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Restorative Dentistry Clinical Reference

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Restorative Dentistry Clinical Reference

  1. 1. Restorative Dentistry ® Clinical Reference Department of Restorative Dentistry University of Washington Seattle, Washington Contributors: Restorative Dentistry Faculty Edited by: Dr. Glen H. JohnsonAlso located at: www.dental.washington.edu/departments/restorative/clin_resource_info.php 2010-2011
  2. 2. SCHOOL OF DENTISTRY  UNIVERSITY of  WASHINGTON  Department of Restorative DentistryTo Our Friends and Dental Colleagues Near and Far:We hope you find the web version of our RestorativeDentistry Clinical Reference useful. The primaryintended users of this reference are our regular faculty,affiliate faculty, students, dental assistants anddispensary staff. The aim is to provide a convenient,concise, standardized source of information for commonclinical materials and procedures employed in ourRestorative Dentistry Clinic. Each fall, we also producea pocket version of the Restorative Dentistry ClinicalReference as a convenient source of information forthose directly involved in our educational process.We also place the contents on our Department website to aid outsidepractitioners and their staff, and to post updates. If you would like thisinformation in booklet form, they are available with a donation to our Department.These funds aid us in maintaining and expanding the Restorative DentistryClinical Reference and to further our academic goals.From all of the hard working folks in the Department of Restorative Dentistry atUniversity of Washington, we extend our very best wishes.Sincerely,Glen H. Johnson, D.D.S., M.S.Professor Box 357456 • 1959 NE Pacific Street, D770 • Seattle, Washington 98195-7456 Tel. 206-543-5948 • www.dental.washington.edu/departments/restorative/
  3. 3. Restorative Dentistry Clinical Reference® 1 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington ContentsSec Procedure Page 1 Cavity bases - what and when 2 2 Cavity liners - what and when 2 3 Cavity sealers - what and when 3 4 General Hints with use of the All-Bond 2 bonding system 3 Treatment of deep caries with exposure or near exposure of pulp 5 4 (Dycal; Fuji Lining LC; dentin sealer) 6 Dentin sealers under amalgam (All-Bond 2 A&B) 5 7 Filling Material Selection 6 8 Foundation Restorations Choices (crown buildups) 6 9 Bonding in association with large amalgams (All-Bond 2) 710 Chemically-cured composite foundation restoration (Ti-Core + All-Bond 2) 811 Class 5 restoration options • Amalgam 8 • Resin composite (Filtek Supreme Plus; All-Bond 2) 8 • Resin Modified Glass Ionomer (Fuji II LC) 912 Class 1, 3-6 resin composite restoration (Filtek Supreme Plus +All-Bond 2) 1013 Ultraconservative Class 1 Restoration (Filtek Flow + All-Bond 2) 1014 Class 2 posterior composite restoration (Filtek Supreme Plus + All-Bond 2) 1115 Surface sealer for a composite restoration (Fortify) 1616 Procedure check list for pulp capping and/or placing restorations 1717 Bonding to and/or repairing an existing composite 1718 Repairing porcelain 1819 Treating root sensitivity (All-Bond 2 A&B) 1820 Sealing teeth prepared for indirect restorations (Gluma Desensitizer) 1921 Luting cements - indications and contraindications 2222 Luting Cements and cementation procedures • Preliminary procedures 23 • Zinc Phosphate Cement (Fleck’s) 23 • Resin-modified Glass Ionomer (RelyX Luting) 23 • Ceramic/Porcelain Cementation (Variolink II) 24 • ZrO2 Ceramic Crown Cementation (Variolink II, RelyX Luting) 25 • Porcelain Veneer Cementation (Variolink II) 2623 Post and Post Cementation 2824 Treating Superficial Enamel Discoloration 3025 Coltolux Curing Light - power output check 32 Dispensary Materials Available 35 References 39 Updates at http://www.dental.washington.edu/departments/restorative/clin_resource_info.php Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  4. 4. Restorative Dentistry Clinical Reference® 2 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of WashingtonThe Restorative Dentistry Clinical Reference® is a “work in progress.” Theintended users of this reference are regular faculty, affiliate faculty, students, dentalassistants and dispensary staff. The aim is to provide a convenient, concise,standardized source of information for common clinical materials and proceduresemployed in our Restorative Dentistry Clinic. For updates, go to www.dental.washington.edu/departments/restorative/clin_resource_info.php Happy Clinic Days, Dr. Glen Johnson1. Cavity BasesA base is used as a replacement material for missing dentinal tooth structure. Theprimary indication for use of a base is to eliminate undercuts, to facilitate draw of apreparation. Additionally, a base can used to reduce the bulk of a direct or indirectrestoration. The rationale for use of a base to gain thermal insulation is not asaccepted today. It is believed that sealing dentin (with a sealer) is far more effective incontrolling post-operative sensitivity. The base should have adequate strength andmodulus of elasticity to support the overlying restoration.Examples of acceptable bases used in the D-2 and D-3 clinics are Type Product zinc phosphate cement Fleck’s Cement chemical-cured resin Ti-Core light-cured resin composite Filtek Supreme Plus resin-modified glass ionomer Fuji II LC2. Cavity LinersA cavity liner is a thin layer (usually less than 1/2 mm) of a flowable material placed ondentin placed to achieve a therapeutic effect (e.g. calcium hydroxide paste) or to createa physical barrier (e.g. glass ionomer, resin-modified glass ionomer). Examples ofcalcium hydroxide liners include Dycal, VLC Dycal, Life. Examples of resin-modifiedglass ionomer liners are Vitrebond, Ketac Bond and Fuji Lining LC. See section 5 fortreatment of deep caries and pulp exposures. Indications for use of calcium hydroxideare for pulp capping of pulpal exposures and near exposures. Indications for use ofother liners (e.g. Fuji Lining LC) are to seal around calcium hydroxide and to sealdentin.Examples of acceptable liners used in D-2 and D-3 Clinics are Type Function Product chemical-cured Ca(OH)2 Therapeutic Dycal resin-modified glass ionomer physical barrier and Fuji Lining LC sealer for Ca(OH)2 Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  5. 5. Restorative Dentistry Clinical Reference® 3 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington3. Cavity SealersA cavity sealer is a thin film which provides a protective coating for freshly cut toothstructure of the prepared cavity.1. Varnish - A natural gum, such as copal rosin, or a synthetic resin dissolved in an organic solvent, such as acetone, chloroform, or ether. Examples include Copalite, Plastodent Varnish, and Barrier. Do not use copal resins (e.g. Copalite) in clinic. In lieu of Copalite, we use the adhesive primers, All-Bond 2 Primer A and B.2. Dental Adhesive Primers - includes the primers and adhesives of dentinal and all- purpose bonding agents. Examples include All-Bond 2 Primer A and B, Scotchbond MP+, OptiBond, ProBond, Amalgabond.3. Other cavity sealers - include GLUMA® Desensitizer, Barrier and Protect. The mechanism for sealing with GLUMA® Desensitizer is that the glutaraldehyde in the solution causes a precipitation of plasma protein in the dentinal fluid to occlude the tubules. Barrier and Protect consist of a fluoride releasing resins that reside on the tooth surface after air-drying to remove the carrier solvent. See section 20 for when and how to use Gluma® Desensitizer. For a nice evidenced-based review of bases, liners and sealers, see pp. 104-8 of your Operative Text24. ALL-BOND 2 General Helpful Hints http://www.bisco.com/instructions/techniqueindex.asp for technique cards1. It is not advisable to use ZnO-Eugenol liners or temporary cements in combination with dentin adhesives and resin composites. If used, place the smallest amount possible.2. After primers are applied, they must be thoroughly air dried with an air syringe to make sure all of the solvent and displaced water is removed in order to form a strong polymer in the dentinal tubules. DO NOT DRY BETWEEN COATS!3. After application of A & B primers on dentin/enamel, the surfaces should be glossy. If not, repeat application.4. If you choose the conservative approach to not etch dentin, it is very important to leave the dentin moist prior to primer application. Moist dentin is important with all procedures when using ALL-BOND ® 2.5. Please us a rubber dam whenever possible, especially with porcelain repair. Moisture leads to failures.6. If PRE-BOND RESIN is not air thinned, it may set-up prematurely. Applying PRE- BOND just prior to cementation will give the best results. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  6. 