9/16/2017 - san gabriel valley dental society lecture handout 2.pdf · these preps were performed...

9/16/2017

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Restorative Dentistry Update 2017

Adhesion & Composites

Richard G. Stevenson III, DDS, FAGD, FACD, ABODProfessor of Clinical Dentistry

Section of Restorative Dentistry

The Gold Standard in Bonding Agents

PRIMEETCH BOND

Current Generations

4th Etch Primer Adhesive => 3 steps

5th Etch Primer + Adhesive => 2 stepsTOTAL ETCH

TOTAL ETCH SYSTEMS

4th generation (3‐step etch and rinse)

• Advantages: separate steps, low

technique sensitivity, proven

effectiveness, most consistent results,

best long‐term results, filled shock

absorber effect

• Disadvantages: over‐etching dentin,

time, risk of contamination, moisture on

surface balance, weak resin‐collagen

interaction, elaborate procedure

5th generation (2‐step etch and rinse)

• Advantages: basic features of 3‐step, simpler,

single dose packaging, consistent

composition, controlled solvent evaporation

(uni‐dose), hygienic application, filled shock

absorber effect

• Disadvantages: not much faster, more

technique sensitive (multiple layers), risk of

thin layer, etch and rinse effects, over‐etching

risk, sensitive to dentin wetness, collagen

collapse, lower bonding effectiveness

Current Generations

6th Etch Primer Adhesive => 2 steps

7th Etch + Primer + Adhesive => 1 stepSELF ETCH

SELF ETCH SYSTEMS6th generation (2‐step self etch adhesive)

• Advantages: less over etching or drying, time‐saving, simultaneous demin. and infiltration, less sensitive to moisture, single dose possible, consistent composition, controlled solvent evaporation, hygienic application, shock absorber, desensitizer, separate adhesive, better strength, no complex mixtures, good clinical performance, reduced post‐op sensitivity

• Disadvantages: more elaborate application than 1‐step, incompatibility with autocuringcomposites, more research required, contain water, reduced shelf life, conflicting results, etch to enamel questioned, high hydrophilicity (acidic monomers), promotes water sorption, impaired durability

7th generation (1‐step self etch adhesive)

• Advantages: most time efficient, few steps, less sensitive to dentin moisture level, single dose, consistent composition, hygienic application, shock absorber

• Disadvantages: complex mixture, phase separation, more technique sensitive, no long term evaluations, less sealing capacity, contain water, reduced shelf life, high hydrophilicity, water sorption, impaired durability, incompatibility with autocuringcomposites, insufficient research, conflicting results

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A “NEW” Generation???

Universal

Etch Primer Adhesive => 2 steps

Etch + Primer + Adhesive => 1 stepSELF ETCH

TOTAL ETCH

SELECTIVE ETCH

Which one is best?

Recent Lab and Clinical Trials are CLEARAn Eight Year Clinical Evaluation of Filled and Unfilled One‐bottle AdhesivesRitter, AV, Swift EJ, Heymann HO, Sturdevant JR, Wilder ADJ AM DENT ASSOC 2009;140:28‐37

•Tested two 5th generation adhesives, one filled and one unfilled

•33 patients, 99 class V NCCL’s, no rubber dam

•Used USPHS criteria at 6 mo, 18 mo, 3 years and 8 years

•56 restorations survived and out of these 80% were clinically acceptable

•No difference between the groups

An Eight Year Clinical Evaluation of Filled and Unfilled One‐bottle AdhesivesRitter, AV, Swift EJ, Heymann HO, Sturdevant JR, Wilder ADJ AM DENT ASSOC 2009;140:28‐37

•RESULTS suggest that without retention grooves, NCCL’s with5th generation adhesives show 50% survival rate at 8 years

A Twelve‐Year Clinical Evaluation of a three‐step Dentin Adhesive in NCCL’sWilder AD, Swift EJ, HeymannHO, Ritter, AV, Sturdevant JR, Bayne SJ AM DENT ASSOC 2009;140:526‐35

•Tested etching enamel vs. enamel and dentin

•4th generation adhesive

•53 patients, 100 NCCL’s, no rubber dam, no retention

•USPHS criteria at Baseline, 1 year, and 12 years•84% retention rate with enamel + dentin etch

•93% retention rate with enamel only etch

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A Twelve‐Year Clinical Evaluation of a three‐step Dentin Adhesive in NCCL’sWilder AD, Swift EJ, HeymannHO, Ritter, AV, Sturdevant JR, Bayne SJ AM DENT ASSOC 2009;140:526‐35

•RESULTS are impressive for 4th

generation adhesive systems, and these preps were performed without retention grooves, with cotton roll isolation

What do the recent studies suggest?

–Self‐etch, 2‐step systems (6th

generation) show better shear

bond strength and fatigue

resistance than Self‐etch one

step (7th generation) systemsSELF ETCH

What do the recent studies suggest?

