Issue 17

In a class II of its own

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pages

Contents

4-5
pages

Clinical Case with Palodent Plus, Sectional Matrix System

6-7
page

Matching the Natural Central, A Ceramists View on Aesthetic Implant Restorations

8
pages

Ceramco PFZ, Porcelain for Zirconia

10-11
pages

DENTSPLY Product News

12-16
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New Techniques and Tools for Back-to-Back Class II Restorations: A Clinical Case with Palodent Plus and SDR

18-19
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Clinical Application of the DENTSPLY Endo-Resto System

20

Nupro Sensodyne Case Study

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Clinical Case with Palodent Plus, Sectional Matrix System

by Dr. Annemie Grobbink (NL)
Replacement of Class I and II restorations
During the initial visit of a 26-year old patient, defective composite restorations were found on the 26 and 27.
A good composite restoration is one of the most challenging treatments. This has to do with the number of steps required and the technique sensitivity to achieve a good result. But what can be seen as a good result? In my opinion a good result is a restoration with a good internal adaptation of the composite to the cavity wall, a good marginal integrity, optimal contact points and an anatomically correct shape. Also the lack of post-operative sensitivity and long durability in function are fundamental for a successful restoration. Any technique or material that simplifies the procedure is very welcome to the clinician. SDR has been on the market for a number of years now, in which time it has proven to be very successful. As a result of the low polymerization stress and the flowable characteristic SDR guarantees an optimal adaptation to the cavity walls, which decreases the chance of postoperative pain. Besides that, SDR can be applied in 4mm layers, which simplifies and speeds up the procedure considerably. However, for a good marginal integrity and optimal contact points just a good composite alone is not enough. The development of sectional matrix systems has made the restoration of the interdental anatomy and contact point much easier and more predictable in the past years. The new Palodent Plus system is a further development of these possibilities and user-friendliness, with an anatomically correct contour, which enables the systematic and reliable restoration of the lost interdental dimensions. The matrices are thinner and the wedge and ring system easier to use. The new protective WedgeGuards were added to the Palodent Plus system for protection of adjacent teeth during preparation.

After consultation these old restorations were replaced by new composite restorations. For an optimal functional and aesthetic result we decided to create a restoration with SDR Smart Dentin Replacement as a base and CeramX mono+, Nano-Ceramic Restorative, as the occlusal layer.

Case The patient was administered an anesthesia, colour was determined. Colour matched Vita shade tab A2, which corresponds to the shade tab M2 of CeramX mono+. A rubber dam was used for ideal absolute isolation (Figure 2A). To protect elements 26 and 27, Palodent Plus WedgeGuards were inserted before the MO and DO preparations of element 26 (Figure 2B). After preparation, the shields (or guards) of the WedgeGuards were removed, which converted the WedgeGuards into regular wedges (Figures 2C - 2E). Matrices were inserted and tucked into the interproximal areas and secured by the rings to enable creation of anatomical and optimal contact points (Figure 2F).

Initial Situation

Figure 2A

Figure 2B

Figure 2C

Figure 2D

Figure 2E

Figure 2F

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Next step was etching with 35% phosphoric acid; enamel during 20 seconds and dentine during 15 seconds. After rinsing thoroughly with a mild jet, primer and bonding were applied (Figures 3A - 3D). SDR and CeramX mono+ are compatible with every conventional methacrylate-based dentine/enamel adhesive system. SDR was applied with the canula placed mesial in the cavity, so that SDR could flow into the cavity under the influence of gravity. The self leveling character of SDR ensures an optimal adaptation to the cavity walls. As soon as SDR forms a smooth surface, the material was light cured (Figures 3E - 3F). Then marginal edges were placed in element 26 with CeramX mono+, matrices and rings were removed carefully (Figures 4A - 4B). This resulted in remaining class I restorations in elements 27 and 26. These were built up per cusp, first to minimize the effects of shrinkage. Secondly this is the way to realize a perfect anatomical result relatively easy (Figures 4C - 4F). After application of CeramX mono+ the composite was shaped with a modified ASH and then fissures were created with a Suter and a probe. The surface was smoothened with a brush. To finish the interdental excess of the restorations, a scaler, a scalpel and an interdental abrasive strip were used. Finally the restorations were polished with a finishing disc impregnated with aluminum oxide (Enhance Finishing System) and a polishing point-brush impregnated with diamond particles. Final restoration is shown in Figure 5.

Figure 3A

Figure 3B

Figure 3C

Figure 3D

Figure 3E

Figure 3F

Figure 4A

Figure 4B

Figure 4C

Figure 4D

Figure 4E

Figure 4F

Figure 5

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Matching the Natural Central A ceramists view on aesthetic implant restorations

by Carlos Montaner, Clinical Dental Technician
Carlos Montaner is a Clinical Dental Technician with thirty years experience. He is an international spokesman for DENTSPLY Ceramco, and has published many articles in Venezuela, Argentina, Brazil and Spain. He now owns Montaner Dental Studio in Cary, North Carolina, USA.