6. Restorative Dentistry Clinical Reference® 4 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington7. Bisco DUAL CURE OPAQUER sets with an oxygen-inhibited layer (“sticky layer”). You may bond composite directly to this or wipe it off and apply D/E BONDING RESIN to the opaqued metal and primed porcelain, if present.8. Lightly air thin the mixture of D/E BONDING RESIN and PRE-BOND RESIN when performing adhesive amalgam technique. This will prevent pooling in the proximal box.9. Desensitizing root surfaces is most effective on a freshly scaled root. A dense pellicle may form over time and make penetration of primers difficult.10. Open primer bottles a few seconds prior to use and gently squeeze. This will allow built up vapor pressure to be released giving better dropper control11. Nylon or Vinyl brush tips are the adhesive applicators of choice. Sponges are not recommended5. Treatment of deep caries with exposure or near exposure of a vital pulpWhen not to pulp cap: If you experience a carious exposure (not mechanical) >0.5mm in size and/ or cannot control the hemorrhage, extirpate the pulp and plan rootcanal treatment. References: Refer to an article by Pameijer and Stanley1 andSummitt, et. al 2 pages 108-9 and TJ Hilton review 3 for evidence-based support for thisapproach to pulp capping. enamelProcedure: caries1. Control the hemorrhage using a cotton pellet. If dentin excavated area pulp hemorrhage cannot be controlled, extirpate the pulp.2. Apply a thin layer of a calcium hydroxide liner (i.e. Dycal) to and slightly beyond the exposure site, or the site of the near exposure. Allow the calcium to harden (note: water will accelerate the reaction of the chemically-cured Dycal).3. Mixing Fuji liner. This is a paste-paste formulation with dispenser. Depress the lever to place a small quantity of the two pastes on a pad. Replace the cartridge cover. Mix for 15 seconds. Note that the Fuji liner is preferred over Vitrebond based on cytotoxicity tests.44. Place one or two layers of the Fuji liner over the Dycal and slightly beyond the margins, to seal and protect the Dycal. Light cure for 20 seconds.5. For bonding associated with composite restorations and large “bonded amalgam restorations”, etch enamel and dentin with Uni-Etch (32% H3PO4), rinse and leave moist. Proceed with instructions for placing these restorations. Note that we only use 32% H3PO4 for all of our procedures in our clinics since 10% H3PO4 has been shown to be not as effective for etching enamel as 32%. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  7. 7. Restorative Dentistry Clinical Reference® 5 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington6. When not bonding (i.e. simple amalgams), do not etch. Apply the sealer (5x All- Bond Primer A & B) over the liner and calcium hydroxide as directed above, air dry and light cure.6. Application of a dentin sealer under amalgam - All-Bond 2 A&BThis “sealing” procedure is employed when the student or attending dentist determinesthat it might be beneficial to seal the dentin before the amalgam is placed. This is notthe “bonded amalgam” procedure described in section 9. Rather this procedure isemployed to prevent and control sensitivity by sealing dentin. Note that it is notnecessary to etch the dentin in this case.Indications: (1) Always seal following pulp capping procedures (section 5) (2) Deeply excavated areas without pulp capping (3) History of thermal sensitivity of toothContraindications: (1) Shallow to moderate depth amalgam preparations (2) Non-vital toothProcedure:1. Following preparation of the cavity, rinse and remove excess water with a brief burst of air. Do not desiccate as All-Bond 2 penetrates better in the presence of moist dentin. Note that it is unnecessary to etch dentin when placing an All-Bond primer as sealer under amalgam.2. Mix primers A and B. Apply five consecutive coats to dentin. Do not dry between coats. After primer application is complete, dry all surfaces for 5-6 seconds with an air syringe to ensure thorough solvent and displaced water removal. Properly primed surface will appear glossy when coverage is sufficient.3. Light cure for 20 seconds.4. If needed, place matrix, then restoration. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  8. 8. Restorative Dentistry Clinical Reference® 6 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington7. Filling Material Selection Chemically-cured Chemically-cured Reinforced ZnO- lightly filled resin resin composite resin composite Resin-modified amalgam- fast glass ionomer glass ionomer Low viscosity, composite Spherical amalgam Admixed Eugenol Material set Type ⇒ Valiant Valiant Filtek Ti- Fuji II Ketac- Filtek IRM Product ⇒ PhD Snap Set Supreme Core LC Fil FlowFoundations/cores √ √1 √ √1Class 1 √ √ √Class 2 √ √Class 3 √Class 4 √Class 5 √ √ √Class 6 √ultraconservative √Class 1composite √provisional repaircomposite filling √repaircrown margin repair √ √ √ √root caries √ √ √temporary filling √ √2 √31 use only when a temporary crown can be placed at the same appointment2 provisional for cusp fracture3 use for caries control8. Foundation Restoration Materials (i.e. core, crown buildups).Foundation restorations are extensive restorations, which will later serve as the“foundation” for complete veneer, or partial veneer (e.g. ¾ crown) cast restorations.Acceptable foundation materials for the Restorative Clinics 1. High copper, admixed dental amalgam Valiant PhD, Valiant PhD-XT 2. light-cured resin composite Filtek Supreme Plus 3. chemical-cured resin Ti-Core**Important –Ti-Core may be used for foundation restorations (i.e. core buildups). Thesetwo fast-setting materials can be used for buildups only when the tooth can be preparedadequately to accommodate a temporary crown which must be placed at the sameappointment. Since both cure quickly, often there are inadequate proximal contacts. Inthe case of Ti-Core, the occlusal anatomy is typically flat. For these reasons, ValiantPhD, Valiant PhD-XT or light-cured composite (Filtek Supreme Plus) must be usedwhen a temporary crown cannot be made. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  9. 9. Restorative Dentistry Clinical Reference® 7 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington9. Bonding in association with large amalgamsEvidence of efficacy - see Summitt et al5Indications:1. Large amalgams2. Incomplete fracturesAdvantages:1. Slight increase in amalgam retention (~10%)2. Seals dentin at same timeDisadvantages:1. costly2. time consuming3. technique sensitiveClinical Procedure (ALL-BOND ® 2 Guide #5B)1. Cavity preparation.2. Etch enamel and dentin using UNI-ETCH (32% H3PO4) for 15 seconds without agitation (timing is important). Rinse thoroughly. Remove excess water with a brief burst of air. DO NOT DESICCATE! ALL-BOND ® 2 prefers moist dentin/enamel.3. Mix PRIMERS A and B. Apply 5 consecutive coats to enamel and dentin. DO NOT DRY BETWEEN COATS! After primer application is complete, dry all surfaces for 5-6 seconds with an air syringe to ensure thorough solvent and displaced water removal. Properly primed surface will appear glossy when coverage is sufficient. If not glossy, repeat step 3. Light cure for 20 seconds.4. Place the matrix band at this time.5. Mix an equal volume of D/E BONDING RESIN and PRE-BOND RESIN on a mixing pad and brush a thin layer onto entire cavity surface. Lightly air thin to avoid pooling. Do this as the amalgam is being mixed to avoid premature setting of the bonding resin.6. Condense amalgam. Carve and finish as usual. NOTE: Matrix band should be placed after application of mixed Primers and should be lightly lubricated by rubbing wax on matrix surface. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  10. 10. Restorative Dentistry Clinical Reference® 8 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington10. Chemically-cured Composite Foundation RestorationImportant - Chemically-cured composite (e.g. Ti-Core) may be used only when thetooth can be prepared and temporary crown placed at the same appointment.Otherwise, amalgam or light-cured composite must be used. This is so that propercontacts and contour are generated.Materials: Ti-Core Composite with All-Bond 2 (All-Bond 2 Guide #7B)Clinical Procedure1. Etch with 32% phosphoric acid gel for 15 sec.2. Rinse thoroughly; dry gently but leave most.3. Mix All-Bond Primer A&B; apply 5 coats; air dry 5-6 sec4. Check for glossy surface. If not, repeat step 3.5. Light cure 20 sec6. Place matrix7. Mix D/E bonding resin and Pre-bond; apply thin layer to dentin8. Simultaneous with #7 above, the dental assistant will mix the catalyst and base of the chemically cured composite (Ti-Core) and load in a Centrix syringe.9. Inject composite deep into matrix and fill to top10. Apply strong finger pressure on the occlusal of setting composite using a plastic Mylar matrix strip to adapt and bond composite well. Hold until initial set. Note that this is similar to the procedure for “bonded amalgam”.11. Class 5 Restoration -- three optionsOption 1: Dental amalgam (use Valiant PhD)Option 2: Resin composite plus dental adhesive Indication: Use preferentially over resin-modified glass ionomer, unless fluoride release is desired. Materials: Filtek Supreme Plus + All Bond 2 (All-Bond 2 Technique Guide #1A) Resin composite Placement Technique 1. Clean and prepare cavity. 