–Self‐etch systems show greater

degradation of enamel bonds

compared to Total‐etch systems

SELF ETCH

4th generation• Deepest, strongest, most predictable,

and long term bond to enamel

• Bonding layer resists microleakage

• Protects dentin bond from degradation

• Forms the thickest hybrid layer

• Works with self‐cure, dual cure and light‐cured composites as well as indirect restorations without concern

• OptiBond FL = 39 MPa to dentin

• Scotchbond MP = 46 Mpa to dentin

Another Strategy to Reduce Post‐op Sensitivity and Improve Dentin Bond

Durability…

Glutaraldehyde/HEMA

• Effective fixative or flocculating agent

• Creates a cross‐linked protein plug in tubules (0.2 mm)

• Eliminates the hydrodynamic mechanism

• Decreases fluid flow onto bonding surface

• Cross‐links with exposed collagen => improved bonds

• Act as re‐wetting agents

• Anti‐bacterial and anti‐caries

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The Collagen Network is Vulnerable!

MMP’s degrade the collagen scaffolding below and within the hybrid layer over time

Chlorhexidine Digluconate 2%• CAVITY CLEANSER [BISCO] or Consepsis

[Ultradent Products]

• Shown to enhance the long‐term bond to

dentin through the inhibition of endogenous

enzymes matrix metalloproteinases: MMP‐2,

MMP‐8, MMP‐9, MMP‐20

• MMP’s degrade the collagen scaffolding below

and within the hybrid layer over time

Leo Tjäderhane

Chlorhexidine Digluconate 2%• CAVITY CLEANSER [BISCO] or Consepsis

[Ultradent Products]

• Shown to enhance the long‐term bond to

dentin through the inhibition of endogenous

enzymes matrix metalloproteinases: MMP‐2,

MMP‐8, MMP‐9, MMP‐20

• MMP’s degrade the collagen scaffolding below

and within the hybrid layer over time

Leo Tjäderhane

UCLA Restorative Recommendations:*

*Based on the highest levels of scientific and clinical evidence available as of 2017

ENAMEL + DENTIN SUBSTRATE

• Total Etch, 3-step system (4th generation)

DENTIN SUBSTRATE

• Total Etch or Self Etch 2-step system (4th or 6th

generation)

• Use CHX 2% after etching

Posterior Composite Restorations

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Class II variations

Isolation (RGS)Caries Removal and Pulp Capping (TS)Liners, Bases, Fluoride Releasing Materials and Glass RGS)Dental Adhesion and Composites (TS)Clinical Adhesion Update (RGS)Ideal Preparation Guidelines (RGS)


Matrix Systems

Posterior Composite Restorations Tofflemire vs. Bitine Ring System

Tofflemire System

Fails to restore proximal anatomy

Thin contact at the marginal ridge

Large food trap below

Increased likelihood of fracture, occlusalinterference, recurrent caries and periodontal disease.

Bi-tine

Operator-friendly retaining system

Naturally contoured bands

Anatomically correct contacts

Contacts at the height of contour

Contacts so tight you’ll need a hemostat to get the band out!

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V‐rings (Triodent or Ultradent) G‐rings (Garrison)

Dual‐Force (Clinician’s Choice)





Centripetal“Wall and Lobe”Techniques


Class II Prep Matrix

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Wall CreationWall Base Matrix Removed First LobeWall Fill Second Lobe

Final Lobe Anatomy ReplicatedContinuity

Dam inverted Preparation

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Liner and Adheisve V‐ring Assembly

V‐ring Assembly

C O M P O S C U L P

#10#3 #5 #9#7#4 #8#6#1 #2

Hu‐Friedy

Wall placed Remove V‐ring

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Build lobes incrementally Build lobes incrementally

Ready for contouring Embrasure ready for contouring

Completed contour

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Occlusion verified, adjusted, polished

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CustomBi‐tine Ring Technique


STYLEITALIANO Managing Proximal Contacts

• Tight proximal contacts in existing

restorations

• Ideal implant crown contacts

• Cement removal

• Polishing contacts after

cementation

• Creating Interproximal Relief

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Composite Restoration Maintenance

• Pharmacologic• NaF‐ Prevident 5000+

(never use Acidulated Fluorides)

• Surface Preservation• Repolish• Surface Sealants

• BisCover (Bisco)• OptiSeal (Kerr)

• Composite Re‐care Visit –Every 2 years






Class V Composites

“NCCL’s”non‐carious cervical lesions

Toothpaste RDA Value

• ADA Limit = 200

• FDA Limit = 250

•Damage occurs at

125‐ 150 and

above!

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Relative Dentifrice Abrasivity

• Water = 4

• Baking soda = 7

• Oxyfresh = 45

• Colgate regular = 68

• Crest regular = 95

• Natural white = 101

• Arm & Hammer Advance white

extreme whitening = 106

• Pepsodent = 150

• Colgate 2‐in‐1 Tartar

Control/Whitening = 200

Is the RDA ADA Limit Safe?• According to Pamela Maragliano‐Muniz,

DMD, who published in the RDA

magazine in December 2016 it is…BUT –

lets examin the math:

– She reports that it takes 100,000 brushes to remove

1 mm or less of dentin to achieve 90% stain free

teeth at RDA 225.

