CEMENTATION OF INLAY AND VARIOUS TECHNIQUE FOR TEMPORIZATION

RESTORATIVE TECHNIQUES FOR INDIRECT RESTORATIONS
1

“However difficult life may seem there is always
something you can do and succeed at. It matters that
you don’t just give up.”
2
Good Morning

TEMPORARY RESTORATION
TRYING-IN THE CASTING
CEMENTATION
SEATING, ADJUSTING,&POLISHING
RESTORATIVE TECHNIQUES FOR CAST METAL RESTORATIONS
IN Direct
Direct
Indirect Tooth-Colored Restorations
Cast Metal Restorations
3

4
Herbert T. Shillingburg, 4th edition

TEMPORARY RESTORATION
Nonirritating & protect the prepared tooth from injury.
Protect and maintain the health of the periodontium.
Maintain the position of the prepared, adjacent, and opposing teeth.
Provide for esthetic, phonetic, and masticatory function, as indicated.
Adequate strength and retention to withstand the forces to which it will be subjected.
5
Sturdevant 6th edition

1. Avoids the possibility of “locking on” the set temporary
material into undercuts on the prepared tooth or the
adjacent teeth.
2. Avoids placing polymerizing temporary material directly on
freshly prepared dentin and investing soft tissue, reducing
potential irritation to these tissues.
3. The post-operative cast made in the indirect technique affords an opportunity to
evaluate the preparation & serves as an excellent guide when trimming and
contouring the temporary restoration.
4. Fabrication of the temporary restoration can be delegated to a well-trained dental
auxiliary.
Technique
Direct Technique
Advantages:
Indirect Technique
6

Technique for In Direct
Temporary Restoration
7

Direct Temporary Restoration
(1) Involves fewer steps and materials because no post-operative impression and
gypsum cast are required,
2) It is much faster than the indirect technique.
(1) There is a chance of locking hardened temporary materials into small undercuts on the
prepared tooth and the adjacent teeth,
(2) The marginal fit may be slightly inferior to the indirect technique,
(3) It is more difficult to contour the temporary restoration without the guidelines offered
by the post-operative cast.
Advantage
Disadvantage
10

Provisional Restoration
Can be made using conventional techniques and bis-acryl composite materials
A lubricant of some sort (e.g., glycerin) can be applied to the preparation,
Resin-based material was used to block out undercuts
13

PFM and cast gold restorations Eugenol
>2 to 3 weeks, zinc phosphate or polycarboxylate cement
Interfere with resin polymerization
Adhesion of the permanent composite cement to tooth structure
Erkut S, et al. Oper Dent ( 2007)
Tooth is thoroughly cleaned using pumice, excavator, or air abrasion before cementation
of the permanent restoration,
Use of a non-eugenol temporary cement
This doesn’t occur if……………..
Abo-Hamar SE et al.Dent Mater (2005)
based Temporary Cements
15

Brand Price Package Contents
GC REVOTEK LC INTRO SET ₹2295 1 putty stick of REVOTEK LC, 1 light-proof storage
case and 1 GC plastic spatula (No. 2)
3M ESPE PROTEMP 4
TEMPORISATION MATERIAL
- REFILLS
₹5555 1 cartridge – 50 ml, A1; 16 Garant™ Mixing Tips,
blue; instructions
COLTENE WHALEDENT
COOL TEMP NATURAL
₹4954 Cartridge 1 X 50ml
DETAX DENTAL TEMPOFIT
PREMIUM 10/1
₹4314 1 X Tempofit catridge 50ml(75g), 10 X Mixing tips
DMG GERMANY LUXATEMP
FLUORESCENCE AUTOMIX
REFILL
₹4978 1 Cartrige @ 76g , 15 automix tips,shade
GC TEMPRON ₹5120 100g Powder 100g (104 ml) Liquid & Accessories
MEDICEPT DENTAL
ACCUTEMP
₹4400 50ml cartridge & 10 mixing tips
16