Aesthetics are subjective. However, the requirement to match natural dentition with a prosthesis gives the dental team a fixed target to apply their collective skills and enhance patient satisfaction. In the authors opinion, the most challenging restoration to create is a mirror image of a natural single central incisor. The authors laboratory has come across many non-conservative or less natural techniques, including preparing otherwise vital teeth for aesthetic matching. However, with skilled operators, consistent dentistlaboratory communication, and aesthetic materials available today, this is a challenge that can be met with a less invasive technique. Careful treatment planning, collaboration between the dental team, and using metal-free material options are all key to enhancing anterior aesthetics. In the case presented, a left central was replaced with a state-of-the art implant using a zirconia abutment and the Ceramco PFZ system, creating a functionally and artistically restored smile.
Case Clinical Background The patient presented to Dr. Kurt McKissick, the restoring dentist, with a left central (No. 8) that was not salvageable. However, the patient wanted the restoration to match his remaining vital teeth (Figure 1). Impressions and photographs were taken before extraction. After extraction and temporization, a photograph was taken with a shade guide in place to provide the lab with aesthetic guidance (Figure 2). The natural teeth were chromatic and Figure 1 characterized, in the A3 to A3.5 shade range. After discussion with the restoring team, including the Figure 2 periodontist, a zirconia abutment was chosen for aesthetic enhancement. Resin was added to the temporary abutment to shape the tissue with the correct emergence profile. A complete set of impressions were taken and forwarded to the laboratory. Laboratory Procedures To reproduce aesthetic results for the correct emergence profile, models needed to be prepared and temporary abutments needed to be customized to give the correct finish line and volume of material Figure 3 in the neck and crown area (Figure 3). This was accomplished by reshaping a temporary abutment with light-cured resin. The optimized situation afforded input that will result in a custom-milled abutment and a sintered zirconia coping. Having similar materials enhanced both the structural and the aesthetic integrity of the case. The ceramic veneering process began after the fit of the coping was confirmed over the custom abutment. A layer of Ceramco PFZ margin porcelain with modifier ceramics was added to increase chroma and fluorescence in some areas of the tooth and to provide the right surface for the subsequent layers of ceramic. The connection was created by mixing the Ceramco PFZ margin material with glaze liquid. The viscosity of the glaze liquid dispersed the ceramic particles, creating a very porous surface after baking up to 1,000C under the vacuum with a 1-minute hold. This bisque layer provided physical retention for the layers of ceramics to be applied on top of it. Especially in this case, it was very important to have a high chroma in the internal layer leaving the external layer to give the translucency necessary of a typical older tooth (Figures 4 and 5).

Figure 4

Figure 5

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Because margin ceramics are a little more opaque, a small layer of this material was Figure 6 added on the mesial and distal of the coping to create a replica of the dentine (Figure 6). The dentine layer mixed with 15% of natural enamel clear was applied to the whole surface of the crown. Opaceous dentine was added with a mix of 15% mamelon yellow-orange to create a very subtle effect to better block the transition of light. Following the aesthetic techniques of Ernst Hegenbarth, the goal was to achieve improved dynamics between absorption and refraction of light (Figure 7). The stratification pattern shown reveals vertical layers on the incisal area Figure 7 enhancing the translucency and deepness of the crown (Figure 8). After baking the ceramic, the entire surface was Figure 8 covered with a material of greater translucency. Layer thickness was deliberately controlled at a low level. This allowed for more control of ceramic contractions during each bake, as well as the chromatic effects; for example, a craze line (Figure 9). Ceramco PFZ stains were used in small portions and in internal layers of the ceramic. The vanilla shade was used to create this effect by simply mixing it with stain liquid and applying a minimal amount on the ceramic surface before it was fired. Stains were used internally to enhance control. Note that this program can be very fast (120C per minute from 650C to 840C with no hold), and it will not affect the previous layers. The ceramic build-up process was continued with points of contact adjusted on the model (Figure 10), and the shape of the crown re-contoured to mimic the original model (Figure 11). The aesthetic

Figure 9

Figure 10

Figure 11

Figure 12

result of the craze line seen in Figure 9 was now visible (Figure 12). Surface texture was the next challenge to be addressed. In this case, because of the patients age, the dental surface was very smooth due to erosion as well as the permanent contact with the internal part of the lip. Ceramco PFZ glaze and stains were used to finish the proper colour and surface of this tooth. Most of the colour comes from inside, but in aged natural teeth there is a lot of staining on the surface. Finally, the surface was polished with pumice and the case was done (Figures 14, 15 and 16). After the case

Conclusion The technicians skills as well as communication between the entire team are key Figure 18 elements in the restorative process. It is great to work with the correct information because this brings out the best of the dental technician, who can see the desired finished product during the whole process, making the work much more enjoyable. The development of aesthetic, wear-friendly ceramicssuch as the PFZ systemgives the skilled dental lab technician a comprehensive single set of materials to fabricate allceramic restorations. The immediate advantages are enhanced reproducibility, excellent aesthetics, a full spectrum of shades for prescription, as well as a reliable shade match in combination cases involving more than one type of restoration. For more information on the Ceramco PFZ range, please visit www.dentsplymea.com or for technical support please email lab.support@dentsplymea.com

Figure 14

Figure 15

Acknowledgements This article has been repurposed with permission by: DENTSPLY Prosthetics; Carlos Montaner, CDT; Inside Dental Technology, January 2012, Volume 3, Issue 1, Published by AEGIS Communications. The author extends special thanks to Andreina Montaner for her support and collaboration on the development on this article. Clinical insights from Dr. Kurt McKissick (restoring dentist) and Dr. Paul Kazmer (implant placement) are sincerely appreciated.

Figure 16

Figure 17

was cemented, it was difficult to distinguish the crown on an implant (Figures 17 and 18) versus the patients natural dentition. These lifelike results were very pleasing for the patient and rewarding for the entire restorative team.

Disclaimer The preceding material was provided by the manufacturer. The statements and opinions contained therein are solely those of the manufacturer and not of the editors, publisher, or the Editorial Board of Inside Dental Technology.

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Ceramco PFZ, Porcelain for Zirconia

Robert Carew, Product and Technical Manager, DENTSPLY (UK) International

Following on from Carlos Montaners article on the application of Ceramco PFZ please find below further information and FAQs about this product.

