Restorative Dentistry Clinical Reference Department of Restorative Dentistry University of Washington Seattle, Washington USA

Transcription

1 Restorative Dentistry Clinical Reference Department of Restorative Dentistry University of Washington Seattle, Washington USA Edited by: Dr. Glen H. Johnson Contributors: UW Restorative Dentistry Faculty

2 SCHOOL OF DENTISTRY UNIVERSITY of WASHINGTON Department of Restorative Dentistry To Our Students, Staff and Dental Colleagues Near and Far: We hope you find our Restorative Dentistry Clinical Reference useful. The primary intended users of this reference are our regular faculty, affiliate faculty, students, dental assistants and dispensary staff. The aim is to provide a convenient, concise, standardized source of information for common clinical materials and procedures employed in our Restorative Dentistry Clinic. Each fall, we produce a pocket version of the Restorative Dentistry Clinical Reference as a convenient source of information for those directly involved in our educational process. We also place the contents on our Department website to aid outside practitioners and their staff, and to post updates. If you would like this information in booklet form, they are available with a donation to our Department. These funds aid us in maintaining and expanding the Restorative Dentistry Clinical Reference and to further our academic goals. From all of the hard working folks in the Department of Restorative Dentistry at University of Washington, we extend our very best wishes. Sincerely, Glen H. Johnson, D.D.S., M.S. Professor

3 Restorative Dentistry Clinical Reference 1 Contents Sec 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 5 Treatment of deep caries with exposure or near exposure of pulp (Dycal; Fuji Lining LC; dentin sealer) 4 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) 7 10 Chemically-cured composite foundation restoration (Ti-Core + All-Bond 2) 8 11 Class 5 restoration options Amalgam (Valiant PhD) 8 Composite resin (Filtek Supreme Plus; All-Bond 2) 8 Resin Modified Glass Ionomer (Fuji II LC) 9 12 Class 1, 3-6 composite resin restoration (Filtek Supreme Plus +All-Bond 2) Ultraconservative Class 1 Restoration (Filtek Flow + All-Bond 2) Class 2 posterior composite restoration (Filtek Supreme Plus + All-Bond 2) Repair of a defective proximal contact composite resin Surface sealer for a composite restoration (Fortify) Procedure check list for pulp capping and/or placing restorations Bonding to and/or repairing an existing composite Porcelain Repair Treating root sensitivity (All-Bond 2 A&B) Sealing teeth prepared for indirect restorations (Gluma Desensitizer) Luting cements - indications and contraindications Luting Cements and cementation procedures for Crowns, Inlays and Veneers Preliminary procedures 25 Zinc Phosphate Cement (Fleck s) 25 Resin-modified Glass Ionomer (RelyX Luting) 25 Implant supported Crowns (RelyX Luting) 26 Ceramic/Porcelain Cementation (Variolink II) 26 ZrO 2 Ceramic Crown Cementation (RelyX Luting) 27 Porcelain Veneer Cementation (Variolink II) Posts and Post Cementation (RelyX Unicem 2 Automix) Treating Superficial Enamel Discoloration Bleaching (at-home with trays) Power Bleaching (In office) Curing Light - power output check 40 Operative Dentistry and Prosthodontic Clinic Cassettes and contents 41 Dispensary Materials Listing 42 References 47

