosphoric acid

Glass Ionomer SealantsGlass Ionomer Sealants

Activate, mix and place glass ionomer

Place Surface Sealant over glass ionomer and light

cure


Glass Ionomer Sealants

5 Year Recall


Gain access to decay using a high speed

Closed Sandwich Technique

Use slow speed and then spoon excavator

Stop if you feel you will expose pulp

38

SEM of dentin treated with PCA

Condition dentin with poly-acrylic acid for 10 seconds and wash


CARD

OS

O et al. J D

ent 2010

Condition enamel only with phosphoric

acid

Rinse thoroughly

Re-prep if necessary after set

Place Glass Ionomer base


Wait 2:30

Apply Seventh Generation Bonding

Agent

Zhang Y, Burrow MF, Palamara JEA, Thomas CDL. Bonding to Glass Ionomer Cements using Resin-based Adhesives. Op Dent 2011;36:618-625.


Finish and polish

Place Composite & Cure

(Sonic Fill)

Preparation w cervical margin in

dentin

Open Sandwich Technique

Acid etch enamel

Condition dentin w PCA

Place glass ionomer base


Place RMGI bonding agent and cure

*recommended by Dr Graeme Milicich

Build up tooth with composite


Shape with diamonds and fine carbides

39

Finished occlusal view


Mesial View

Glass Ionomer

Composite

RMGI

Restoration Under Crown

Internal Cracks


Deep decay w affected dentin







40


Do Not Use in Anterior Teeth to replace Large Defects

RUC with crack

But… How long do they last?

Zanata RL, Fagundes TC, Freitas MC, Lauris JR, Navarro MF. Ten-year survival of ART restorations in permanent posterior teeth. Clin Oral Investig. 2011;15(2):265-71

Placement 2 years 10 years

92.7% success

65.2% success

Survival Rate

Single Surface Restorations*(*based on placement of older GI formulations)


Zanata RL, Fagundes TC, Freitas MC, Lauris JR, Navarro MF. Ten-year survival of ART restorations in permanent posterior teeth. Clin Oral Investig. 2011;15(2):265-71

Placement 2 years 10 years

86.8% success

30.6% success

Survival Rate

Multiple Surface Restorations*

(n=62)

(*based on placement of older GI formulations)


Five Year Restorations


How long do they last?• 8-12 years- single surface• 5-8 years- multiple surface• The larger the restoration, the

shorter its lifetime

41


Then what?• Re-prepare surface and place posterior

composite restoration• Prepare tooth for a crown

Equia

Glass Ionomer/Filled Resin Sealant

RIVA Self Cure HV

Surface Sealant

• Fills in microcracks and porosity

• Provides a high gloss, smooth surface

• Increase wear resistance and allows material to mature

•Light Cured-Do not etch before applying

•Sealant retains moisture w/in restoration allowing better maturation and hardness before surface is exposed to forces

Surface Sealant

Restoration w large crack Restoration w large crack

42

Large restoration with internal fractures Dentist-Multiple Radiographic Caries

Before and After

•Acid/base and polymerization reaction

•Ionic and micromechanical bonding

•Dual-curing

•Fluoride release

•Bioactive

Resin-Modified Glass Ionomers

•Acid/base and polymerization reactions•Dual cured-faster•Shortens time needed to control moisture•More esthetic and translucent•Fluoride release•Higher tensile, bond strength and wear

Resin-Modified Glass Ionomer Characteristics

•Liner or Base•Class V Restorations•Restoration Under Crown•Temporary prior to crown•Sandwich technique•Cements

Resin-Modified Glass Ionomer Uses

43

Resin-Modified Glass Ionomers-Advantages

Brackett WW, Dib A, Brackett MG, Reyes AA, Estrada BE. Two-year clinical performance of Class V resin-modified glass-lonomer and resin composite restorations. Oper Dent. 2003;28:477-81

37 pairs of caries-free unprepared abfraction lesions were treated with resin modified and resin composite restorations (single bottle total etch dba). Retention of the composite restorations at six months was below the minimum specified in the ADA Acceptance Program for Dentin and Enamel Adhesives. At two years retention was 96% for the resin-modified glass ionomer and 81% for the resin composite. The resin composite restorations generally had a better appearance, with a 100% alpha rating in color match, versus 85% for the resin-modified glass ionomer.