Do I have to use the liner? Whilst it is not essential to apply the liner it is though highly recommended particularly for cases where space and therefore good shade matching will be an issue. The liner will prevent the opacity of the framework from affecting the finished restoration helping to maintain good shade reproduction where porcelain thickness is less than 1mm. Ceramco PFZ system has been designed to the highest quality and is available for purchase from your local DENTSPLY sales representative or dealer. Patients, technicians and dentists alike will benefit from the aesthetics and excellent wear characteristics of this system. For more information on Ceramco PFZ and other Ceramco lines, please visit www.dentsplymea.com or for technical support please email lab.support@dentsplymea.com

What is Ceramco PFZ? Ceramco PFZ has been engineered from cutting edge leucite free, synthetic porcelain with the entire system being designed to impart the fluorescence of natural dentition.

Is Ceramco PFZ compatible with all zirconia milled frameworks? It is suitable for use on all 100% zirconia frameworks and is designed to support a variety of indications from single crowns to full restorations.

What can I expect from this material? Ceramco PFZ in common with other Ceramco Porcelains delivers exceptional aesthetics, thermal stability, with the excellent handling and increased productivity associated with Ceramco porcelains.

What shade options does it have? Ceramco PFZ is available in the 16 classic shades and 26 3D shades in either full or mini-kit form or as individual shades. The complete system will provide the technician with the full range of opaques, dentines, incisal, modifier and effect porcelains, to complete the most challenging cases. Four of the most popular bleach shades from the Ceramco Illumin bleach line are also available in Ceramco PFZ.

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K-FILES HEDSTROEMS K-REAMERS

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PRODUCT NEWS
from DENTSPLY
The X-Smart Plus, the new generation of the popular X-Smart endo motor from DENTSPLY Maillefer, is the endo motor of choice for General Dental Practitioners performing root canal treatments with the reciprocating, single file technique or traditional continuous rotation file systems. The X-Smart user interface has been further improved by a large, bright colour screen, with a colour coded file library for file selection at a single glance making it the endo motor of choice for all Protaper Universal users. In the X-Smart Plus you will recognise the highly regarded X-Smart features such as the miniature contra-angle head and the On / Off button on the motor headpiece. X-Smart Plus is everything you like about X-Smart with a Plus.

Crosslinked gutta-percha core obturator Gutta Core is the first obturator with a crosslinked gutta-percha core. Crosslinking is a well-established scientific process that connects the polymer chains and therefore, makes the gutta-percha stronger, whilst keeping its best features: Superior 3D fills The hydraulic force sends warm gutta-percha flowing equally in three dimensions. Centrally compacted gutta-percha creates predictable and consistent 3D fill that follows curves, finds accessory canals and flows into isthmuses. Gutta Core offers a superior 3D fill with the ease of a single insertion. Ease of retreatment No plastic core remaining in the root canal. The obturators core comes out efficiently, saving the dental practitioner time and effort. Post space simplified Fast and easy to create post space.

DENTSPLY Maillefers new maccess brand, brings a comprehensive and affordable hand file range to general practitioners in fast growing markets. The complete range is designed to deliver quality at an affordable price. maccess stainless steel files are ergonomically designed, with ISO colour coded handles, in six sizes per pack across the whole range. maccess hand files offer convenience and simplicity. The silicone stop marker gives control to the practitioner, which further aids the tips direction in the root canal. This feature improves the safety and effectiveness of the file during treatments.

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For dentists placing Class II restorations, Palodent Plus is the new sectional matrix system that delivers easy, predictable and accurate contact creation by utilising advanced ring, matrix and wedge technology. Palodent Plus offers accurate contacts and tight marginal seal, minimised overhang and finishing, easy placement and removal. Palodent Plus delivers: Consistently accurate, tight contacts: Rings are made with nickel-titanium to create a consistent force to separate teeth, and then return to their original shape after use, helping to deliver a tight gingival seal and anatomically-shaped restoration. Wide applications for sectional matrix system use: Ring tine design helps the system remain stable on significantly damaged teeth. Rings are stackable for multiple restorations at once. Minimised flash and finishing: Ring tines maintain a fit on the tooth that complements the wedge and works with the matrix to seal and shape the restoration, minimising required finishing. Wedge compatibility and performance: The V-shape of the tines accommodates the wedge from both sides. Fine wave-shaped wings compress and flare for easy placement and minimise the impingement of soft tissue. Take the stress out of Class II restorations: Use a combination of Palodent Plus and SDR Posterior Bulk Fill Flowable Base. SDR can be bulk filled up to 4mm and provides excellent cavity adaption and reduced polymerization stress.

SDR now available in syringes In 2010, SDR flowable composite base material was successfully introduced in a Compula form. From November 2012, SDR will also be available in a syringe, making the application of this composite material even more flexible. With three years of clinical experience behind it, SDR has become a world success. Thanks to its extremely low polymerization stress, this bulk-fill composite base material is self-levelling and adapts perfectly to the cavity walls. Unlike conventional flowables, SDR can be applied in increments of 4mm in one step. It is designed for use as a base in large class I and class II cavities and now also as a liner for smaller class I cavities or as a fissure sealant, as well as for filling defects or undercuts in tooth preparations for crowns, inlays or onlays. SDR can be overlaid with any methacrylate-based adhesive or composite. From November, SDR will be available in pre-filled syringes, allowing multiple cavities to be restored in one go. The syringe features an ergonomic easy-to-grip handle that simplifies the application process. SDR in syringes is available in two package sizes, a three-syringe refill pack and a ten-syringe eco refill pack.

Launching New Cavitron Jet Plus and Cavitron Plus with Tap-On Technology. DENTSPLYs latest addition to the Cavitron range will give dental surgeries the modern touch. The new Cavitron Jet Plus and Cavitron Plus have a 360 wireless foot control with tap on technology. The new improved foot pedal mechanism reduces leg and foot fatigue. The wireless foot pedal can be tapped to activate, then the foot can be relaxed during the procedure (taken off the foot pedal) and then tapped again to deactivate. In addition the Cavitron Jet Plus supports air polishing, ultrasonic periodontal debridement with turbo boost, the Blue Zone and deep pocket ultrasonic lavage delivering medicament.