4 Restorative Dentistry Clinical Reference 2 The Restorative Dentistry Clinical Reference is a work in progress. The intended users of this reference are our regular faculty, affiliate faculty, students, dental assistants and dispensary staff. The aim is to provide a convenient, concise, standardized source of information for common clinical materials and procedures employed in our Restorative Dentistry Clinic. For color images and for updates, go to Happy Clinic Days, Dr. Glen Johnson 1. Cavity Bases A base is used as a replacement material for missing dentinal tooth structure. The primary indication for use of a base is to eliminate undercuts, to facilitate draw of a preparation. Additionally, a base can used to reduce the bulk of a direct or indirect restoration. The rationale for use of a base to gain thermal insulation is not as accepted today. It is believed that sealing dentin (with a sealer) is far more effective in controlling post-operative sensitivity. The base should have adequate strength and modulus 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 composite resin Ti-Core light-cured composite resin Filtek Supreme Plus resin-modified glass ionomer Fuji II LC 2. Cavity Liners A cavity liner is a thin layer (usually less than 1/2 mm) of a flowable material placed on dentin placed to achieve a therapeutic effect (e.g. calcium hydroxide paste) or to create a physical barrier (e.g. glass ionomer, resin-modified glass ionomer). Examples of calcium hydroxide liners include Dycal, VLC Dycal, Life. Examples of resin-modified glass ionomer liners are Vitrebond, Ketac Bond and Fuji Lining LC. See section 5 for treatment of deep caries and pulp exposures. Indications for use of calcium hydroxide are for pulp capping of pulpal exposures and near exposures. Indications for use of other liners (e.g. Fuji Lining LC) are to seal around calcium hydroxide and to seal dentin. 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 sealer for Ca(OH) 2 Fuji Lining LC

5 3. Cavity Sealers Restorative Dentistry Clinical Reference 3 A cavity sealer is a thin film which provides a protective coating for freshly cut tooth structure 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 allpurpose 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 21 for when and how to use Gluma Desensitizer. For a nice evidenced-based review of bases, liners and sealers, see pp of your Operative Text 2 4. ALL-BOND 2 General Helpful Hints for technique cards 1. It is not advisable to use ZnO-Eugenol liners or temporary cements in combination with dentin adhesives and composite resins. 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 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.

6 Restorative Dentistry Clinical Reference 4 7. 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 control 11. Nylon or Vinyl brush tips are the adhesive applicators of choice. Sponges are not recommended 5. Treatment of deep caries with exposure or near exposure of a vital pulp When not to pulp cap: If you experience a carious exposure (not mechanical) >0.5 mm in size and/ or cannot control the hemorrhage, extirpate the pulp and plan root canal treatment. References: Refer to an article by Pameijer and Stanley 1 and Summitt, et. al 2 pages and TJ Hilton review 3 for evidence-based support for this approach to pulp capping. Procedure: 1. Control the hemorrhage using a cotton pellet. If 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 enamel caries dentin pulp excavated area cytotoxicity tests Place one or two layers of the Fuji Lining LC 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% H 3 PO 4), rinse and leave moist. Proceed with instructions for placing these restorations. Note that we only use 32% H 3 PO 4 for all of our procedures in our clinics since 10% H 3 PO 4 has been shown to be not as effective for etching enamel as 32%.

7 Restorative Dentistry Clinical Reference 5 6. 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&B This sealing procedure is employed when the student or attending dentist determines that it might be beneficial to seal the dentin before the amalgam is placed. This is not the bonded amalgam procedure described in section 9. Rather this procedure is employed to prevent and control sensitivity by sealing dentin. Note that it is not necessary 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 tooth Contraindications: (1) Shallow to moderate depth amalgam preparations (2) Non-vital tooth Procedure: 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.

8 Restorative Dentistry Clinical Reference 6 7. Filling Material Selection Material Type Admixed amalgam composite resin Chemicallycured composite resin Resin-modified glass ionomer Chemicallycured glass ionomer Low viscosity, lightly filled composite resin Reinforced ZnO-Eugenol Product Valiant Filtek Fuji II Ketac- Filtek IRM Ti-Core PhD Supreme LC Fil Flow Foundations/cores 1 Class 1 Class 2 Class 3 Class 4 Class 5 Class 6 ultraconservative Cl 1 Bisacryl provisional repair composite filling repair crown margin repair root caries temporary filling use only when a temporary crown can be placed at the same appointment 2 provisional for cusp fracture 3 use for caries control 8. 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 composite resin Filtek Supreme Plus 3. chemical-cured resin Ti-Core * * Important - Chemically-cured composite (e.g. Ti-Core) may be used only when the tooth can be prepared and temporary crown placed at the same appointment. Otherwise, amalgam or light-cured composite must be used. This is so that proper contacts, occlusal anatomy and axial contours are generated.