•Better retention

Resin-Modified Glass Ionomer Base/Restorative

Capsule

Fuji II LC RIVA LC

Fuji Filling LC

Resin-Modified Glass Ionomer Base/Restorative

Ketac Nano

Paste-Paste

Class V Restoration

257

Gingival recession & root caries

• 1st molar and bicuspid

• Remove decay‐place retention


258

Gingival recession & root caries

• 1st molar and bicuspids

• Remove decay‐place retention

Condition with PA

• Pre‐treatwith dentin conditioner (Poly‐

acrylic acid)


44

259

Material Placed and Light Cured

• Place excess material

• Light Cure


260

Final Restorations

• Shape restorations

• Hold back gingiva and shape with fine

diamond

• Etch with phosphoric acid, wash and dry

• Place surface sealant and light cure

Material Placed and Light Cured

• Place excess material

• Light Cure


Restoration Under Crown Quick Temporary prior to Crown

Temporary placed 5 years ago Sandwich Technique

45

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


Glass Ionomer

•Core-Cemented posterior crowns

•Entire Class I or II (Long Term Interim)

•Class V-high caries

•All deciduous posteriors

•Sandwich technique-Co Cure

Glass Ionomer Preferred Uses

•Core-all crowns

•Base Class I or II-re-prepared sandwich

•Class V-more esthetic

•Quickly placed short-term interim restorations


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

46

Ceramir

Forms apatite crystals(a group of phosphate minerals, usually referring to hydroxyapatite, fluorapatite and chlorapatite, named for high concentrations of OH−, F−, Cl− or ions, respectively, in the crystal. The formula of the admixture of the four most common end members is written as Ca10(PO4)6(OH,F,Cl)2, and the crystal unit cell formulae of the individual minerals are written as Ca10(PO4)6(OH)2, Ca10(PO4)6(F)2 and Ca10(PO4)6(Cl)2.)

Ceramir

Forms apatite crystals Powder and water are mixed Dissolution results in nano-crystal formation Gibbsite and Katoite forms

Gibbsite

Tooth apatite

Mixed zoneChemically formed apatiteGibbsite(Calcite)

Katoite

Ceramir

Forms apatite crystals Powder and water are mixed Dissolution results in nano-crystal formation Gibbsite and Katoite forms Crystals form on tooth and restoration Long-term stable bond Ceramir Dentin

Physical Properties– Creates Apatite when in contact with phosphates– No shrinkage– Hydrophilic system with Alkaline pH– Thermal properties similar to tooth structure– Low film thickness -15 microns– 160 Mpa compressive strength– Anti-bacterial-inhibits caries– Gets stronger over time– Acid resistant– Bonds well to metal, porcelain, ceramics, zirconium

Ceramir

Ceramir

Jeffries SR, Fuller AE, Boston DE. Preliminary Evidence that Bioactive Cements Occlude Artificial Marginal Gaps. J Esthet Restor Dent. 2015.

Self Adhesive Resin Cement


Glass Ionomer

Calcium AluminateRMGI

Calcium Silicate

0:00

Ceramir

47

2:00

Ceramir

4:00

Ceramir

Glass IonomersThe “missing link” of esthetic

restorative materials •Once the pulp is exposed, it is off to the endodontist for my patient!

•The reason I do not always achieve adequate mandibular block anesthesia is that I am a lousy dentist!

OK, Now what can you tell me that I OK, Now what can you tell me that I already donalready don’’t know?t know?

OOPS!

Endodontic Root Canal Endodontic Root Canal Therapy?Therapy?

Asymptomatic

Single small exposure

Able to achieve hemostasis

Perhaps not IF:

48

Traditional Pulpal ProtectionIndirect Pulp Capping

Best not to expose pulp• Asymptomatic• Sound 2mm around margins• Stop when next scoop will expose pulp• Place GI or Ca(OH)2

Traditional Pulpal ProtectionIndirect/Direct Pulp Capping

What are we trying to accomplish?