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New techniques and tools for back-to-back Class II restorations: A clinical case with Palodent Plus and SDR
by Dr. Walter R. Dias, DDS, MS
Dental Marketing Manager and Lecturer for DENTSPLY DETREY, Germany

Dr. Andre F. Reis, DDS, MS, PhD

Assistant Professor, Guarulhos University, Brazil
The increasing demands of patients and clinicians regarding aesthetic restorations together with the improvements in adhesive materials, composite resins and dental porcelains have brought the possibility of conservative long-lasting Composites aesthetic treatments.1 restorative materials are frequently selected for the aesthetic restorations of the posterior dentition due often to their tooth potential for adhesion2,3 reinforcement and lifelike appearance.4 Posterior composite restorations can be a challenging procedure especially in relation to the formation of a tight proximal contact as well as the attainment and maintenance of the marginal seal (marginal integration). Poor or lack of proximal contact is promptly recognized as an inconvenience by the patient due to the potential and likelihood of food impaction, whereas a lack of marginal integration, manifested clinically as white lines, poor marginal adaptation and later interfacial staining, is the most common reason for failure of adhesive resin-based restorations, and it predisposes the restorations to retention failures5 and recurrent caries.6,7 Nevertheless, modern dental adhesives have the potential to impart remarkable and clinically proven retention and marginal seal.5,6,7,8,9 A relatively recent scientific publication has shown a promising survival rate of 89% for class V bonded composite restorations after 12 years.5 Following the recommendations of the American Dental Association (ADA) guidelines, this recent study5 was designed to evaluate the bond strength to dentine on non-beveled class V preparations. That is, preparations which have not received any type of extension or beveling on enamel. Such a protocol (nonbeveled) is quite common for studies primarily investigating clinical bond strengths to dentine. Under the yet disputable premise that beveling the enamel margins may increase the and fracture marginal seal10,11 12,13 resistance as well as to reduce the occurrence of micro-cracks14 and increase the surface area15 it is then plausible to assume that class V restorations placed according to clinical guideline; that is, restorations placed on beveled Class V preparations have the potential to show an even higher survival rate than the 89% after 12 years as reported in the study mentioned above.5 Continuing forward with this rationalization, once accepted that there is potential for long-term and successful bonding to tooth structure, the operators next logical step should be to master a restorative technique, which allows him to obtain an immediate, effective and successful integration between tooth and restoration. In order to accomplish that, one needs to obtain an excellent internal and marginal seal at the restoration margins throughout the whole operative procedure, and should be maintained during the effective life of the restoration. Microleakage, not retention, is the primary cause of clinical failure in noncarious cervical restorations9 and no method of handling an adhesive restoration can ensure that it is leak 6,8,9 Nonetheless, it is clinically proof. feasible to obtain and maintain marginal integrity throughout the placement procedure as well as through the life-time of the restoration, as the authors of the 12year recall and many other investigators have repeatedly attested.5,9,15,17 This clinical case report aims to address a few techniques and to a minor extent also materials, in order to illustrate the modus operandi of the authors, their simple approach aiming a swift, effective and successful restoration of complex clinical cases on the posterior quadrant. More specifically, the authors focus on their approach to establish and maintain marginal Integrity, which may increase the longevity of the restoration.5,11,12,14,16,17 Additionally, a technique will be described for the effective and simultaneous formation of proximal contact point between teeth number 46 (DOB) and 47 (MOB) which may be easier than one might expect given the right technique and materials.

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Clinical Case: Patient of 32 years of age with no relevant medical history presents with temporary restorations and failed composite restorations in teeth number 46 (DOB) and 47 (MOB). The teeth presented secondary caries radiographically. It was decided to use the new Sectional Matrix System Palodent Plus (DENTSPLY) which allows for the simultaneous restoration of back-to-back class II due to its integration between the ring and the wedge. The restoration was performed with an opaque flowable composite, SDR Smart Dentin Replacement (DENTSPLY), and Ceram.X Mono+ Universal NanoCeramic Restorative in shade M2 (DENTSPLY). The removal of the previous restorations was performed following the principles of minimally invasive dentistry. The old restorations as well as the demineralized enamel were removed with a round stone in high-speed and infected dentine was eliminated with a slow-speed round carbide bur. Care was taken not to disrupt or remove the affected dentine, which is firm and is not easily removed with a dental excavator but it could be easily removed by a rotary instrument. We used a round diamond stone to remove the defective restoration to prepare the enamel and a round carbide bur with light pressure for the removal of caries and infected dentine. secondary decay and therefore indicate a restoration replacement.

Fig. 4

Fig. 4. Placement of the Palodent Plus matrix band. This step is a good example of where good materials can synergistically propel good techniques to a better result. The matrix band has been designed with holes in the top and at the sides to use them in conjunction with Palodent Plus PinTweezers; this way, it is easier to place and remove the matrix band properly.

Fig. 1

Fig. 3A

Fig. 1. Lingual View. Failed composite restorations and provisional material on teeth number 46 (DOB) and 47 (MOB).
Fig. 5

Fig. 3B

Figs. 3A, 3B. Final preparation. Note the maintenance of the sclerotic and affected dentine, especially on tooth number 36. The presence of affected dentine was confirmed with a dental excavator and blunt dental explorer (nonsharp probe). No beveling was performed on the margins, except that any acute angle present was slightly rounded with a diamond stone in slow speed in order to facilitate the subsequent composite adaptation and to ensure marginal integration. Nevertheless, the authors tried to be very conservative and avoid a removal of more than 0.2mm of enamel, by using very light pressure and avoiding extended bur contact with a certain enamel area for any given time. Also, the cavity was performed alongside, removing any internal stains or dark spots which might become visible through the final restoration. This is made with a diamond bur in slow speed (for tissue preservation) to ensure or at least aid to a seamless marginal integration and to avoid unnecessary replacements of this restoration by dentists who might mistake these harmless discolorations as for

Fig. 5. Placement of the second Palodent Plus interproximal matrix band, observing that this was done after the Palodent Plus Wedge insertion. This is only possible thanks to the unique design of this particular wedge, which does not aim to achieve a separation between the teeth, but actually to seal the cervicalgingival wall of the proximal box. It is important to note that this feature is applied to specific clinical cases and in some other cases the wedge should be placed after the placement of the ring.