9 Restorative Dentistry Clinical Reference 7 9. Bonding in association with large amalgams Evidence of efficacy - see Summitt et al 5 Indications: 1. Large amalgams 2. Incomplete fractures Advantages: 1. Slight increase in amalgam retention (~10%) 2. Seals dentin at same time Disadvantages: 1. costly 2. time consuming 3. technique sensitive Clinical Procedure (ALL-BOND 2 Guide #5B) 1. Cavity preparation. 2. Etch enamel and dentin using UNI-ETCH (32% H 3 PO 4 ) 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.

10 Restorative Dentistry Clinical Reference Chemically-cured Composite Foundation Restoration Important Chemically-cured Ti-Core may be used for foundation restorations (i.e. core buildups). This fast-setting material can be used for buildups only when the tooth can be prepared adequately to accommodate a temporary crown which must be placed at the same appointment. Since this polymerizes quickly, a flat occlusal and open proximal contacts are common. That is not a clinical problem if a provisional crown is placed. Valiant PhD, Valiant PhD-XT or light-cured composite (Filtek Supreme Plus) must be used when a temporary crown cannot be made and the buildup appointment. Materials: Ti-Core Composite with All-Bond 2 (All-Bond 2 Guide #7B) Clinical Procedure 1. 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 sec 4. Check for glossy surface. If not, repeat step Light cure 20 sec 6. Place matrix 7. Mix D/E bonding resin and Pre-bond; apply thin layer to dentin 8. 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 top 10. 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 options Option 1: Dental amalgam (use Valiant PhD) Option 2: Composite resin 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) Composite resin Placement Technique 1. Clean and prepare cavity. 2. Etch enamel and dentin using UNI-ETCH (32% H 3 PO 4 ) for 15 seconds without agitation (timing is important). Rinse thoroughly. Remove excess water with a

11 Restorative Dentistry Clinical Reference 9 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. 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 8 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.

12 Restorative Dentistry Clinical Reference Composite Resin Restorations (Classes 1, 3-6) Use Filtek Supreme Plus with All-Bond 2 (see the ALL-BOND 2 Guide #1A) Clinical Procedures 1. Clean and prepare cavity. 2. Etch enamel and dentin using UNI-ETCH (32% H 3 PO 4 ) 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 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 each increment for at least 20 sec. 6. Contour, finish and polish restoration. 13. Ultraconservative Class I Filling Filtek Flow or Filtek Supreme Plus; All Bond 2 Indications: 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 bur 3. 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 composite resin and All Bond 2 (see section 12 above) for the filling material. Composite resin is better formulated to match the material properties of dentin and exhibits less wear in areas of occlusal function.

13 Restorative Dentistry Clinical Reference 11 Technique for Flowable Composite (Filtek Flow): 1. Use the D801 round diamond bur or ¼ or ½ round carbide bur (in slow or highspeed 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 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 Composite Resin Restorations Advantages of Class 2 Posterior Composites 1. esthetics 2. seal (resistance to microleakage) 3. conservation of tooth structure 4. slight tooth reinforcement 5. low thermal conductivity 6. no corrosion Disadvantages of Class 2 Posterior Composites 1. increased chair time 2. difficult technique (placement, anatomy, contacts, embrasures) 3. shorter clinical half-life than amalgam 4. occasional postoperative sensitivity 5. minimal radiopacity of some products 6. higher coefficient of thermal expansion than dentin 7. biocompatibility of some components unknown 8. polymerization shrinkage 9. increased incidence of recurrent caries compared to amalgam 6