2. Etch enamel and dentin using UNI-ETCH (32% H3PO4) for 15 seconds without agitation (timing is important). Rinse thoroughly. Remove excess water with a brief burst of air. DO NOT DESICCATE! ALL-BOND ® 2 prefers moist dentin/enamel. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  11. 11. Restorative Dentistry Clinical Reference® 9 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington 3. Mix PRIMERS A and B. Apply 5 consecutive coats to enamel and dentin. DO NOT DRY BETWEEN COATS! After primer application is complete, dry all surfaces for 5-6 seconds with an air syringe to ensure thorough solvent and displaced water removal. Properly primed surface will appear glossy when coverage is sufficient. Repeat step 3 if not glossy. 4. Brush a thin layer of D/E BONDING RESIN over enamel and dentin. Light cure for 20 seconds. 5. Place composite in layers not to exceed 2 mm; light cure for at least 20 sec. 6. Contour, finish and polish restoration.Option 3: Resin-modified glass ionomer (Fuji II LC Capsules) Indications: Use preferentially over composite only when long-term fluoride release is desired and esthetics is not paramount. Technique 1. Select shade 2. Apply GC Cavity Conditioner for 10 sec 3. Rinse thoroughly, dry gently, but avoid desiccation and contamination. 4. Tap capsules to loosen powder. Depress plunger. Click once in capsule applier to activate. 5. Mix capsule for 10 sec at high (4300 cycles/min). 6. Apply filling material in increments not to exceed 2 mm. 7. Light cure 20 sec. 8. Repeat steps 5 and 6 until filled. 9. Finish and polish immediately 10. Apply thin layer of Fortify resin to seal and protect the surface. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  12. 12. Restorative Dentistry Clinical Reference® 10 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington12. Resin composite Restorations (Classes 1, 3-6)Use Filtek Supreme Plus with All-Bond 2 (see the ALL-BOND 2 Guide #1A)Clinical Procedures1. Clean and prepare cavity.2. Etch enamel and dentin using UNI-ETCH (32% H3PO4) for 15 seconds without agitation (timing is important). Rinse thoroughly. Remove excess water with a brief burst of air. DO NOT DESICCATE! ALL-BOND ® 2 prefers moist dentin/enamel.3. Mix PRIMERS A and B. Apply 5 consecutive coats to enamel and dentin. DO NOT DRY BETWEEN COATS! After primer application is complete, dry all surfaces for 5-6 seconds with an air syringe to ensure thorough solvent and displaced water removal. Properly primed surface will appear glossy when coverage is sufficient. If not shiny, repeat step 3.4. Brush a thin layer of D/E BONDING RESIN over enamel and dentin. Light cure for 20 seconds.5. Place Filtek Supreme Plus composite in layers not to exceed 2 mm, light cure for at least 20 sec.6. Contour, finish and polish restoration.13. Ultraconservative Class I Filling Filtek Flow, Filtek Supreme Plus; + All Bond 2Indications: Minimally invasive carious lesion or defect in the anatomical grooves of a posterior tooth. A flowable composite (Filtek Flow) can be used if the defect resides within enamel and a composite (Filtek Supreme Plus) must be used if the defect extends into dentin.Contraindications for Flowable Composite:1. Any anatomical feature other than the occlusal, lingual and buccal grooves.2. If the preparation width is larger than the ½ round bur3. If the caries or defect extends into dentin.4. Need for local anesthetic (for defect removal)Materials: (see All-Bond 2 Technique Guide #1A)1. Filtek Flow and All Bond 2 can be used if no contraindications exist.2. Given any of the contraindications above, use Filtek Supreme Plus resin composite and All Bond 2 (see section 12 above) for the filling material. Resin composite is better formulated to match the material properties of dentin and exhibits less wear in areas of occlusal function. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  13. 13. Restorative Dentistry Clinical Reference® 11 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of WashingtonTechnique for Flowable Composite (Filtek Flow):1. Use the D801 round diamond bur or ¼ or ½ round carbide bur (in slow or high- speed handpiece) to eliminate areas that are stained, defective, or carious.2. The bonding procedure is the same as for all composite restorations, thus you will etch, prime and bond. See section 12.3. Inject flowable composite (Filtek Flow) into the prepared fissures by moving the syringe tip from distal to mesial areas, maintaining constant pressure on the syringe to prevent voids.4. Run the explorer tip through the prepared fissure(s) to eliminate entrapped bubbles and facilitate flow of the composite.5. You may use a fine-tipped brush or small sponge tip to adapt composite to cavosurface and to eliminate excess.6. Light-cure for 40 seconds, moving the light guide slowly to cover all areas of the restoration.7. Check the occlusion and remove excess with a slow speed round bur.8. Polish with rubber points found in the composite finishing kit.Fee Code:1. If the restoration is within enamel, use the code for sealant.2. If the groove restoration enters dentin, Filtek Supreme Plus must be used. Thus use the code for a one surface composite restoration.14. Class 2 Posterior Resin composite RestorationsAdvantages of Class 2 Posterior Composites1. esthetics2. seal (resistance to microleakage)3. conservation of tooth structure4. slight tooth reinforcement5. low thermal conductivity6. no corrosionDisadvantages of Class 2 Posterior Composites1. increased chair time2. difficult technique (placement, anatomy, contacts, embrasures)3. shorter clinical half-life than amalgam4. occasional postoperative sensitivity5. minimal radiopacity of some products6. higher coefficient of thermal expansion than dentin7. biocompatibility of some components unknown8. polymerization shrinkage9. increased incidence of recurrent caries compared to amalgam Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  14. 14. Restorative Dentistry Clinical Reference® 12 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of WashingtonIndications for Class 2 Posterior Composites1. patient requirement for an esthetic restoration2. proper isolation of entire cavosurface margin attainable3. natural centric occlusal contacts remain4. demonstrated maintenance of good oral hygiene5. low caries rate6. few, if any, non-tooth colored restorations7. conservatively-sized restorationsContraindication for Class 2 Posterior Composites1. history/evidence of parafunctional wear due to bruxing and/or clenching.2. poor oral hygiene3. history/evidence of recurrent caries4. deep subgingival areas requiring restoration5. proper isolation cannot be achieved6. patient desire for removal of clinically acceptable amalgams (UW policy)7. large molar restorationsFor a nice review of the Class 2 technique, read pp. 305-31 of your Operative Text2Materials1. In addition to your tray with standard instruments, request a composite finishing kit, a set of separating rings, and precontoured Dixieland Bands from the Dispensary.2. Filtek Supreme Plus nano resin composite is the best choice for Class 2 composites since they can be inserted, adapted, contoured and formed somewhat easier than other composites which can slump some prior to curing.3. Palodent System - separating rings and sectional matrices.4. Elliot-style separator and soft, pre-contoured Dixieland Band and Tofflemire holder (in reserve)5. All-Bond 2 kit with Fortify resin6. Bard Parker handle & #12 scalpel blade7. Sof-Lex Kit - disks and strips8. UW Composite Polishing Kit (#10) in dispensary Kit contains green (prepolish) and tan (polish) rubber points, cups and discs, where the rubber is impregnated with diamonds. Twelve- and thirty-bladed carbide burs for contouring are also in the kit.Technique Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  15. 