Brand Price Package Contents
DIADENT DIA TEMP BLUE ₹1272 3x3g syringe in blue shade
GC UNIFAST III 2-1 PKG ₹4865 2-1 Pkg of Unifast III
IVOCLAR VIVADENT
SYSTEMP.INLAY &
SYSTEMP.ONLAY REFILLS
₹2778 Refill 3x 2.5g Syringes
IVOCLAR VIVADENT TELIO
CS C&B REFILL
₹8147 1 x 78 gm cartridge
IVOCLAR VIVADENT
SYSTEMP C&B II REFILL
₹7074 1 cartridge containing 78g of shade
VOCO STRUCTUR 3 - QM
SYRINGE & CARTRIDGE
REFILLS
₹7837 Cartridge 50 ml, Mixing tips type 6
17

NON-EUGENOL
TEMPORARY CEMENT
Price Package Contents
META NETC Rs.918 60g Base paste. 20g Catalyst paste and a Mixing pad
3M ESPE RELYX TEMP
NE
Rs.1,490 1 Base Paste 30 g. 1 Catalyst 13 g. 1 Mixing Pad
PREVEST ORATEMP NE Rs.595 1 x Automix Syringe . Base & Catalyst . 15g * 20 x
Automix Tips.
KERR TEMP-BOND NE Rs.1,836 1 Tube Base.1 Tube Accelerator (Total 65g).1 Mixing
Pad
Medicept ACCUCEM
Automix NE
Rs 1,100 2 x 5mL Syringes
18

Seating, Adjusting & Polishing the Casting
Trying-in the Casting Preparing the Mouth
Proximal Contacts Occluding the Casting
Lateral working
Maximum Intercuspation
Improving Marginal Adaptation
Removing the Casting
Cementation : Cement Selection Cementation Technique
19

Armamentarium
Seating, Adjusting & Polishing the Casting
Carborundum disk
No. 2 burnisher
No. 1 round bur
Knife edge rubber polishing wheel
Articulating paper
Abrasive point
Bristle disk.
Felt wheel
Chamois wheel and rouge
20

Voids in critical areas indicate rejection of the casting, unless they can be corrected by
soldering.
Ideally, when being placed on the die, it should have the same feel as the feel of the wax
pattern when it was seated on the die 21

X1.5 or X2 Magnification
Hand Burnishes
Proper BurnishesOver Burnishes
Improves The Retention Of The
Casting On The Die
Prevents Complete Seating Of The
Casting
Crush & Destroy The Underlying Die
Surface
A casting must not be loose on the die if the inlay is to be polished properly
23

The operator should guard against the polishing wheel
Carborundum Disk
No. 1 round bur
Knife-edge Rubber Polishing Wheel
24

Knife-edge Wheel
Rubber Point
Do not touched Die Surface & Anatomic Contours Smooth, Satin Finish
It should be ensured that the contact relationships with the adjacent and opposing teeth have
the correct size, position, and intensity.
25

Soft Bristle Disk Small Felt Wheel Chamois Wheel
Marginal adaptation on the die is not as good as it should be.
No polishing compounds should be found on the preparation side
of the casting
Polished Castings
26

Trying-in the Casting Preparing the Mouth
Local anesthesia
Blocks Stimuli From Inducing Pain & Salivation
Teeth are Not particularly Sensitive
27

3 × 3 inch (7.5 × 7.5 cm)
Do NOT force the casting on the tooth
If the floss cannot enter or if it tears on entering, the contact is excessive.
In MOD restoration, only one excess contact should be adjusted at a time
Seating the Casting and Adjusting the Proximal Contacts
If Casting Does Not Seat Completely -------> Over-contoured Proximal Surface
28

Patient is able to indicate whether the contact is strong, particularly when an anesthetic
has not been given
The correct “tightness” of the contacts is best judged with dental floss
If the contact is open (short of touching the adjacent tooth), a new contact area must be
soldered to the casting
Burlew rubber wheel is used to adjust the proximal contour
Bright Spot
29

Occluding the Casting
Supporting Cusp Tips Placed Against Flat Or Smoothly Concave Surfaces = Stability
Incline contacts are less stable and tend to deflect the tooth.
31

(1) The heavy markings are no longer produced,
(2) The contacts on the restoration have optimal position and form,
(3) An even distribution of contacts exists on the casting and the adjacent teeth.
The use of articulating paper and the stone is continued…….
Visual inspection should verify that the adjacent unprepared teeth are absolutely
touching.
Not to over-reduce the occlusal contacts.
32