– She states that we deliver 1500 brush strokes in two

months => 100,000/1,500 = 66 months = 5.5 years

– 1 mm of tooth loss in 5.5 years? Safe?

The Nimbus

http://www.nimbusdental.com

Restoring the Non‐Carious Cervical Lesion (NCCL)UCLA Restorative Section Guidelines

6 reasons

1. Caries: new caries is detected or with a previously placed restoration

2. Sensitivity: conservative attempts have not resolved sensitivity regarding this lesion

3. Severe tooth loss (pulp threatened): when the tooth is continuing to erode or abrade

4. Esthetic enhancement (patient preference): keep in mind that root surfaces are difficult to match with composite.

5. Plaque trap: when the tissue is experiencing inflammation due to a plaque trap, or the surface is at risk for caries.

6. RPD retentive arm: when the design requires an I-bar or clasp to be placed

Retention groove

Fuji Lining LC

Layered Composite

enamel

root surface

long bevel

1

2

3

THE “world class” CLASS V

BEVELRETENTION

LINERMGI

LAYER 1HYBRID

ETCH

PRIME

BOND

PREPARATION RESTORATION

LAYER 2HYBRID

LAYER 3HYBRID

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Bulk Filling

SonicFill

• Sonic waves

cause viscosity to

drop by 87%

• Highly filled

• Bulk fill 5 mm

Polymerization Shrinkage and Depth of Cure of Bulk Fill Flowable Composite ResinsD Garcia • P Yaman • J Dennison • GF NeivaOp Dent July/Aug 2014 Vol 39. No. 4 pp. 441-448

• SonicFill demonstrated the best results compared to FlowableComposites for depth of cure, and hardness




Snow‐plow Technique

Injection Molding• Small Cavities

• Flowable Composite

as a liner

• Paste Composite

displaces flowable

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Open Sandwich Technique

Posterior Composite RestorationsPatient:25 Year oldDental Student

#13 Tests VitalNo Hx of Spontaneous painNo PARL

Patient:25 Year oldDental Student

#13 Tests VitalNo Hx of Spontaneous painNo PARL

Slot prep completed TheraCal liner/base

Modified TofflemireMatrix ‐½ width

Martrix appliedNo wedge required

Fuji IX packed intobox – filled to CEJ

Margin elevatedV‐ring system placed

Adhesive stepsfollowed

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Place compositehalf way up box

Push composite towards matrix

Create occlusalembrasure with IPC

Light cureCentripetal Wall

Remove V‐ringand Sectional Matrix

Increased accessReady for lobes

Lobes placedTint added

Light curedReady for finishing

Occusion marked with12 micron paper (Bausch)

Final polish

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UCLA Restorative Recommendations:*

*Based on the highest levels of scientific and clinical evidence available as of 2016

• Use WALL and LOBE Technique

• GI margin elevation

• Light cure thoroughly

• Low RDA dentifrice

• Treat lesions differently based on depth and pulpal proximity

1. Rubber dam

2. New burs

3. After prep, use Gluma or Hurriseal

– 30 seconds

4. Acid etch 15 seconds

5. Rinse for 20 seconds

6. Suction excess moisture – don’t dry

7. Apply CHX 2% for 30 seconds

8. Use 4th gen or 6th gen with selective etch,

or universal with selective etch

9. Use centripetal wall and lobe fill technique

10. Light cure 20 second each layer

11. Keep light directly on tooth (check light

weekly)

12. Finish and Polish with water spray

13. Use surface sealant

14. Adjust occlusion with patient upright

Restoration Protocol for ZERO sensitivity and increased longevityShallow Preparation Depth [0.5 -1.0 mm into dentin]

SHALLO

W

1. Rubber dam

2. New burs

3. After prep, use Glumma or Hurriseal

– 30 seconds

4. Glass ionomer liner in deep areas










weekly)




Restoration Protocol for ZERO sensitivity and increased longevityModerate Preparation Depth [1.5 mm into dentin - 1 mm away from pulp]

MODERATE

1. Rubber dam

2. New burs

3. After prep, use Glumma or Hurriseal

– 30 seconds

4. MTA or Calcium Hydroxide

5. Glass ionomer liner to cover










weekly)




Restoration Protocol for ZERO sensitivity and increased longevityDeep Preparation Depth [0.5 mm away from pulp]

DEEP

1. Rubber dam

2. New burs

3. After prep, use 3% NaOCl

– bleeding stops in under 10 minutes

4. MTA or Calcium Hydroxide

5. Glass ionomer liner to cover










weekly)




Restoration Protocol for ZERO sensitivity and increased longevityPulp Exposure [Bleeding is controlled]

PULP EXPOSURE

9/16/2017 - san gabriel valley dental society lecture handout 2.pdf · these preps were performed...

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