Fig. 2A

Fig. 2B

Fig. 6A

Fig. 2C

Figs. 2A, 2B, 2C. Cavity preparation principles and procedure.

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After acid etching with phosphoric acid 36% (minimum of 15 seconds on enamel and an additional maximum of 15 seconds on dentine), XP BOND was applied.

see the simultaneous placement and adaptation of the composite material to the distal marginal ridge of tooth number 46 and to the adjacent mesial ridge of tooth number 47.

Fig. 6B

Figs. 6A, 6B. Placement of a secondary Palodent Plus wedge to securely seal the gingival and proximal walls of the respective adjacent proximal boxes. Although recommended, this step is optional. It is also important to note that the Palodent Plus wedges are stackable and design to impart lateral seal rather than to separate the teeth. The subsequent ring placement will impart all the necessary tooth separation, in a predictable and effective manner, so that a successful proximal contact can be obtained. Actually, more than two wedges can be securely stacked in the same inter-proximal area if need be.

Fig. 8 Fig. 10A

Fig. 8. Placement of SDR (DENTSPLY) as a base material after the application of the flow opaque material. The opaque flowable material was applied over the dark sclerotic dentine areas for masking effect.20 SDR was applied as a base over all the dentinal areas and cervical enamel. SDR imparts remarkable low shrinkage stress and allows a maximum depth of cure of 4mm. SDR selfadapting feature avoids unnecessary handling or modeling of the material, which enables the operator to save precious operative time. With more time to spare, the operator is more likely to strive for a more precise and optimal placement of the occlusal layer using a composite of choice.

Fig. 10B

Figs. 10A, 10B. Simultaneous restoration of the marginal ridges. Note the accurate placement and optimal formation of the buccal and lingual embrasures. Given the simplified and swift approach it is also remarkable the absence of excess material and of gaps between the restoration and the tooth surface. The application of SDR base material and the simultaneous restoration of the marginal ridges were carried out in just less than four minutes.

Fig. 7A

Fig. 9

Fig. 9. Adaptation of SDR. Notice the good fit obtained after the placement of the base material SDR. There was neither inclusion nor presence of air bubbles as well as no visible imperfections. With the time savings that SDR provides, one can concentrate more readily in subsequent and more critical parts of the restoration, as the formation of the lateral (buccal and lingual) grooves, cusp ridges as the creation of the marginal ridge and secondary grooves and ridges. Ceram.X Mono+ shade M2 was the material of choice for complete build up of the occlusal layer. As M2 is a body-shade composite, it presents ideal translucency, being able to emulate both dentine and enamel, it imparts a chameleon like property making it an ideal material for the posterior composite restorations. Here we

Fig. 7B

Fig. 11A

Fig. 7C

Figs. 7A, 7B, 7C. Etching and adhesive application (XP BOND, DENTSPLY).

Fig. 11B

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grooves as well as secondary ridges. This step is performed with didactical purposes in mind and has little if any value for the patient himself. It was necessary to carry out minor adjustments using a fine-grit finishing diamond on the distal-buccal cusp of the second lower molar. Polishing was accomplished with PoGo and Prisma Gloss Polishing Pastes (aluminum-oxide based, DENTSPLY). The natural anatomy and the obvious resulting marginal integration are excellent, with no postoperative sensitivity detected. Moreover, the restoration boasts a natural secondary anatomy as well as a correct and functional anatomy of the cusp ridges and buccal surfaces. Because these structures are corresponding to a natural anatomy and are occlusaly adjusted, the restoration will most likely be more resistant since it was possible to add more composite to the whole area of the restoration without incurring on interferences during the mandibular excursions. Discussion and Conclusions The use of an evidence-based and simplified technique greatly facilitates and reduces working time allowing for predictable and assured results. A reduced work time ensures better accuracy and acuity, which translate into predictability and reproducibility. The right materials also have a remarkable potential to synergistically interact with the right techniques, culminating in easier and fast restorations. The minimal invasive technique used to prepare the teeth promotes tissue conservation and maintenance of undermined enamel, which greatly reduces the external extension and size of the preparation.5,6,7 The preservation of the affected dentine minimizes potential for pulpal inflammation or pulpal necrosis. In addition, several studies have demonstrated that smaller composite restorations impart a higher survival rate and the clinician should therefore maintain as much sound tissue as possible, even if that means unsupported enamel (unsupported enamel can be reinforced with a base or regular composite material). The cavity promotes better adhesion as well as cleaner surfaces to bond to and therefore have an aesthetic appeal. The use of round burs prevents the formation of acute angles, which might induce to stress areas and induce crack formation and propagation. The use of a dental adhesive based on tertiary-butanol solvent (XP BOND, DENTSPLY) allows for a larger window of opportunity regarding the control of dentinal moisture prior to the adhesive placement.