14 Restorative Dentistry Clinical Reference 12 Indications for Class 2 Posterior Composites 1. patient requirement for an esthetic restoration 2. proper isolation of entire cavosurface margin attainable 3. natural centric occlusal contacts remain 4. demonstrated maintenance of good oral hygiene 5. low caries risk/rate 6. few, if any, non-tooth colored restorations 7. conservatively-sized restorations Contraindication for Class 2 Posterior Composites 1. history/evidence of parafunctional wear due to bruxing and/or clenching. 2. poor oral hygiene 3. history/evidence of recurrent caries 4. deep subgingival areas requiring restoration 5. proper isolation cannot be achieved 6. patient desire for removal of clinically acceptable amalgams (UW policy) 7. large molar restorations For a nice review of the Class 2 posterior composite technique, read pp of your Operative Text 2 Materials 1. In addition to your tray with standard instruments, request a composite finishing kit, a set of separating rings, and pre-contoured Dixieland Bands from the Dispensary. 2. Filtek Supreme Plus nano composite is our choice for Class 2 composites since it can be inserted, adapted, contoured and formed somewhat easier than low viscosity composites which can slump some prior to curing. 3. Palodent Plus System - separating rings, wedges and sectional matrices. 4. All-Bond 2 kit with Fortify resin 5. Bard Parker handle & #12 scalpel blade 6. Sof-Lex Kit - disks and strips (3M ESPE) 7. Enhance Finishing & PoGo Polishing Systems (Dentsply) alumina embedded Enhance cups, points and/or disks for finishing (brown shank) and micro-diamond embedded PoGo polishing cups, points and/or disks (white shank).

15 Restorative Dentistry Clinical Reference 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 1. ISOLATION. For placement of Class 2 composite restorations, it is a requirement to isolate prepared tooth and area with rubber dam. 2. PROTECT APPROXIMAL TEETH (optional). One can insert the Wedge Guard from the Palodent System as needed, to protect the approximal surfaces when preparing the proximal boxes. 3. PRE-SEPARATION (optional). When placed between teeth, the spring action of the Palodent 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 special forceps (below) and place the ring into the interproximal space to be restored. Note that the ring can be placed in either direction and inserts nicely over the wedge. There are two rings, dark blue narrow and turquoise -universal. Either can be used for separation and in either direction. 4. 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. 5. 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

16 Restorative Dentistry Clinical Reference 14 the enamel and dentin and light cure 20 sec. Take care not to pool the resin on the pulpal floor or gingivoproximal area. 6. MATRIX SELECTION. Choose from one of the dead-soft, pre-contoured sectional matrixes in the Palodent Plus box and as shown to the right (3.5, 4.5, 5.5, 6.5 mm). Whether restoring one or two proximal surfaces, it is best to use the sectional matrix. The smaller matrices are generally used with primary teeth. The matrix on the far right, is designed for larger proximal boxes where there an extension to accommodate an extended gingival floor. The small occlusal flap with the hole can be used with the special pin tweezers for placement, and the flap can be bent onto the neighboring occlusal to stabilize the wedge. 7. MATRIX APPLICATION. ONLY ONE PROXIMAL SURFACE IS TO BE RESTORED AT A TIME. Remove the ring if used to pre-separate the teeth. Place a sectional matrix into one of the proximal areas to be restored. Select a proper fitting wedge (wooden or Palodent Plus plastic) and insert it into the gingivoproximal using the cotton pliers or pin tweezers. 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 burnished as for amalgam since this may create a rough proximal contour that is difficult to polish. 8. SEPARATION. Apply the ring to the proximal using the special forceps. The v- shaped rubberized tines of the ring are to be positioned over the ends of the wedge. An extra wedge can be added to adapt 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.