15. Restorative Dentistry Clinical Reference® 13 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington1. ISOLATION. Always isolate with rubber dam. 2. PRE-SEPARATION. When placed between teeth, the spring action of the steel ring supplies a constant, gentle wedging force to create orthodontic-type separation of teeth. When possible, place the ring prior to, and during cavity preparation to help gain additional proximal separation. Secure the ring with the rubber dam forceps as shown below, and place the ring into the interproximal space to be restored. Note that the prongs of the ring point toward the gingiva, and that the ring can be placed in either direction to facilitate preparing the tooth. There are two rings, circular and elongated. Either can be used for separation and in either direction, but note that the circular ring is held with the forceps differently than the elongated ring.3. PREPARATION. Employ a conservative preparation as for amalgam. Do not bevel the proximogingival or occlusal margins. It is much easier to locate a non-beveled finish line on the occlusal during contouring and finishing.4. BONDING. Etch dentin and enamel for 15 sec with 32% phosphoric acid. Rinse thoroughly; dry but leave the dentin somewhat moist. Apply 5 coats of All-Bond Primer A&B and thoroughly dry with air. Apply a thin layer of D/E Bonding Resin to the enamel and dentin and light cure 20 sec. Take care not to pool the resin on the pulpal floor or gingivoproximal area.5. MATRIX SELECTION. There are three styles of dead-soft, pre-contoured sectional matrixes as shown. Whether restoring one or two proximal surfaces, it is best to use the sectional matrix. The standard matrix on the left is most commonly used. The next (mini- matrix) is designed for use with primary teeth and patients with poorly erupted posterior teeth. The “plus matrix” on the right, is designed for larger proximal boxes. Note flaps that can accommodate an extended gingival floor, a high marginal ridge or extended proximal walls. The longer flap is to be placed in the gingival area. The standard and mini-matrixes have notches on one edge to denote the occlusal orientation.6. MATRIX APPLICATION. ONLY ONE PROXIMAL SURFACE IS TO BE RESTORED AT A TIME. Remove the ring(s) if used to pre-separate the teeth. Place a sectional matrix into one of the proximal areas to be restored. Select a proper fitting wooden wedge and insert it into the gingivoproximal using the cotton pliers. Then use the large end of your amalgam condenser to advance the wedge as much as possible. The sectional matrix can be carefully adapted if the contact is not closed, but it should not be Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  16. 16. Restorative Dentistry Clinical Reference® 14 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington burnished as for amalgam since this may create a rough proximal contour that is difficult to polish.7. SEPARATION. Apply the steel ring to the proximal using your rubber dam retainer forceps. The tines of the ring may be positioned in front, on, or behind the wedge. Lightly adapt the wings of the matrix against the tooth to aid in forming contours. IMPORTANT. Take care to protect your and your patient’s eyes when placing the steel ring. And only place them with a rubber dam in place to prevent patient aspiration of a “flying separator”. Are you permitted to restore two proximals simultaneously? You should separate and restore only one contact at a time since it is more difficult to attain the needed separation when filling two proximal areas at the same time. Only with explicit permission from your clinical instructor, may you restore both contacts simultaneously. When restoring MOD preparations, the Palodent System allows one to place two round rings in opposite directions or one round ring first, then the elongated one in the same direction as shown above. If the sectional matrixes do not function well, then try the dead soft, pre-contoured Dixieland Band (below) with the Tofflemire holder.8. COMPOSITE PLACEMENT. Place composite in 2 mm increments (maximum) and cure each increment for 40 sec. Begin with the proximal boxes. As increments near the marginal ridge area, take care to form the proximal and occlusal embrasures with the IPC instrument to avoid excess and to reduce the time for finishing. Similarly, the occlusal anatomy should be formed to the extent possible before light curing. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  17. 17. Restorative Dentistry Clinical Reference® 15 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington9. PROXIMAL CURE. Remove the ring separator and wedge, and bend the flanges of the matrix back to check the proximal surfaces for adequacy of filling. If needed, add composite to deficient areas and cure. Under any circumstances, cure the facial and lingual proximal areas, each for 40 sec.10. PROXIMAL CONTACT. At this point, check the adequacy of the proximal contact with floss. If restoring a second proximal contact on the same tooth, proceed with restoring this surface even if the first contact is light. If curing is complete and a contact is open or too light, note instructions below for re-establishing a Class 2 proximal contact. Make this repair before finishing and polishing.11. FINISHING AND POLISHING. If necessary, use the #12 scalpel blade to remove excess on the gingival and proximal. Use a careful technique to prevent tissue injury and to promote shearing of excess, rather than bulk fracture which can become submarginal. The brown, plastic-backed Sof-Lex series of disks are ideal for finishing and polishing proximal and other smooth surfaces. The twelve- and thirty- fluted finishing burs should be used on the occlusal to remove excess and further define the anatomy. Finally, use the rubber points, disks and/or cups in the “composite polishing kit” to create a smooth occlusal surface. The small, blue, rubber-backed Sof-Lex discs can also be used to finish the occlusal surface, and always for smooth surfaces. Proximal surfaces are best polished with Epitex Finishing and Polishing Strips. Composite Finishing and Polishing Instruments course finish fine finish DC1M green point 12 bladed carbide bur on kit DC1 tan point 30-bladed carbides DC2M green disk 7404;7801;7901 12-bladed DC2 tan disk fine & xfine SofLex disks DC3M green cup carbides DC3 tan cup blue SofLex strips gray SofLex strips course; medium SofLex disks12. RESIN GLAZE. An instructor should check the restoration while the rubber dam is still on. If acceptable, clean the surface with etchant and apply Fortify resin. See section below for instructions on the use of the Fortify sealer.13. CHECK THE OCCLUSION. Remove the rubber dam, check and adjust the occlusion. Thereafter, re-polish these areas. Using your hand mirror, show the patient your fine work. ☺Repairing a Proximal Contact1. INDICATIONS. If at the time of restoring a tooth, or during an exam (i.e. existing composite restoration), you note a open or light proximal contact, one should follow this procedure to re-establish a proper contact. Remember open contacts can lead to tooth migration and/or food impaction. So let’s make it right.2. PLACE OR RE-PLACE RUBBER DAM.3. PREPARATION. A small proximal box must be prepared into the existing composite, generally extending to the proximal walls and below the contact, but not necessarily to the gingival floor. You can also air-abrade the prepared surface of an older composite to facilitate bonding. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  18. 18. Restorative Dentistry Clinical Reference® 16 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington4. BONDING. Once prepared, repeat etching and bonding with All-Bond 2 as before. Note that this is the same procedure as given in section 15 – Bonding or Repair of an Existing Composite.5. MATRIX BAND. Place a sectional matrix into the proximal area as mentioned above. Check to see that the matrix is against the approximal surface.6. SEPARATION. Do not use the circular ring for separation if its use just resulted in an open/light contact. We need a fail- safe separator at this point. Apply the Elliot posterior separator to the gingivoproximal and tighten the screw snugly for gingival adaptation of the band and to separate the teeth. Advise your patient that they will feel pressure from the separation. It is necessary to have adequate facial and lingual tissue anesthesia since the Elliot separator applies pressure also to the gingiva.7. FILLING & CONTOURING is accomplished as before. If the proximal contact is too strong and/or slightly rough to flossing, re-separate the proximal surface after band removal to reduce and polish the proximal surface using Sof-Lex strips. Check the contact with floss.15. Surface Sealer for a Composite RestorationComposite Surface Sealing (ALL-BOND® 2 Guide #1D)Indication: Application of FORTIFY Composite Surface Sealant is required forrestorations subject to functional wear (e.g. occlusal surfaces) and suggested for otherrestorations including resin-modified glass ionomer (Fuji II LC). This is to be done afterfinal polishing and finishing. Evidence has shown significantly decreased occlusal wearof sealed restorations in the first year of service.1. Rinse tooth and restoration with copious amounts of water to remove all debris.2. Etch the surface of the composite restoration and approximately 1-2 mm of enamel beyond the tooth/composite margin with UNI-ETCH (32% H3PO4) for 15 seconds. Rinse and dry thoroughly.3. Using a sponge tip, carefully apply a thin layer of FORTIFY to etched enamel and composite surface with a disposable brush tip. Do not air thin. Take care when placing Fortify, as excess can pool, and when cured, becomes difficult to remove.4. Light cure for 20 seconds.5. Check occlusion. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  19. 19. Restorative Dentistry Clinical Reference® 17 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington16. Procedure Check List for Pulp Capping and/or Placing RestorationsStep Composite Casting Amalgam Amalgam Ti-Core Build-up Build-upcaries removal √ √ √ √ √control hemorrhage √ √ √ √ √apply thin layer Ca(OH)2 √ √ √ √ √apply Fuji liner LC √ √ √ √ √place base as needed as needed as neededetch with 32% H3PO4 √ √ √apply All-Bond A+B √ √ √ √air dry 5-6 sec √ √ √ √light cure for 20 sec √ √apply metal matrix √ √ √Prebond + DE bond resin √ √apply DE bonding resin √ √ √light cure for 20 sec √ √apply plastic matrix √place filling √ √ √ √17. Bonding to and/or Repairing an Existing CompositeSee Allbond-2® technique card #4; Evidence: Gordon et al6, D’Alpino et al7, Rathke etal8, Gordan et al91. Pumice tooth.2. Prepare the fractured or defective composite surface with a medium to coarse diamond bur, carbide bur, or disk to create a fresh composite surface. Make sure enough material has been removed to provide for some bulk of composite and ease of filling and finishing. Place a long cavosurface margin bevel. One can also use the sandblaster shown next, to enhance the bond.3. Apply UNI-ETCH (32% H3PO4) for 15 seconds over the entire composite surface to be repaired. Also etch any enamel which will be included in the repair procedure.4. Rinse with water and dry thoroughly.5. Mix PRIMERS A and B. Apply 5 consecutive coats to the composite and tooth structure that was etched. DO NOT DRY BETWEEN COATS! After primer application is complete, dry all surfaces for 5-6 seconds with an air syringe to insure thorough solvent and displaced water removal. Properly primed surfaces will appear glossy when coverage is sufficient.6. Brush a thin layer of D/E RESIN over the primed surfaces. Light cure for 20 seconds7. Proceed with composite layering and finishing. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  20. 20. Restorative Dentistry Clinical Reference® 18 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington18. Repairing PorcelainPorcelain/Acrylic Repair (ALL-BOND ® 2 Guide #2)1. Place rubber dam! Clean surface of porcelain and metal with pumice.2. Bevel porcelain margin with a diamond bur.3. For optimum results, sandblast metal and porcelain with microabrasion unit. If microabrasion unit is not available, abrade with medium diamond bur.4. Apply UNI-ETCH (32% H3PO4) for 5-10 seconds to cleanse and acidify the porcelain surface. Rinse and dry.5. Apply Porcelain Primer (silane) to porcelain surface for 1-2 minutes. Air dry. Mix PRIMERS A & B and apply 2 coats to metal and porcelain. Air dry for 5-6 seconds with air syringe.6. If acrylic is present, treat the same as porcelain. Omit silane.7. Shake opaquer catalyst and base well before using. Mix Bisco DUAL CURE OPAQUER base and catalyst and apply a thin layer to metal. Light cure for 30 seconds to prevent slumping. If metal is not present, omit metal opaquer step.8. Apply thin layer of D/E BONDING RESIN to porcelain and opaqued metal. Light cure for 20 seconds.9. Proceed with composite layering and finishing. Microfil composites are not recommended.19. Treating Sensitive Root Surfaces with a resin sealerDesensitizing Root Surface (ALL-BOND ® 2 Guide #6A)Also needed: 2% Chlorhexidine (e.g. Bisco CAVITY CLEANSER)1. Clean dentin surface by scrubbing with 2% Chlorhexidine and pumice. (Dip cotton pellet soaked with 2% Chlorhexidine into flour of pumice).2. Rinse thoroughly with warm water.3. Blot gently with moistened cotton pellet. To minimize patient discomfort, do not air dry.4. Mix PRIMERS A & B. Apply five consecutive coats to enamel and dentin. DO NOT DRY BETWEEN COATS! After the fifth coat, dry for 5-6 seconds with an air syringe to ensure thorough solvent and displaced water removal.5. REPEAT STEP 4.6. Light cure for 10 seconds.7. With care, apply a thin layer of Fortify resin with a sponge tip and light cure. Take care when placing Fortify, as excess can pool, and when cured, becomes difficult to remove. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  21. 21. Restorative Dentistry Clinical Reference® 19 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington8. Charge for this service: Code 9911 - Application of desensitizing resin for cervical and/or root surface, per tooth. Do not use this for sealers, bases and liners under restorations. And if using a resin root sealer to desensitize, do not use code 9910 (application of desensitizing medicaments) as this is more for fluoride varnishes.20. Sealing Teeth Prepared for Indirect RestorationsBased on the work of Dr. Martin Brännström at the Karolinska Institute in Stockholm,Sweden, it is universally accepted that a common cause of pulpal sensitivity is bacterialingress into dentinal tubules and/or movement of dentinal fluids and concomitantirritation of nerve bundles within the tubule. A pressure differential can cause fluidmovement in the tubules. This may be brought about by drying dentin with a three-waysyringe or by hot and cold stimuli. This is why we caution folks to never over dryexposed dentin and to always keep the exposed dentin physiologically moist. With this introduction, the rationale for sealing sensitive root surfaces and prepared teeth is to control post-operative sensitivity by limiting fluid movement and to prevent ingress of bacteria. Often the term microleakage is used to describe the cause of symptoms of tooth sensitivity. This refers to a communication between the oral environment and dentinal tubules allowing bacterial ingress and pressure changes causing fluid movement. For reference, a compilation of Dr. Brännström’s studies can be found in the monograph entitled “Dentinand Pulp in Restorative Dentistry” by Dr. Martin Brännström10. A modified illustrationfrom his monograph is provided above. The product chosen for use in the in the Department of Restorative Dentistry clinics is called GLUMA® Desensitizer from Heraeus/Kulzer (1-800-343-5336). The composition is 5% glutaraldehyde, 35% hydroxyethylmethacrylate (HEMA) and 60% water. The mechanism for sealing is precipitation of plasma protein in the dentinal fluid to occlude the tubules11. This study also demonstrated that the glutaraldehyde component, and not HEMA, produced the precipitate. A clinical study also substantiated the effectiveness of the sealer in reducing post-cementation sensitivity12. In other studies, it was shown that a resin sealingsystem (e.g. composite bonding system) reduced the retention of cemented castingswhen zinc phosphate cement was used13, whereas the retention was unaffected for anycement when the GLUMA® Desensitizer was used.14 Given laboratory and clinical Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  22. 22. Restorative Dentistry Clinical Reference® 20 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington ®evidence that GLUMA Desensitizer is safe and effective, the decision was made to usethis product over other systems. Why don’t we use GLUMA® Desensitizer as sealer under amalgam and to seal sensitive roots? Good question!! The reason is that Allbond 2 A+B has been shown to penetrate dentin effectively without removal of the smear layer (i.e. etching of dentin) and the polymer laid down with the A+B primer is very complete and durable. Given the risk of decreased retention of castings cemented with zinc phosphate when Allbond 2 A+B primer is used to seal prepared teeth,this tipped the scales toward selection of GLUMA® Desensitizer for this purpose. This isthe rationale for this apparent inconsistency. Why do you think a resin sealer mightdecrease retention of castings cemented with zinc phosphate, but the GLUMA®Desensitizer not? You have the tools to deduce this, so give it some thought. In caseyour eyes are led principally to bold print, note that Allbond 2 A+B, and NOT GLUMA®Desensitizer, is to be used in our clinics to treat sensitive root surfaces and as asealer under amalgam. In these cases we are not concerned about loss of retention ofa restoration when the resin sealer is used.When should you use GLUMA® Desensitizer? In general, use it on exposed dentinof vital teeth that are prepared for an indirect restoration. It is not to be placed on thefoundation (i.e. buildup). Since the product is costly and the procedure will consumeimportant chair time, use the material judiciously and note the specific indications whichfurther compel the use of this sealer on prepared teeth.Specific Indications for Use of GLUMA® Desensitizer1. History of thermal sensitivity of tooth to be restored.2. Radiographic evidence of a pulp with little recession or large pulp horns.3. Preparation of a virtually unrestored tooth (e.g. bridge abutment).4. Over-reduction of tooth, thereby encroaching on the pulp.5. History of thermal sensitivity during provisionalization period.Contraindications for Use of GLUMA® Desensitizer1. Non-vital tooth2. Previous history of allergic reaction to glutaraldehyde or HEMADirections for use at the time of Preparation1. Prepare the tooth for the indirect restoration as normal.2. Prior to cementing the temporary crown, apply the GLUMA® Desensitizer.3. Make sure the tooth is physiologically moist, and not overly wet, nor dry.4. Using a continuous rubbing motion with a small cotton pellet or the Kerr “tufted” Applicator, apply the GLUMA® Desensitizer liquid to the exposed dentinal surface for 30 seconds. Although only one coat is required, supply fresh liquid to different areas of exposed dentin so glutaraldehyde is always available to form a precipitate in the tubules.5. Dry thoroughly with air.6. Do not rinse and avoid contact of the GLUMA® Desensitizer with soft tissue. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  23. 23. Restorative Dentistry Clinical Reference® 21 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of WashingtonCaution: If contact with soft tissue occurs, flush the area immediately with water.Extended contact with tissue will cause redness and burning. There is another cautionfrom the manufacturer. If using cotton rolls for isolation, do not allow the liquid to beabsorbed into the cotton as this exposure may cause a redness or burning of thegingival tissue. If cotton rolls are wetted with the GLUMA® Desensitizer, remove therolls and rinse the tissue. Then re-isolate the area.7. Proceed with cementation of the provisional restoration.Directions for use at the time of cementation1. Remove the temporary crown and all of the temporary cement.2. Seat the indirect restoration by adjusting the proximal contacts, checking the adaptation of the restoration to the finish line and by adjusting the occlusion.3. Polish the gold and/or porcelain indirect restoration.4. Clean the indirect restoration by cleaning the internal with a soft tooth brush and liquid soap. Thereafter, place the completed restoration in a plastic baggy with soap and water to clean it completely. Rinse thoroughly and dry.5. Clean the preparation with a prophy cup using a slurry of flour of pumice and 2% chlorhexidine.6. Rinse and leave moist, but not wet.7. Using a rubbing motion with a small cotton pellet or Kerr “tufted” Applicator, again apply the GLUMA® Desensitizer liquid to the exposed dentinal surface for 30 seconds. Although only one coat is required, you may need to supply fresh liquid to several areas of exposed dentin to provide a continuous source of glutaraldehyde.8. Dry thoroughly with air.9. Proceed with cementation of the casting using the luting cement indicated for this clinical situation. Sealing Technique Summary: Using a rubbing motion with a small cotton pellet or the Kerr “tufted” Applicator, apply the GLUMA® Desensitizer liquid to the exposed dentin for 30 seconds. Although only one coat is required, you may need to supply fresh liquid to several areas of exposed dentin to provide a continuous source of glutaraldehyde, the important ingredient. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  24. 24. Restorative Dentistry Clinical Reference® 22 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington21. Indications and Contraindications for Use of Luting Cements available in theRestorative Dentistry Clinic at the University of Washington Luting Cements Type Indications ContraindicationsFleck’s* zinc complete veneer metal and porcelain/ceramic restorations(Mizzy) phosphate metal-ceramic crowns; partial coverage castings (inlays, onlays, partial veneer crowns); posts; cast post/coresRelyX Luting dual-cured, complete veneer metal or porcelain/ceramic restorations;(3M ESPE) resin- metal-ceramic crowns; partial coverage castings; modified preferred when minimal posts; cast post/cores; and if glass resistance and retention form a temporary cement with ionomer exists eugenol was used.Variolink II** dual-cured used exclusively for all- all other cementations(Ivoclar); both resin porcelain/ceramic restorationsused with Allbond (ceramic veneers, inlays,2 (Bisco) onlays, complete veneer crowns)Comspan resin used exclusively for base all other cementations(Dentsply Caulk); metal, acid-etched, resin-use bonding resin retained bridges. (a.k.a.in kit Maryland Bridge)* Zinc Phosphate is the only cement to be used when cementing cast post/cores, manufactured posts and partial coverage cast-metal restorations (inlays, onlays, partial veneer crowns).** five shades with try-in pastes Type Zinc Resin-mod Dual-cured Resin Phosphate glass ion Resin composite Brand RelyX Fleck’s Variolink II CompspanRestoration Lutingcast metal inlay or onlay Yes No No Nopartial coverage cast crown Yes No No Nocomplete cast metal or metal Yes Yes No Noceramic crowncomplete cast metal or metal Yes Yes No Noceramic FPDcast post & core Yes No No Nomanufactured post Yes No No Noceramic veneer No No Yes Noceramic inlay or onlay No No Yes Noceramic crown (Emax, Finesse) No No Yes NoZrO2 crowns (Procera, LAVA)* No Yes Yes** Noresin-retained FPD No No No Yes* See page 25 for specific procedures as they differ from conventional ceramic.** Variolink II is preferred for anterior crowns since it has more translucence. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  25. 25. Restorative Dentistry Clinical Reference® 23 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington22. Cements and Cementation ProceduresSeating/Cleaning of Casting and Preparation1. Remove the temporary crown and the temporary cement.2. Seat the casting restoration by adjusting the proximal contacts, checking the adaptation of the restoration to the finish line and by adjusting the occlusion.3. Polish the gold and/or porcelain as needed.4. Clean the internal of the casting with a small tooth brush and liquid soap.5. Thereafter, place the casting in a plastic bag with 2% chlorhexidine and clean in an ultrasonic bath. Rinse thoroughly and dry.6. Clean the preparation using a prophy cup and a slurry of flour of pumice and 2% chlorhexidine.7. Rinse, dry some but leave dentin slightly moist.8. Apply dentin sealer if needed.9. Isolate the quadrant for cementation with cotton and saliva ejector.Zinc Phosphate Cement Fleck’s (Mizzy)Zinc Phosphate Cementation Tips1. Chill the mixing slab2. Employ careful mixing technique (P:L ratio!)3. Always check the consistency - cement strings 1-2 cm4. Line internal of the casting with a layer of cement.5. Seat with firm pressure; check occlusion and adaptation for proper seating. Zinc Phosphate6. Have patient bite firmly on cotton until cement min:sec has achieved initial set. Mixing time 02:007. Clean cement after completely hard. Working time 04:00 Setting time 07:00Video: zinc phosphate mixing techniquehttp://www.dental.washington.edu/departments/restorative/clin_resource_info.phpResin-modified Glass Ionomer Cement Rely X™ Luting™ (3M ESPE)RelyX Luting Cementation1. Roll the powder bottle; dispense 3 level scoops. 1 scoop per drop liquid.2. Hold liquid bottle vertically, squeeze gently to dispense 3 drops of liquid for one crown (6 for two).3. Mix all of the powder into the liquid rapidly.4. Continue mixing for 30 seconds.5. Line internal of casting with a layer of cement. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  26. 