Lateral working (functional) contacts on the casting are marked by -
(1) Inserting a strip of articulator paper over the quadrant with the casting,
(2) Having the patient close into maximum intercuspation,
(3) “Sliding” the teeth toward the side of the mouth where the casting is located.
33

Contacts between the lingual inclines of the maxillary facial cusps and the facial inclines of
the mandibular facial cusps should remain only if they are passive and a group function
pattern of occlusion is desired
34

Improving Marginal Adaptation
35

Fine-grit
Carborundum Stone
Fine-grit Paper Disk GMT Rubber Polishing
Points
No.27 ball burnisher
36

Removing the Casting
Black spoon (15-8-14)
The spoon is pivoted in the direction of the
curved arrow by using the adjacent tooth
as a fulcrum.
37

Cementation : Cement Selection Cementation Technique
Best cement for inlay????
How to improve the adhesion of inlay???
How to handle inlay????
Relation of margin discrepancy while inlay and it’s repair material????
38

Cement Selection & Cementation Technique
Cast Metal Restorations
39

Currently, NO commercially available luting cement is ideal for all situations.40

A dental cement used to attach indirect restorations to prepared teeth is called a luting
agent.
The glossary of prosthodontic terms. JPD 2005
Requirements -
It Must
Not Harm The Tooth Or Tissues
Allow Sufficient Working Time
Fluid Enough To Allow Complete Seating
Of The Restoration
Quickly Form A Hard Mass Strong Enough
To Resist Functional Forces.
Not Dissolve Or Wash Out, & Must
Maintain A Sealed
de la Macorra JC, Pradies G. Conventional and adhesive luting cements. Clin Oral Investig 2002;6:198–204.
41

Low viscosity at mixing.
Rosentiel et al
Ideal Luting Agent
Biocompatible
Preventing caries or plaque
Resistant to microleakage
Strength to resist functional forces
Low water solubility & No water sorption
Adhesive
Radiopaque
Esthetic
Easy to manipulate
Low in cost
42

Classifications
Powder (base) Liquid (an acid)
Unreacted powder
Salt Hydrogel Matrix
(Weakest & Most Soluble)
Craig
According to chief ingredients
According to matrix-forming species
O’Brien
Donovan
Based on knowledge & experience using these materials
Conventional
Contemporary 43

Zinc Phosphate
Oldest & AB luting cement
Liquid bottle should remain Closed unless dispensing to prevent water loss by evaporation
Should be mixed on a cool, dry, glass slab to slow the Exothermic reaction
The restoration should be seated within 3 to 5 minutes with firm, steady pressure, which
should be maintained several minutes until the initial set has occurred
Non Adhesive bonding
1st ‘‘self-etch cement,’’
Disadvantages – Pulp irritation, LACK, Elevated solubility in oral fluids
Adhesion Antibacterial Action
44

Advantages
AB & self-adhesive cementSilicate Polycarboxylate
Low CTE Physicochemical bonding to tooth structures Fluoride Release
Dispensing should be exactly to manufacturer instructions
Too Much Powder
Increasing Viscosity
Little Powder
Physical Properties
Working Time
Glass Ionomer
Only Materials That Are Self-adhesive To The Tooth Tissue Without Any Surface Pretreatment
Adsorb permanently to the hydrophilic surfaces of oral hard tissues, offering the possibility of
sealing margins developed at the tooth-material interfaces during restorative and luting
procedures
45
P/L ratio ≈ 1.5:1

Glass Ionomer
It should have a glossy surface when the restoration is placed
It should flow easily to allow complete seating without the sustained pressure.
Prior to cementation, the tooth surface should be clean and dry but not dehydrated, with
the smear layer retained. To reduce potential postoperative sensitivity.
Snap Set
Setting Reaction Which begin at mixing and take several months to reach completion
Patients should limit heavy functional stress on restorations luted with glass-ionomer
cements for several days to allow physical properties of the cement to fully develop.
46
DCNA (2007); 643–658

When to remove the excess & how to expose the glass-ionomer to the oral environment?????
Contamination by saliva must be avoided for several minutes to prevent loss of material
by erosion caused by early solubility
Shelf life may be an issue, because viscosity has been shown to increase after 24 months
Glass Ionomer
Glass Ionomer
RMGIC COMPOMER
Snap Set
Dehydration Shrinkage -----> Stress Fractures
Overall curing shrinkage is greater for RMGI, plus the hydrophilic nature of the added resin
results in a varied degree of long-term water sorption, leading to volumetric expansion.
Light Activation
47