Fig. 11C

Fig. 13

Fig. 13. Final polymerization of each restoration for 20 seconds with a minimum output of 800 mW/cm2

Fig. 11D

Figs. 11A, 11B, 11C, 11D. Placement of the occlusal increments. Each cusp is (occlusal or buccal) and ridge was individually restored with individual oblique increments and provisionally tack cured for 3 seconds each (step-cure technique).18,19 This technique not only significantly reduces the stress of polymerization and probably the subsequent formation of white lines, but it also significantly reduces the working time.20 Please note, that no attempt was made to restore the buccal and occlusal surfaces at the same time. Instead, the occlusal ridges and anatomy was given priority in order to maximize accuracy and avoid excess placement, which causes excess occlusal adjustment. The buccal areas were restored by separate (and therefore more accurate) increments, which were also tack-cured for 3 seconds each. After placement and finishing of the occlusal surface, all increments in each restoration were simultaneously lightcured for 20 seconds each using a curing light with output greater than 800 mW/cm2.

Fig. 14

Fig. 14. Finishing performed with Enhance (DENTSPLY). Enhance Finishing System is an aluminum-oxide based material which finishes the composite to a matt luster. Enhance has the interesting ability of not scratching or harming enamel, being able to remove the composite material well enough for finishing of the margins, as well as small to medium adjustments (gross or large adjustments should be performed with a fine or extra-fine diamond or finishing carbide bur). The buccal and lingual embrasures were minimally finished (because little excess was present) with an experimental finishing disk.

Fig. 15A

Fig. 12

Fig. 12. Application of tint material.

Fig. 15B

The application of the tint material demonstrates the formation of detailed aesthetic and functional anatomy including the central fossae, primary and secondary

Figs. 15A, 15B. Immediate final results after minor occlusal adjustment and polishing with PoGo (One Step Diamond Micro-Polisher, DENTSPLY).
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The immediate dentinal sealing technique (SDR, DENTSPLY) protects the dentinal bond obtained and ensures for long-term retention, as far as the dentinal bonding is concerned. The use of a sectional matrix system with integrated wedge system such as Palodent Plus allowed for a somewhat unprecedented procedure involving the restoration of two class II restorations simultaneously using the same ring and the same wedge for both preparations. Further, the Palodent Plus Sectional Matrix

System allowed for a natural contour of the bands, a better control of the points of contact and minimized finishing and polishing. The use of the base material SDR, which presents self-leveling, selfadaptation, 4-milimeter increment application and low-shrinkage stress allows the clinician to operate in a userfriendly, predictable, consistent and reproducible manner. Incidentally, the time spared with the base build-up allows the operator to dedicate more time for an effective and more realistic occlusal restoration, which on its turn favouring a final restoration with less occlusal

adjustments and finishing requirements. Composite restorative materials are frequently selected for the aesthetic restorations of the posterior dentition due often to their potential for adhesion2,3 tooth reinforcement and lifelike appearance. With the right materials and technique, the clinician can not only accomplish a biological, mechanical and aesthetic restoration, but also in an effective and swift manner and actually enjoy it and have fun during the process.

Bibliography 1. Dias2001 Dias WR, Bergamini NM, Salvador JL. Indirect all-ceramic restorations, an interesting option for general dentistry. Braz J of Clinic Lab Prosth 2001;3:5-6 2. Dias2004A Dias WR, Pereira PN, Swift EJ Jr. Early Bond Strengths of SelfEtching Primers to Dentin Cut with Different Burs. J Adhes Dent 2004; 6:195-203 3. Dias WR, Pereira PN, Swift EJ Jr. Early Bond Strengths of Self-etching primers to Enamel Cut with Different Burs. J Adhes Dent 2004; 6:279-85 4. Pena CE, Viotti RG, Dias WR, Santucci E, Rodrigues JA, Reis AF. Esthetic rehabilitation of anterior conoid teeth: comprehensive approach for improved and predictable results. Eur J Esthet Dent. 2009 Autumn;4(3):210-24 5. A 12-year clinical evaluation of a threestep dentin adhesive in noncarious cervical lesions. Wilder AD Jr, Swift EJ Jr, Heymann HO, Ritter AV, Sturdevant JR, Bayne SC. J Am Dent Assoc. 2009 May;140(5):526-35 6. Mjr IA, Shen C, Eliasson ST, Richter S. Placement and replacement of restorations in general dental practice in Iceland. Oper Dent 2002;27(2):117-123 7. Qvist V, Qvist J, Mjr IA. Placement and longevity of tooth-colored restorations in Denmark. Acta Odontol Scand 1990;48(5):305-311 8. Davidson CL, Feilzer AJ. Polymerization shrinkage and polymerization shrinkage stress in polymer-based restoratives. J Dent 1997; 25(6):435-440 9. Van Meerbeek B, Perdigao J, Lambrechts P, Vanherle G. The clinical performance of adhesives. J Dent 1998;26(1):1-20 10. Holan G, Eidelman E, Wright GZ. The effect of internal bevel on marginal leakage at the approximal surface of Class 2 composite restorations. Oper Dent. 1997 Sep-Oct;22(5):217-21 11. Owens BM, Halter TK, Brown DM. Microleakage of tooth-colored restorations with a beveled gingival margin. Quintessence Int. 1998 Jun;29(6):356-61 12. Eid H. J Clin Pediatr Dent. Retention of composite resin restorations in class IV preparations. 2002 Spring;26(3):251-6 13. Hoelscher DC, Gregory WA, Linger JB, Pink FE. Effect of light source position and bevel placement on facial margin adaptation of resin-based composite restorations. Am J Dent. 2000 Aug;13(4):171-5 14. Han L, Okamoto A, Iwaku M. The effects of various clinical factors on marginal enamel micro-cracks produced around composite restoration. Dent Mater J. 1992 Jun;11(1):26-37 15. Bichacho N. Direct composite resin restorations of the anterior single tooth: Clinical implications and practical applications. Compend Contin Educ Dent. 1996;17(8):796-802 16. Boghosian AA, Drummond JL, Lautenschlager E. Clinical evaluation of a dentin adhesive system: 13 year results (abstract 0228). J Dent Res 2007;86(special issue A). http://iadr.confex.com/iadr/ 17. van Dijken JW, Sunnegardh-Gronberg K, Lindberg A. Clinical long-term retention of etch-and-rinse and selfetch adhesive systems in non-carious cervical lesions: a 13 years evaluation. Dent Mater 2007; 23(9):1101-1107 18. Santos AJ, Sarmento CF, Abuabara A, Aguiar FH, Lovadino JR. Step-cure polymerization: effect of initial light intensity on resin/dentin bond strength in class I cavities. Oper Dent. 2006 May-Jun;31(3):324-31 19. Ilie N, Jelen E, Hickel R. Is the softstart polymerization concept still relevant for modern curing units? Clin Oral Investig. 2011 Feb;15(1):21-9. Epub 2009 Nov 24 20. Dias WR. Pereira PN. Swift EJ Jr. Maximizing esthetic results in posterior restorations using composite opaquers. J Esthet Rest Dent 2001;13:219-27.