26. Restorative Dentistry Clinical Reference® 24 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington6. Seat with firm pressure; check occlusion and adaptation for proper seating.7. Have patient bite firmly on cotton roll until cement has achieved initial set.8. Clean excess cement when set (no earlier than 3 min after seating).. RelyX Luting Cement min:sec Mixing time 00:30 Working time 02:30* Setting time 05:30* *Important - that the w.t. and s.t. are shortened significantly at elevated temperatures.All-Ceramic Crown CementationCement: Variolink II (Ivoclar)Type of crowns: Lithium Disilicate (Emax – Ivoclar; Finesse - Dentsply) and ZrO2Crowns (LAVA; Procera)Variolink II Cement - Tooth Preparation(see All-Bond Technique Guide 3B and Cement Instructions)1. Check restoration fit; use Try-In paste if color is to be altered. Otherwise, use Liquid Strip glycerin gel to seat ceramic restoration.2. Etch dentin with UNI-ETCH (32% H3PO4) for 15 seconds without agitation (timing is important). Rinse thoroughly. Remove excess water with a brief burst of air.3. Mix PRIMERS A and B. Apply 5 consecutive coats to dentin. DO NOT DRY BETWEEN COATS! After primer application is complete, dry all surfaces for 5-6 seconds with an air syringe to ensure thorough solvent and displaced water removal. Properly primed surface will appear glossy when coverage is sufficient. Light cure for 20 seconds.4. Apply a thin layer of PRE-BOND RESIN to dentin immediately prior to cementation. AIR THIN. DO NOT LIGHT CURE!Variolink II Cements - Ceramic Preparation(see All-Bond Technique Guide 3B and Cement Instructions)1. Clean internal of the ceramic restoration with UNI-ETCH (32% H3PO4) for 15 seconds. Rinse thoroughly and dry.2. Apply silane to internal of the ceramic restoration for 30 sec and dry.3. Apply a thin layer of D/E bonding resin to this surface. DO NOT LIGHT CURE. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  27. 27. Restorative Dentistry Clinical Reference® 25 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of WashingtonVariolink II - Cementation (see All-Bond Technique Guide 3B)1. Mix equal amounts of base and catalyst pastes on a mixing pad for 10 seconds.2. Line internal of ceramic restoration with a layer of cement and place some cement onto the preparation.3. Seat with slow, even pressure; check occlusion and adaptation for proper seating.4. Maintain seating pressure and remove some of the excess with a brush lightly Variolink Cement coated with D/E resin. min:sec5. Liquid strip may be applied to margins. Mixing time 00:106. Light cure all sides of the restorations for Working time 03:30* 40 sec at each position.7. Clean excess cement; adjust and finish as *Important - note that the w.t. and s.t. are shortened significantly in the absence of needed. oxygen or at elevated temperatures.Zirconium Oxide-based Crown Cementation RelyX Luting or Variolink IIThis type of crown consists of a CAD/CAM produced zirconium oxide coping over whichtraditional feldspathic veneering porcelain is applied and fired. The ZrO2 coping is“tough” and cannot be etched internally to facilitate bonding. For this reason, theprocedures for cementation are different that those given above for alumina andfeldspathic porcelain restorations.Type of crowns: LAVA (3M ESPE), Procera Zirconia (Nobel Biocare)Zirconia Coping Surface Preparation (normally done by the dental laboratory) Sandblast the internal of the coping with 50 micron grit alumina for a maximum 15 seconds using 4-5 bars of pressure. Clean the crown in an ultrasonic bath containing isopropyl alcohol for 3 min.Cleaning of Prepared Tooth before try-in (chair-side) Remove excess temporary cement. Prophy with a mixture of flour of pumice and water. Rinse and dry gently, leave moist taking care to not desiccate surface. If needed cover the tooth preparation with a moist 2x2 gauze. Do not allow contamination of the prepared tooth. If so, repeat above steps.Cleaning of ZrO2 Crown after try-in (chair-side) After try-in of crown, rub the interior of the crown with 37% phosphoric acid gel with an applicator in order to dissolve saliva and other protein remnants. Rinse thoroughly with water for 1 minute. Dry gently with air Dehydrate with isopropyl alcohol and air dry.Cementation with RelyX Luting & Variolink II (see previous instructions) Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  28. 28. Restorative Dentistry Clinical Reference® 26 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of WashingtonPorcelain Veneer Cementation By Dr. Gabriela Ibarra, Clinical Associate ProfessorCement: Variolink II (Ivoclar)Type of veneers: Feldespathic, IPS Empress (Ivoclar Vivadent)Variolink II Cement - Tooth Preparation(see All-Bond Technique Guide 3B and Cement Instructions)1. Remove temporary restoration and pumice tooth. If there was no temporary restoration placed, you still need to pumice the tooth to clean it. Use floss or sandpaper strips to clean interproximally. Avoid tissue damage.2. Place either mylar strips, plumber’s tape or shim stock strips interproximally on both sides of the tooth to be veneered. This will avoid accidental etching of the adjacent teeth.3. Etch with UNI-ETCH (32% H3PO4) for 15 seconds, rinse thoroughly and dry (if only enamel present). If there is an area of exposed dentin within the preparation, be careful not to over-dry it.4. Mix Primers A and B and apply 5 consecutive coats to the area of exposed dentin. Do not dry between coats. Dry surface for 5-6 seconds to evaporate the solvent. Surface should appear glossy. Light cure for 20 sec.5. Apply a thin layer of D/E RESIN to the tooth surface immediately before cementation. Air thin. DO NOT LIGHT-CURE.Variolink II Cements - Veneer Preparation(see All-Bond Technique Guide 3B and Cement Instructions)1. Try-in each veneer dry. Check the fit and marginal integrity.2. Try-in each veneer with its adjacent veneers with water. This will allow you to check for sequential fit problems. If the shade match is crucial, a try in with a supplied try-in paste (translucent, light, dark) is recommended. a. Apply a thin layer of the try-in paste to the internal aspect of the veneer and proceed to seat the restoration. b. Check the color match. Work without the operatory light to avoid setting of the paste and to have a better appreciation of the shade. c. Try-in pastes are usually water-soluble and need to be cleaned off with water spray and dried with oil-free air. If the try-in paste is not water-soluble, you will need to clean the veneer with acetone. d. You may need to repeat the process with a different shade of try-in paste if the color match is not satisfactory.3. Acid etch the internal aspect of the restoration with 4% hydrofluoric acid (HF) for 3-4 minutes. Rinse and dry. It is recommended that you etch the veneer chairside before cementation, rather than have the lab do it. Safety Alert - Be careful when handling this acid. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  29. 29. Restorative Dentistry Clinical Reference® 27 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington4. Apply the silane coupling agent to the internal aspect of the veneer. Let seat for 60 seconds and dry. AVOID CONTACT OF THE SILANE WITH THE EXTERNAL SURFACE OF THE VENEER.5. Immediately before cementation, apply a thin layer of D/E RESIN to the internal surface of the veneer. Air thin. DO NOT LIGHT-CURE.Variolink II – Veneer Cementation (see All-Bond Technique Guide 3B)1. Load the veneer with an even layer of the base material, making sure the margins are covered. Veneers can be cemented with only the base of the cement (not the catalyst) since they are very thin and quite translucent.2. Using finger pressure, push gently, but firmly, on the veneer until it’s seated in place. Clean the gross excess material from the margins with an explorer.3. Increase finger pressure and hold for a few seconds, bringing the veneer to a complete seat. Remove excess cement with a sable brush from difficult to access areas such as the interproximal and cervical embrasures. Be careful not to brush the cement out of the margins.4. At this point, you can tack the veneer by light curing an area of the incisal edge with a very small diameter tip (2mm) for 10-20 seconds. Do not light-cure the proximal or cervical areas.5. Remove the mylar strips by pulling to the lingual and floss the proximal areas to remove residual cement.6. Cover the restoration margins with a glycerin gel and light-cure for 60 seconds from the buccal, incisal, lingual and proximal aspects. If the tip of the curing light is not large enough to include all the margins of the veneer, each margin will have to be light-cured separately for 60 seconds. The glycerin gel will avoid an oxygen inhibition layer at the margins.7. Use a #12 scalpel blade to remove any overhangs from the cervical or interproximal areas very carefully. The blade is very sharp and you can initiate gingival bleeding. You can also use a sharp scaler or gold knife.8. If necessary, a diamond finishing strip can be used to finish the proximal surfaces, followed by Epitex strips. Margins can be finished with very fine diamonds (under 25µm) and finishing flexible disks9. . Adjust occlusion with fine diamonds under water spray and polish with silicon points and disks.10. Apply a neutral fluoride varnish. For additional information on insertion of porcelain veneers, refer to p 485 of your Operative Text2 Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  30. 