Glass Ionomer
Chemical adhesion to tooth structure by chelation with calcium and phosphate ions in dentin
and enamel,
Good translucency,
Fluoride-release–enhancing cariostatic
Extremely Popular Definitive Luting Agent
48

Resin cements
The successful use of resin cements depends on several aspects related to the bonding
mechanisms to both dental and restorative substrates.
Bonding to tooth structure: incompatibility issue
Bonding to the surface of esthetic restorations (ceramics)
Curing protocol for resin cements
Concerns regarding mixing and working time
Resin cement and water sorption phenomenon
49
DCNA (2007) 453–471

Tertiary Amines
Acidic
Group
Water
When cementing inlays, onlays, and crowns, immediate dentin sealing concept may be a
useful clinical alternative to overcome the incompatibility and permeability issues.
Advised to use less permeable adhesive systems
Layer of a relatively more hydrophobic and non
acidic resin.
This additional layer will not cause an adverse reaction with the basic amines of the cement
and will reduce the permeability of the adhesive layer to water transudation from the dentin
Bonding to tooth structure: incompatibility issue
50

Dentin Treatments Immediate Dentin Sealing (IDS)
It is a strategy in which a dentin bonding agent is applied to freshly cut dentin and
polymerized before making an impression J Esthet Restor Dent.2005;17(3):144-155
It can,
•Reducing restoration thickness
•Ensuring the light-cured polymerization of the luting agent
It Protects dentin against bacterial leakage and sensitivity during provisionalization.
No IDSIf no dentinal areas expose
Clin Oral Investig. 2012:16(4):1071-1079.
Bond Strength Delayed Dentin Sealing (DDS)IDS
J Prosthet Dent. 2009;102(1):1-9
51

Bonding to the surface of esthetic restorations (ceramics)
Bond for dental ceramics is usually attempted via - micromechanical attachment to porosities
originated from hydrofluoric acid etching , with or without grit blasting ----> both associated
with a silane coupling agent.
Silane coupling agentsCeramic surfaces Resin cement or adhesive
OH Organic
(G-methacryloxypropyl-trimethoxy Silane)
Silane primers have a limited shelf-life
Clinically, the only indicator seems to be the appearance of the liquid. A clear solution is
useful, whereas a milky-like solution should be discarded.
An alcoholic solution (one-bottle systems) stays transparent, and the signs of alterations
cannot be identified; therefore, two-bottle solutions are preferred.
52
DCNA (2007) 453–471

SMALL
OLIGOMERS
MONOLAYER
CERAMIC
OLIGOMERS
Hot Air Drying (50 5C) For 15 Seconds
Rinses With Hot Water (80°C) For 15 Seconds
Hot Air Drying For 15 Seconds
Recommendations for the time of silane application vary from 30 seconds to 2 minutes.
53
DCNA (2007) 453–471

Curing protocol for resin cements
Light-cure Cements ---> Veneers Or Shallow Inlay
Extended working time,
Setting on demand,
Improved color stability
Dual-cure Resin Cements --->
Material Opacity May Inhibit Sufficient Light Energy
From Being Transmitted To The Cement
Auto-cure System Alone Was Not Sufficient To Achieve Maximum Cement Hardening
It is advisable to delay the light-curing procedure of dual-cure cements to the maximum time
clinically possible.
The ideal time frame between mixing and the light-activation has not yet been determined,
but some studies have shown that light-curing 5 to 10 minutes after mixing.
54
DCNA (2007) 453–471

Concerns regarding mixing and working time Entrapped Voids
Shrinkage Stresses
(At The Thin Cement Layer)
Stress Raisers
Generating Crack Propagation
Degradation Of The Cement Interface
Dual-cure Resin Cements
Benzoyl Peroxide Tertiary Amines
Both the inhibitors and peroxides are organic chemical compounds susceptible to
degradation upon storage ----> recommended (18–22C).
Degradation
Peroxide
Extend Working Time/Setting Time
Inhibitors
Shorten
55
DCNA (2007) 453–471