17 Restorative Dentistry Clinical Reference 15 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 establish proximal contacts when filling two proximal areas at the same time (i.e. thickness of two matrices). Only with explicit permission from your clinical instructor, may you restore both contacts simultaneously. When restoring MOD preparations, the Palodent Plus 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 (right) with the Tofflemire holder. 9. COMPOSITE PLACEMENT. Place composite in 2 mm increments (max) and cure each increment for 20 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. 10. 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. Remove the matrix. 11. PROXIMAL CONTACT. Next, check the adequacy of the proximal contact with floss and by viewing it with a mouth mirror. 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 reestablishing a Class 2 proximal contact (Sec 15). Make this repair before finishing and polishing. 12. FINISHING AND POLISHING. If needed, 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. The yellow-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 can be used on the occlusal to remove excess and further define the anatomy. One can also use Enhance Finishing and PoGo Polishing cups, points and/or disks. See page 12. There are also a rubber points, disks and/or cups in the Composite Polishing Kit. 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 Instrument Kit course finish fine finish DC1M green point DC2M green disk DC3M green cup gray SofLex strips 12 bladed carbide bur on kit 7404;7801; bladed carbides course; medium SofLex disks DC1 tan point DC2 tan disk DC3 tan cup 30-bladed carbides fine & xfine SofLex disks blue SofLex strips Epitex finishing strips

18 Restorative Dentistry Clinical Reference RESIN SURFACE SEAL. An instructor should check the restoration while the rubber dam is still on. If acceptable, clean the occlusal surface with etchant and apply Fortify resin. See Section 16 for instructions on the use of the Fortify surface sealer. 14. 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. 15. Repair of a Defective Proximal Contact 1. 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. 4. BONDING. Once prepared, repeat etching and bonding with All-Bond 2 as before. Note that this is the same procedure as given in section 18 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 failsafe 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 & FINISHING 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 Epitex Finishing and Polishing Strips. Check the contact with floss.

19 Restorative Dentistry Clinical Reference Surface Sealer for a Composite Restoration Composite Surface Sealing (ALL-BOND 2 Guide #1D) Indication: Application of FORTIFY Composite Surface Sealant is required for restorations subject to functional wear (e.g. occlusal surfaces) and suggested for other restorations including resin-modified glass ionomer (Fuji II LC). This is to be done after final polishing and finishing. Evidence has shown significantly decreased occlusal wear of sealed restorations in the first year of service 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% H 3 PO 4 ) 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. 17. Procedure Check List for Pulp Capping and/or Placing Restorations Step Composite resin Casting Amalgam Amalgam Build-up Ti-Core Build-up caries removal control hemorrhage apply thin layer Ca(OH) 2 apply Fuji liner LC place base as needed as needed as needed etch with 32% H 3 PO 4 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

20 Restorative Dentistry Clinical Reference Bonding to and/or Repairing an Existing Composite See Allbond-2 technique card #4; For evidence, see Gordan et al 8, D Alpino et al 9, Rathke et al 10, Gordan et al 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 alumina air-blaster shown in Section 19, to enhance the bond by creating more surface area. 3. Apply UNI-ETCH (32% H 3 PO 4 ) 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 seconds 7. Proceed with composite layering, polymerization, finishing and polishing. 8. Fee: Typically this is a single surface restoration. Charge for the # surfaces created. 19. Porcelain Repair Porcelain/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, alumina air-blast metal and porcelain with air microabrasion unit shown here. If microabrasion unit is not available, abrade with medium diamond bur. 4. Place BARRIER GEL on the gingival tissues that may be exposed and/or on porcelain areas which are not to be etched. For optimum bonding, etch prepared area with Porcelain Etchant* (4% hydrofluoric acid) for 3-4 minutes. Rinse and dry. If hydrofluoric acid is not available, apply UNI-ETCH (32% H 3 PO 4 ) for 5-10