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In a class II of its own

Cl NE in W ica : 3 lT 6 ria M l R ont es h ul ts *

NEW 36 Month Clinical Trial Results*

Advanced Matrix System

No failures attributable to SDR No recurrent caries No post-operative sensitivities

Predictable tight contacts Tight gingival seal Less flash, less finishing Easy-to-use system

Bulk fill up to 4 mm

Increments up to 4mm without layering Unique self-levelling consistency Excellent flow-like cavity adaption Compatible with your current adhesive**
** chemically compatible with methacrylate based adhesives and composites.

* Data on file

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Clinical application of the DENTSPLY EndoResto System

by Claudia Schaller, Dr. med. dent.

The recently introduced DENTSPLY Endo-Resto System has been designed for immediate post-endodontic restorative treatment. This perfectly matched kit contains all the materials necessary to create a safe post-endodontic adhesive seal of root canal fillings. Studies have shown that root canal fillings alone never offer a reliable seal, regardless of the material or technique employed (Magura et al., 1991; Wu et al., 1998). For this reason, the importance of an effective post-endodontic seal for the long-term prognosis of an endodontically treated tooth is similar to that of the endodontic treatment itself: The success rate of even a good root canal obturation is massively reduced if the seal is poor and insufficient (Ray and Trope, 1995)
If a root canal filling is exposed to the oral environment for more than three months, one must expect it to be infected throughout (Wu et al., 1998). This situation is not all that uncommon in everyday practice, as core restorations, fillings or crowns may develop leakage. If the affected teeth are subsequently re-treated, they will often develop apical lesions, or existing apical lesions may fail to heal. Health insurance guidelines that preclude immediate post-endodontic restorative treatment unintentionally aggravate the problem. The Endo-Resto System is a complete solution (Figure 1) that facilitates cleaning of the endodontic cavity following root canal treatment. The AH Plus Cleaner removes all excess AH Plus sealer. In a second step, the cavity floor and walls are lined with a thin-flowing composite resin (SDR) for a complete anti-bacterial seal. This article describes how this was implemented in a specific clinical retreatment case.

for this tooth had been performed many years previously, while the crown restoration had been delivered only three or four years ago (Figure 2).

Fig. 2

Fig. 1

A 32-year-old man in general good health presented with minor complaints emanating from tooth 46. He had sought emergency dental help the previous weekend due to increasing occlusal pain in the right mandible. The emergency dentist had prescribed an antibiotic and recommended to have the tooth removed or and an apicoectomy to be performed. At the time of presentation, the complaints had largely subsided. The patient reported having noted a sensation of pressure on previous occasions, at times accompanied by a bad taste. The root canal treatment

An intraoral fistula was found at site 46. The tooth was slightly tender to percussion. Pocket depth was between 2 and 4 mm. The tooth was not mobile and showed incipient grade I furcation involvement. Radiographs showed an insufficiently endodontically treated tooth 46 with a pronounced peri-radicular translucency, primarily around the distal root, and in incipient interradicular translucency. In addition to three treated root canals that were underfilled, it was suspected that a fourth canal was present (Figure 3).

Fig. 3

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The patient was advised of the possibilities associated with revision surgery as well as of alternative treatment modes (extraction followed by bridge or implant treatment). The patient was very keen on preserving the tooth and opted for revision surgery. Rubber dam having been duly placed, the metal-ceramic crown was trephined. The pulp cavity exhibited a greasy gangrenous mass mixed with sealer and excess guttapercha from the old root canal filling, accompanied by fetor (Figure 4). After cleaning and rinsing with NaClO, it was found that four root canal orifices were in fact present. The distal lingual canal had not been treated. The old root canal filling material was removed completely. All four canals could be instrumented up to the apical constriction and were prepared in a hybrid technique using manual files and the ProTaper Universal system (Figure 5). filling (Figure 6), it was noted that the periapical and interradicular translucencies had already subsided somewhat. the high transparency of SDR, thorough curing is possible even in deep cavities; layers may be up to 4 mm in depth. Since the material is not designed for occlusal areas, definitive occlusal closure is always made with a methacrylate-based universal composite resin.

Fig. 6

Following the radiological control of the root canal filling, the gutta-percha in all four canals was cut off slightly below the orifice, making sure that no residual gutta-percha remained on the cavity floor or walls (Figure 7).