Ceramic Cement Adhesive Tooth
Resin cement and water sorption phenomenon
Water Sorption Phenomenon
Flexural Strength
Modulus Of Elasticity
Hygroscopic Expansion
Cements that present an extended working time or setting time do not cure properly with
light activation or have a compromised self-cure mechanism and will be affected by
hygroscopic issues
When using dual-cure cements, clinicians should delay the light-curing procedure to the
maximum time clinically possible. In this way, the maximum degree of conversion of resin
cement may be achieved after light activation, reducing the risk of excessive water uptake
Thick Areas Of Resin Cement
56

Characteristics of the Abutment-Prosthesis Interface
58
Phillip’s 11th edition

Procedure for Luting Prostheses, Placement of Cement & Seating
A Luting Agent Must Be Sufficiently Fluid To Flow Into A Continuous Film Of 25 Um
Thickness Or Less
Cement On The Inner Surface Of A Prosthesis
Seating The Prosthesis On The Preparation
Removing The Excess Cement At An Appropriate Time
The occlusal aspect of the tooth preparation must be free of voids
It should fill approximately half or the interior crown volume
Lower viscosity cement,
Increasing the taper,
Decreasing the height of the crown
preparation
Vibration by tapping on the prosthesis
59

It is important to ensure that a prosthesis is completely seated during cementation.
Evaluation of the marginEvaluation Of Occlusion
The thick layer poses two potential problems
1) The prosthesis may be in hyperocclusion,
2) The thicker cement gap may increase the risk for marginal "ditching," which may occur
when using a hard scaling and root-planing instrument
Cool Slab Warm Slab
60
Phillip’s 11th edition

Removal of Excess Material
Does not adhere to the tooth Adhere to the tooth
(Zinc phosphate & ZOE cements )
(Glass ionomer, zinc polycarboxylate, & resin cements)
Best To Remove It After It Sets
1) The surrounding surfaces can be coated with a separating medium.
2) Removal of excess cement as soon as the seating is completed
Some instructions from the manufacturer for GIG and dual-cure resin cements indicate that
once the prosthesis is seated, the cement should be allowed to set for 1.5 to 3 min after the
completion of cement mixing, but before the excess cement is removed.
Rationale is that the cement becomes more viscous, but not rigid during this period In this
consistency, removal of the excess cement is facilitated 61

Mechanism of Retention
Mechanical
Strength of retention
depends on the strength of
the luting agent to resist
applied forces
Resist interfacial separation
Chemical Mechanical + Chemical
Aqueous Cements - Polyacrylic Acids
Resin Cements - NPG-GMA, 4-META
Contemporary dentin-bonding agents
62

Dislodgment of Prostheses
Physical Reasons Biological Factors + Physical ReasonsBiological Factors
Secondary caries
Disintegration Of Luting Agents
Fracture Of The Prosthesis
63

1. The film thickness of cement beneath the prosthesis should be thin
2. The cement should have high strength values
3. The dimensional changes occurring in the cement during setting should minimize
4. A cement with the potential to chemically bond to teeth and prosthesis surfaces
or to enhance bonding of restorative material to tooth structure should be used.
Cement layer is the weakest link of the entire assembly, higher-strength luting agents
should be chosen to enhance retention and prevent prosthesis dislodgment by providing a
firm support base against applied forces.
Factors can influence the retention of these fixed prostheses
When mechanical undercuts are the principal mechanism of retention, failure tends to
occur along the interfaces.
When chemical bonding is involved, the failure often occurs cohesively through the cement
itself.
The prosthesis becomes dislodged only when the luting cement fractures or dissolves. 64

Film Thickness
Freshly mixed cement is placed between two optically flat surfaces and a 150 Newton (N)
vertical load is applied 10 sec before the end of the measured working time.
When at least 10 min have elapsed after application of the load, the thickness of the film
between the two flat surfaces is measured
Size of particles
P/L ratio
This film thickness varies with –
(1) The amount of force applied during seating of a prosthesis,
(2) The manner- in which the force is applied to the prosthesis during seating,
(3) The configuration of the prosthesis relative to its hindering or facilitating the flow of
cement,
(4) The fit of the prosthesis on the prepared tooth.
The film thickness values reported in the literature typically range between 25 and 150 um
Luting applications - 25 um
65

Bonding
Dentin Treatments
Surface Treatments
Try-in
Preliminary Steps
Proximal Contact Adjustment
Finishing & Polishing
Acid etching
Sandblasting
Silane coupling
Tribiochemical coating
Laser treatment67