21 Restorative Dentistry Clinical Reference 19 seconds to cleanse and acidify the porcelain surface. 5. Apply Porcelain Primer (silane) to porcelain surface for 1-2 minutes. Air dry. 6. Mix All-Bond 2 Primers A & B and apply 2 coats to metal and porcelain. Air dry for 5-6 seconds with air syringe. 7. If acrylic is present, treat the same as porcelain but omit silane. 8. If metal is exposed, use Bisco DUAL CURE OPAQUER. Shake both bottles well before using. Dispense and mix base and catalyst and apply a thin layer to metal. Light cure for 30 seconds to prevent slumping. If metal is not present, omit this metal opaquer step. 9. Apply thin layer of D/E BONDING RESIN to porcelain and opaqued metal. Light cure for 20 seconds. 10. Proceed with composite layering and finishing. Microfil composites are not recommended. * PORCELAIN ETCHANT - IMPORTANT PRECAUTIONS (Obtained from Dispensary only by floor Instructor request) Hydrofluoric acid is a very powerful and aggressive chemical. It is a severe eye and tissue irritant. If accidentally splashed into the eye, flush with copious amounts of water for 15 minutes and seek immediate medical attention. Hydrofluoric acid also releases a vapor that irritates respiratory passageways. Chronic inhalation of fumes is dangerous and can cause damage. Extreme care must be taken to protect the patient, operator and assistant. These individuals must wear protective eyewear. The operator and assistant must wear protective gloves. Rubber dam isolation must be used for intraoral porcelain repair. If PORCELAIN ETCHANT comes in contact with other tissues: rinse affected area immediately with copious amounts of water for several minutes. Injury may result if etchant is allowed to remain on the skin or mucosa for any length of time. BISCO's 4% PORCELAIN ETCHANT has been buffered, gelled and packaged to minimize problems, provided that it is used in accordance with these instructions. Do not use this product until you have thoroughly read and understood these instructions.

22 Restorative Dentistry Clinical Reference Treating Sensitive Root Surfaces with a resin sealer Desensitizing 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. 2. Rinse thoroughly with warm water or blot with a sponge tip and warm water. 3. Blot gently with moistened cotton pellet. To minimize 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 Light cure for 10 seconds. 7. Optionally, one can, apply a thin layer of Fortify resin with a sponge tip and light cure. Avoid any excess since that can be difficult to remove. 8. Charge for this service: Code 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 Why use 2% Chlorhexidine? 2% chlorhexidine is an aqueous solution intended for cleansing, moistening and disinfecting cavity preparations. It is recommended for use upon completion of tooth preparation, before cementation or etching, prior to sealing dentinal tubules. For evidence, chlorhexidine has been shown to be an effective antimicrobial agent 12, 13 and has been shown to decrease post-operative sensitivity 14.

23 Restorative Dentistry Clinical Reference Sealing Teeth Prepared for Indirect Restorations Based 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 bacterial ingress into dentinal tubules and/or movement of dentinal fluids and concomitant irritation of nerve bundles within the tubule. A pressure differential can cause fluid movement in the tubules. This may be brought about by drying dentin with a three-way syringe or by hot and cold stimuli. This is why we caution folks to never over dry exposed 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 Dentin and Pulp in Restorative Dentistry by Dr. Martin Brännström 15. A modified illustration from 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 ( ). 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 tubules 16. 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 postcementation sensitivity 17. In other studies, it was shown that a resin sealing system (e.g. composite bonding system) reduced the retention of cemented castings when zinc phosphate cement was used 18, whereas the retention was unaffected for any cement when the GLUMA Desensitizer was used. 19 Given laboratory and clinical evidence that GLUMA Desensitizer is safe and effective, the decision was made to use this 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 All- Bond 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

24 Restorative Dentistry Clinical Reference 22 phosphate when All-Bond 2 A+B primer is used to seal prepared teeth, this tipped the scales toward selection of GLUMA Desensitizer for this purpose. This is the rationale for this apparent inconsistency. Why do you think a resin sealer might decrease 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 case your eyes are led principally to bold print, note that All-Bond 2 A+B, and NOT GLUMA Desensitizer, is to be used in our clinics to treat sensitive root surfaces and as a sealer under amalgam. In these cases we are not concerned about loss of retention of a restoration when the resin sealer is used. When should you use GLUMA Desensitizer? In general, use it on exposed dentin of vital teeth that are prepared for an indirect restoration. It is not to be placed on the foundation (i.e. buildup). Since the product is costly and the procedure will consume important chair time, use the material judiciously and note the specific indications which further compel the use of this sealer on prepared teeth. Specific Indications for Use of GLUMA Desensitizer 1. 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 Desensitizer 1. Non-vital tooth 2. Previous history of allergic reaction to glutaraldehyde or HEMA 3. In conjunction with pulp capping, deep cavities or given signs of pulpitis (see below for mfg precautions)