Fig. 8

Fig. 4

Fig. 7

Fig. 5

This was followed by sonic NaClO rinses and application of a calcium hydroxide medical root canal dressing. The access cavity was adhesively sealed (using a temporary filling material, XP Bond and SDR). Six weeks later, the patient, by now pain-free, presented for placement of the new root canal filling. He reported that the fistula had disappeared as soon as three days after the previous treatment. Rubber dam was once again placed and the adhesive seal removed. This was followed by another extensive sonic rinse (EndoActivator) with NaClO, EDTA and CHX and subsequent drying of the canals. The filling material was introduced thermoplastically using vertical compaction with gutta-percha and AH Plus. During a radiological inspection of the root canal

Using small foam rubber pellets (Roeko Endo Frost Pellets) soaked in AH Plus Cleaner, the entire cavity was cleaned from sealer residue. AH Plus Cleaner was developed specifically for the removal of AH Plus. The cleaning procedure was repeated until the milky-white layer had disappeared, followed by a thorough rinse with water spray. The floor of the pulp cavity and the trephined access cavity were then etched with phosphoric acid (DETREY Conditioner) for 15 seconds. Another rinse was performed to ensure that the etch gel was removed completely. After drying, XP Bond was introduced with an applicator, allowed to soak for 20 seconds and then air-thinned for approximately 5 seconds. While no excess liquid should remain in the cavity, the dentine should not be excessively dry, either. The XP Bond was then light-cured for 10 seconds. The next step was the application of a thin layer of SDR, which thanks to the long metal cannula of the compula is easily directed specifically to the canal orifices. SDR is flowable; the material will distribute evenly all by itself (Figure 8). If, in rare cases, a small air bubble does form, it can be removed with a probe and the SDR can be spread to fill the void. The first layer was polymerized with a curing lamp for 20 seconds. Given

The Endo-Resto System provides a useful match of endodontic and post-endodontic components. This combination of materials has been scientifically examined (Hopp et al., 2010) and certified as a system. I personally consider it a great help for inoffice quality management. From a clinical point of view, I appreciate that the immediate adhesive seal of the endodontic cavity renders reinfection or microleakage less likely. Furcal accessory canals in molars such as those frequently seen in younger patients are also sealed effectively. Finally, tooth stability, which is compromised by the endodontic access cavity and reduced by approximately 60%, is increased because the adhesive chemical bond between the SDR, the capping (composite resin) and the tooth has a stabilizing effect. None of these positive effects can be achieved with nonadhesive sealer such as cements. References Hopp I, Roggendorf M, Petschelt A, Ebert J. Secondary protective seal with SDR. Part 1: dye penetration test. IFEA (2010). Magura ME, Kafrawy AH, Brown CE, Jr., Newton CW (1991). Human saliva coronal microleakage in obturated root canals: an in vitro study. J Endod 17(7):324-31. Ray HA, Trope M (1995). Periapical status of endodontically treated teeth in relation to the technical quality of the root filling and the coronal restoration. Int Endod J 28(1):12-8. Wu MK, Pehlivan Y, Kontakiotis EG, Wesselink PR (1998). Microleakage along apical root fillings and cemented posts. J Prosthet Dent 79(3):264-9. (First publication in Endodontie Journal 2/2012)

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by Dr. Antonella Abbinante (Bari, Italy)

Discover all the benefits of the new prophylaxis paste, Nupro Sensodyne, now enriched with exclusive Novamin technology for immediate relief from dentinal sensitivity.1
Nupro Sensodyne prophy paste actually provides immediate relief from dentinal sensitivity while continuing to offer all the benefits which you would expect from the Nupro brand, including excellent polishing properties. Nupro Sensodyne is the only prophy paste to offer the triple benefit of stain removal, polishing and desensitisation in a single step.

Clinical case number one

Nupro Sensodyne: Hypersensitivity (post-treatment) Female patient, 70 years, non-smoker. Diagnosis: Periodontitis (mild to moderate), recession, plaque and tartar. After debridement the patient indicated some sensitivity. Debridement procedures frequently cause gingival recession, and even patients who do not normally suffer dentinal sensitivity can experience the problem after professional oral hygiene treatments. At the end of the procedure Nupro Sensodyne prophy paste was used (stain removal). After use of the paste, the patient noted a reduction in sensitivity and was able to continue as normal without reporting discomfort from the debridement. Nupro Sensodyne prophy paste (stain removal) was used to reduce both sensitivity and surface discolouration. Fig 3. Debridement. Fig 4. Application of Nupro Sensodyne prophy paste at end of treatment.

Fig 1. Initial situation.

Fig 2. Plaque disclosed in the patients mouth.

Clinical case number two

Nupro Sensodyne: Hypersensitivity (pre-treatment) Female patient, 65 years, non-smoker. Diagnosis: Advanced periodontal disease Symptoms: Hypersensitivity prior to non-surgical periodontal treatment. Nupro Sensodyne prophy paste (polishing) was applied before commencing periodontal treatment. Symptoms were significantly reduced after use and allowed non-surgical periodontal treatment to be carried out without anaesthesia and without causing discomfort to the patient, despite the compromised pre-treatment clinical situation. Use of the prophy paste allowed periodontal debridement to be carried out without further symptoms. The paste was also used after treatment (stain removal) to reduce post-treatment symptoms and to remove the majority of the stains. Fig 1. Advanced Periodontal disease in the patient. Fig 2. Pre-treatment application of Nupro Sensodyne prophy paste.

Fig 3. Periodontal treatment after use of the Nupro Sensodyne prophy paste.

Pictures by kind permission of Dr. Antonella Abbinante, Italy

1

Data on file

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For dental professionals striving for greater comfort!

The next big step in ultrasonic scaling: Tap-On Technology

NEW!

The next big steps in ultrasonic scaling: NEW Tap-On Technology is designed to reduce hygienist leg strain A single tap activates or deactivates scaling or air polishing, allowing you to rest your foot during the procedure Prophy Mode Auto Cycles designed to improve efficiency Additional power options enable quick removal of tenacious calculus Expanded Blue Zone for improved patient comfort Patented Sustained Performance System: SPS to maintain tip stroke automatically
DENTSPLY Limited | Building 1 | Aviator Park | Station Road | Addlestone | KT15 2PG | United Kingdom | +44 (0) 19 32 85 34 22 www.dentsplymea.com For more information |please visit w w w.dentsply.eu

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