30. Restorative Dentistry Clinical Reference® 28 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington 23. Posts and Post Cementation By Dr. Douglas Verhoef, Clinical Associate ProfessorMaterials: ColteneWhaledent® ParaPost® SystemGuidelines for Posts Prefabricated Stainless Steel Round to slightly oval canal shape. post (ParaPost®X System) Most anterior teeth and premolars with ≥2mm ferrule. Many molars do not require posts due to adequacy of remaining tooth structure and depth of pulp chamber. If necessary, one SS post is placed in palatal or distal canal. A second smaller post can be placed into another canal at a different angulation and requires less length. Prefabricated fiber post All-ceramic crowns (ParaPost® Fiber Lux) Must have optimal ferrule to prevent fracture Generally not indicated for maxillary canines Core material is light-cure composite Core Materials - CVGC and Amalgam or composite is permitted, but EVC crowns decision to be made based upon strength, need for longevity, esthetics, need for bonding. Consult with instructor before appointment. Ti-Core may be used, but only of the crown is prepared the same day. See Section 10. Cast Post Any shape canal OK, but necessary for irregular shape. Tooth will demonstrate minimal ferrule when restored. May be fabricated at slight angle from long axis of root if tooth is tipped. Direct technique utilizes serrated plastic pattern and Duralay resin to create desired core shape. Indirect technique utilizes smooth plastic post and subsequent impression. Much higher cost due to lab fee and 2nd appointment. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  31. 31. Restorative Dentistry Clinical Reference® 29 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of WashingtonDesign of Post Length:Several suggested optimal lengths have been proposed in the literature. No single“rule” is applicable for all clinical applications. In ALL situations there must be 4-5mmof remaining gutta percha seal at the apex of the root. In ALL situations it isadvantageous to maximize the length, but without compromising the integrity of theroot thickness. The diameter of the post should be instrumented to engage verticalwalls of the canal space except in highly tapered canals (Fig. a below).Among the suggested lengths are (see figures below): The length of the post should be greater than or equal to the length of the crown (Fig #1). The length of the post below the level of the bone should be greater than or equal to the length of the post/core above the level of the bone. (Fig #2) The length of the post should be greater than the length of the core. (Fig #3)Cements for Posts:• Stainless Steel Zinc Phosphate with lentulo spiral• Stainless Steel (minimum length) RelyX Luting with endo explorer• Fiber Posts RelyX Luting with endo explorer Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  32. 32. Restorative Dentistry Clinical Reference® 30 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington24. Treating Superficial Enamel DiscolorationTechnique Summary (references 15, 16, 17, 18,19)• Examine enamel defect(s) while the tooth is hydrated to assess the degree of defect removal needed.• Isolate of the tooth or teeth with a double application of heavy weight rubber dam.• Apply the usual patient protective items including clothing drapes and protective eye wear.• Disks or abrasive points can be first used to remove some of the defect.• Place flour of pumice into a glass dappen dish and add a few drops of 18% hydrochloric acid with a medicine dropper to create a thick paste.• Fashion the wooden end of a cotton-tipped applicator to resemble the end of a straight chisel.• Pick up a small amount of the acid-pumice paste and apply to the defect by rubbing the abrasive mix with the end of the wooden applicator. Rub for 5 seconds and gently rinse for 10 seconds using only water in the air-water syringe. Use high volume evacuation to remove water and abrasive; dry gently. It is best to visualize the effect of acid-abrasion treatment by moistening the tooth. If the defect is still prominent, repeat the step described above. Note that under a rubber dam, the defect will appear more noticeable than for a totally hydrated tooth. Therefore, limit the degree of removal to the point where there is noticeable change, but a hint of the defect can still remain.• Polish the enamel with the Sof-Lex series of disks and strips. Apply APF fluoride gel to the enamel.• Additional appointments can be scheduled as needed for additional treatment. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  33. 33. Restorative Dentistry Clinical Reference® 31 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of WashingtonAdditional Information: Time needed 30-60 minutes/appointment Billing bleaching of vital a teeth Department of Restorative Dentistry Box 357456 University of WashingtonSeattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  34. 34. Restorative Dentistry Clinical Reference® 32 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington25. Coltolux Curing Light – Power Output Check Optilux Curing Radiometer o Obtain the Optilux radoimeter from the Dispensary. Use only this brand of radiometer since others often give high or low readings. o Hold the tip of the light wand flat on the sensor, turn on the light. The value for this particular light normally reads about 700-800 mW/cm2. Do this two to three times in succession. Often power output will decay a bit as the light is turned on a few times. o Given a value significantly lower than this (i.e. <500 mW/cm2), the QTH bulb may need to be checked. See Leng or Dave in Dental Maintenance (543-5958) for a second check. They can replace the bulb if needed. Other causes of low values may be a faulty light guide (tip) or feature this, composite bonded to the tip! o If you replace the bulb, check the output again to make sure you’ve got power. o This test is accomplished so simply and the rewards are potentially enormous. Do this quarterly to make certain you are curing resin composite, adhesives and liners polymers with adequate power. To not do so, is really bad news since the restorations or liners may be inadequately polymerized at deeper levels. Department of Restorative Dentistry Box 357456 University of Washington Seattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  35. 35. Restorative Dentistry Clinical Reference® 33 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington Department of Restorative Dentistry Box 357456 University of WashingtonSeattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  36. 36. Restorative Dentistry Clinical Reference® 34 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington Department of Restorative Dentistry Box 357456 University of WashingtonSeattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  37. 37. Restorative Dentistry Clinical Reference® 35 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of Washington Department of Restorative Dentistry Box 357456 University of WashingtonSeattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/
  38. 38. Restorative Dentistry Clinical Reference® 36 Edited by Glen H. Johnson, D.D.S., M.S. Copyright © 2010 by the Department of Restorative Dentistry, University of WashingtonADHESTIVE/BONDING AGENTS ARTICULATING FORCEPS (Miller)• Biscos All Bond 2 - Includes: • Metal - in instrument trays Primer A & B, D&E Bond, • Paper -disposable (From AR- Prebond, Opaquer, Porcelain Dent) etch, and Silane coupler BITE REGISTRATION MATERIALS • Regisil 2X (Dentsply Caulk)ADHESIVE PLACEMENT TIPS• True-Grip (tacky sticks to hold BLEACHING MATERIALS inlays, veneers, etc.-They come • Opalescence Patient Kit (10%) in 2 sizes - Standard or Mini • Block out resin (Ultradent) (Clinicians Choice) • Sof-Tray sheets 5x5 0.035", UltradentANTIBIOTICS• Amoxicillin 500 mg BRUSHES & APPLICATORS• Clindomycin 150 mg • Benda Brushs From Centrix • Kerrs Applicator sticks - multi-AMALGAM brushes• Valiant PhD Regular set (Ivoclar/Vivadent) BURS (for crown removal)• Valiant PhD-XT (extended • Dentsply bur working time) Ivoclar/Vivadent CARIES INDICATORANESTHETICS, Local • Caries Indicator (Henry Schein)• Xylocaine 2% (1:100,000 and 1:50,000) CAVITY CLEANSERS• Polocaine 3% • Biscos Cavity Cleanser (2%• Septocaine 4% chlorhexidine)ANESTHETICS, Topical CAVITY LINERS• Hurricane (unit dosed topical) • Caulks Dycal (chemical cured )• Hurricane (spray) • Fuji Lining LCASTRINGENTS AND CEMENTS, For Gold and PFMHEMMORAGE CONTROL • Flecks cement liquid• Astringident (15% ferric sulfate) • Flecks Zinc Phosphate, Lt.• Viscostat gel (20% ferric sulfate) Yellow • Flecks Zinc Phosphate, Sno-ARTICULATING PAPER/and WhiteDETECTORS • RelyX Luting (resin-mod glass• Articulation Ribbon, red silk ionomer)• Articulation Ribbon, green• Accu-Film/Exacta-Film (ArDent)• Fit Checker (GC)• Occlude (Pascal) Department of Restorative Dentistry Box 357456 University of WashingtonSeattle, Washington 98195-7456 www.dental.washington.edu/departments/restorative/

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