25 Restorative Dentistry Clinical Reference 23 Directions for use at the time of Preparation 1. 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 a 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. 7. Proceed with cementation of the provisional restoration. Caution: If contact with soft tissue occurs, flush the area immediately with water. Extended contact with tissue will cause redness and burning. There is another caution from the manufacturer. If using cotton rolls for isolation, do not allow the liquid to be absorbed into the cotton as this exposure may cause a redness or burning of the gingival tissue. If cotton rolls are wetted with the GLUMA Desensitizer, remove the rolls and rinse the tissue. Then re-isolate the area. Directions for use at the time of cementation 1. 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.

26 Restorative Dentistry Clinical Reference Indications and Contraindications for Use of Luting Cements available in the Restorative Dentistry Clinic at the University of Washington Luting Cements Type UW Restorative Clinic Indications UW Contraindications Fleck s* (Mizzy) zinc phosphate Partial coverage castings (inlays, onlays, partial veneer crowns) porcelain/ceramic restorations RelyX Luting (3M ESPE) RelyX Unicem 2 Automix (3M ESPE) Variolink II** (Ivoclar); both used with Allbond 2 (Bisco) Comspan (Dentsply Caulk); use bonding resin in kit dual-cured, resinmodified glass ionomer Selfadhesive, modified resin Dual-cured composite resin Self-cure composite resin complete veneer metal or metalceramic crowns; zirconia-based crowns; implant supported crowns; preferred when minimal resistance and retention form exists Fiber-reinforced posts, cast posts, manufactured posts used exclusively for allporcelain/ceramic restorations (e.g. ceramic veneers, e.max inlays, onlays, complete veneer crowns) used exclusively for base metal, acidetched, resin-retained bridges. (a.k.a. Maryland Bridge) porcelain/ceramic restorations; partial coverage castings; posts; cast post/cores; and if a temporary cement with eugenol was used. all other cementations all other cementations all other cementations * Zinc Phosphate is used when cementing partial coverage cast-metal restorations (inlays, onlays, partial veneer crowns) given a long working time to finish margins. ** five shades with try-in pastes Brand RelyX RelyX Unicem Fleck s Restoration Luting 2 Automix Variolink II cast metal inlay or onlay partial coverage cast crown complete cast metal or metal ceramic crown complete cast metal or metal ceramic FPD Implant supported crowns cast post & core manufactured metal post Fiber-reinforced resin post ceramic veneer ceramic inlay or onlay ceramic crown (lithium disilicate - e.max) Monolithic Zirconia crowns* resin-retained FPD * See page 27 for specific procedures as they differ from conventional ceramic. Compspan

27 Restorative Dentistry Clinical Reference Cements and Cementation Procedures Seating/Cleaning of Casting and Preparation 1. Remove the temporary crown and clean prepared tooth of all 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 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 Tips 1. Chill the mixing slab 2. Employ careful mixing technique (P:L ratio!) 3. Always check the consistency - cement strings 1-2 cm 4. Line internal of the casting with a layer of cement. 5. Seat with firm pressure; check occlusion and adaptation for proper seating. 6. Have patient bite firmly on cotton until cement has achieved initial set. 7. Clean cement after completely hard. Zinc Phosphate min:sec Mixing time 02:00 Working time 04:00 Setting time 07:00 Video: zinc phosphate mixing technique Resin-modified Glass Ionomer Cement Rely X Luting (3M ESPE) RelyX Luting Cementation 1. Roll the powder bottle; dispense 3 level scoops. 1 scoop per drop liquid. Close caps. Did you know that moisture contamination of the powder can cause the cement not to set? 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.