Try-in and Bonding
Try-in and bonding of tooth-colored inlays or onlays are more demanding than those for
cast gold restorations -
 The relatively fragile nature of some ceramic materials
 The requirement of near-perfect moisture control
 The use of resin cements.
Occlusal evaluation and adjustment generally are delayed until after the restoration is
bonded, to avoid fracture of the ceramic material
Dent Mater 27:109–113, 2011.
68

Preliminary Steps
69

Restoration Try-in and Proximal Contact Adjustment
So Check There Is No Better Fit Before Binding For Ever
70

Bonding
Increases surface relief
Results in micromechanical bonding of the composite
cement to the ceramic restoration.
The inlay or onlay is tried-in again and checked for fit
71
Avoid Interference Of The Wedges With The Seating Of The Restoration.

Finishing and Polishing Procedures
74
Slender Flame Shapes
Larger Oval Or Cylindrical Shapes

Much care must be exercised to avoid damaging the gingiva or the root surfaces when using
such instruments interproximally.
With care and appropriate instrumentation, ceramic restorations can be polished to a surface
as smooth as glazed porcelain using the abrasive sequence ----->
Instrumentation for Finishing and Polishing Ceramic Restorations
Sequence Instruments
1 Medium-grit to fine-grit diamond rotary instrument
2 30-fluted carbide burs
3 Sequence of rubber, abrasive-impregnated porcelain polishing
points
4 Diamond polishing paste
75

76
Rubber Abrasive Points Diamond Polishing Paste With A Bristle Brush
In selected cases, the occlusion can be adjusted on the opposing dentition. This is feasible
only if –
Adjustment is done to correct the occlusal plane of opposing teeth
To reduce a pronounced cusp present on the tooth opposing the restoration to avoid occlusal
trauma.

Repair of Ceramic Inlays and Onlays
Whether Replacement, Rather Than Repair, Is The Appropriate Treatment?????
Mechanical Roughening
Coarse Diamond
Aluminum Oxide
5% to 10% HF acid gel
Silane Coupling Agent
Resin Adhesive Is Applied + Light-cured
Composite
(Facilitate Mechanical Bonding) (2 min)
(Mediate Between Ceramics
& Resins)
77

Indirect restoration offer excellent restorations that may be under-used in dentistry.
The technique requires multiple patient visits and excellent laboratory support, but
the resulting restorations are durable and long lasting.
Advances in ceramic, polymer, and adhesive technologies have resulted in the
development of a variety of tooth-colored indirect restorations & it offer an excellent
alternative to direct composite restorations, especially for large restorations, and are
more conservative than full-coverage restorations.
Because the clinical procedures are relatively technique-sensitive, however, proper
case selection, operator skill, and attention to detail are crucial to success.
Conclusion
78

• Phillip’s 11th edition
• Sturdevant 6th edition
• Herbert T. Shillingburg 4th edition
• O’Brien W. Dental materials 3rd edition.
• Mount GJ. An atlas of glass ionomer cements;3rd edition.
• Abo-Hamar SE, Federlin M, Hiller KA, et al: Effect of temporary cements on the bond strength
of ceramic luted to dentin. Dent Mater 21:794–803, 2005.
• de la Macorra JC, Pradies G. Conventional and adhesive luting cements. Clin Oral Investig
2002;6:198–204.
• The Academy of Prosthodontics. The glossary of prosthodontic terms. J Prosthet Dent 2005;
94(1):21–38.
• Thiago A. Pegoraro et al;Cements for Use in Esthetic Dentistry:Dent Clin N Am 51 (2007) 453–
471
• Christa D Hopp, Martin F Land; Considerations for ceramic inlays in posterior teeth: a review
Clinical, Cosmetic and Investigational Dentistry 2013:5
• Edward E. Hill; Dental Cements for Definitive Luting: A Review and Practical Clinical
ConsiderationsDent Clin N Am 51 (2007) 643–658
• Thiago A. Pegoraro et al ; Cements for Use in Esthetic Dentistry; Dent Clin N Am 51 (2007)
453–471
• Christa D Hopp et al Considerations for ceramic inlays in posterior teeth: a review;Clinical,
Cosmetic and Investigational Dentistry 2013
79
References

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