• Mechanical Sealing of the Pulp• Stimulate hydroxyapatite formation• Dentin bridge formation


How does this happen?

• Material sets hard and adheres to dentin• Alkaline pH• Release of Ca++ ions Ca+2

OH-

H2O

Ca+2

OH-


Ca(OH)2 Paste• DyCal– Dentsply/Caulk (paste/paste)

• Multi-Cal– Pulpdent (non-setting)

Ca(OH)2 in VLC resin• Prisma VLC DyCal (light cured)

• Life– Kerr (light cured)

Unproven Pulpal ProtectionIndirect/Direct Pulp Capping

Resin Dentin Bonding?• Dentin Bonding Agent-Composite

“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.

Unproven Pulpal ProtectionIndirect/Direct Pulp Capping

Glass Ionomer/RMGI?

“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.

49

Improved Pulpal ProtectionIndirect/Direct Pulp Capping

Ca(OH)2 Paste• Ultra-Blend Plus– Ultradent

Pulpal Protection – Indirect/DirectPulp Capping

MTA (Mineral Trioxide Aggregate)

• ProRoot-Dentsply• Biodentine-Septodont• Thera-Cal LC-Bisco

Bismuth oxide Bi2O3

Gypsum CaSO4 · 2 H2O

Tetracalcium aluminoferrite (CaO)4.Al2O3.Fe2O3

Tricalcium aluminate (CaO)3.Al2O3

Dicalcium silicate (CaO)2.SiO2

Tricalcium silicate (CaO)3.SiO2

Biodentine

50

Latest Pulpal ProtectionIndirect/Direct Pulp Capping

Resin Modified Calcium Silicate• Theracal

Latest Pulpal ProtectionIndirect/Direct Pulp Capping

Light cured apatite forming MTA in a unique hydrophilic resin (polyethylene glycol methacrylate) that releases calcium

How many of you have How many of you have problems with Mandibular Nerve problems with Mandibular Nerve

Blocks?Blocks?

Really, Final

Answer?

Trustworthy, loyal helpful, friendly, courteous, kind

obedient..

YES NO….?


Blocks?Blocks?

30-Minute Time Course for Pulpal Analgesia - Lidocaine IANBsData from 30 PRP Studies (1991 - 2008), n = 1162 Subjects, Lidocaine/Epi IANB


Blocks?Blocks?

Mean 30-Minute Time Course for Pulpal Analgesia - Lidocaine IANBsData from 30 PRP Studies (1991 - 2008), n = 1162 Subjects, Lidocaine/Epi IANB


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%)

51


Blocks?Blocks?

30-Minute Time Course for Pulpal Analgesia - Articaine IANBsData from 5 PRP Studies - 222 Subjects (1990 - 2008)


Blocks?Blocks?

Mean 30-Minute Time Course for Pulpal Analgesia - Articaine IANBsData from 5 PRP Studies - 222 Subjects (1990 - 2008)


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

52

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


67%

8 minute Buffered anesthetic 8 minute Buffered anesthetic gives 90+% efficacy of IANBgives 90+% efficacy of IANB


67%

Onset by OnpharmaOnset by Onpharma

Advantages– Increased onset of

analgesia

– Increased efficacy of analgesia

– Decreased discomfort during injection

Challenges– Only approved for

lidocaine

– Opened cartridge is effective for one day

– CostCartridge Connector Mixing PenBicarbonate Solution

Onset by OnpharmaOnset by Onpharma

Important:

The indication for use for Onpharma® Sodium Bicarbonate Inj., 8.4% USP Neutralizing Additive Solution is to adjust the

pH of lidocaine with epinephrine toward physiologic pH in order to hasten onset of analgesia and to reduce injection pain.

The full prescribing information is contained in the Onpharma Sodium Bicarbonate Inj., 8.4% UPS Neutralizing Additive

Solution Package Insert, which may be downloaded at www.onpharma.com.

Onset by OnpharmaOnset by OnpharmaThank You!

www.drwardhandouts.com

[email protected]

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