Dr Ho Kerr Asia 2012 ( PDF )

R E S TO R AT I V E
SOLUTIONS
Updates and Concepts
Dr Christopher C.K. Ho
BDS Hons (SYD), Grad Dip Clin Dent (Oral Implants), M. Clin. Dent. (Prosthodontics)
C H A L L E N G E S
Bonding - oooowww it hurts
Composite placement and finishing
Staining/microleakage
Optimising contact points
Ceramic types
Cementation
The Goal!!!
“Replacement of lost or damaged structures with artificial materials
that possess biological, physical and functional properties that are
similar to natural teeth”
(Chu S and Ahmad I, 2003)
OUTLINE
• Adhesive dentistry and isolation
• Composite restorations
• All-Ceramics
• Cementation
Workshops
1.! Class I restorations – Successive cusp buildup
2.! Class II restorations – Centripital buildup and use of matrix systems
3.! Class IV restorations – Use of putty index
4.! Direct Resin Veneer – Characterisation and surface texture
5.! Direct Resin Veneer – Blocking discolouration
A D H E S I V E
D E N T I S T RY
1. Micro-mechanical retention
2. True chemical adhesion
adhesive dentistr y
Enamel
ETCH
Dentine
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Dentine bonding
adhesive dentistr y
Dentine mainly organic, collagen and water - humid nature and
organic nature make it hard to bond to.
Total Etch remove smear layer and demineralise dentine (smear
layer occludes tubules reduces dentine permeability 86%).
Self Etch penetrates and modifies smear layer.
ETCH &
RINSE
BONDING
STRATEGIES
SELF-ETCH
adhesive dentistr y
“Total Etch” technique....
Dentine bonding

Retention from the intertubular dentine
hybridisation.

Latticework of unsupported collagen,
with adhesive infusing collagen with resin
(like seaweed) Need moisture otherwise
collagen fibers collapse.

Resin tags do not provide retention but
desensitisation
SELF-ETCH BONDS
Resin tags
adhesive dentistr y
• Condition and prime enamel and dentine simultaneously by
infiltrating and partially dissolving the smear layer.
• Enamel bond strengths lower
• Weaker acids - shallower enamel demineralisation (roughen
with bur)
• Simpler and faster, less sensitivity???
adhesive dentistr y
“The must have adhesive is??????”
16
adhesive dentistr y
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Filled 15% 0.4 Ba glass
8-10um film thickness
Fluoride releasing
Ethanol based (wet/dry)
No multiple coats
Higher viscosity (thicker)
adhesive dentistr y
Problems with “total etch” bonding

Over-etch dentine: denatures collagen, makes them gel
(Gwinnett). 15s only!!!

Over dry: collagen fibrils collapse, monomers (primers)
cannot penetrate.

Too wet

Under priming: place for 15s allow penetration of primer/
resin goes into demineralised dentine and tubules
Aesthetic Dentistry
adhesive dentistr y
Problems with bonding, cont…

Poor isolation – blood, saliva, crevicular fluid

Ineffective curing light

Too large a composite increment

Etch on root surfaces
Aesthetic Dentistry
Self Etch Bonds
Revolutionary
Optibond technology
adhesive dentistr y
OptiBond XTR and ClearFil SE etching efficacy on uncut enamel
OptiBond XTR
SEM images magnified at 50,000X
ClearFil SE
adhesive dentistr y
Op#Bond(XTR(and(ClearFil(SE(Comparison(of(Film(Thickness
~5μm
Op#Bond(XTR((~5(microns)(
~35μm
ClearFil(SE((~35(microns)
SEM images magnified at 2,000X
Isolation & Haemastasis
Isolation
1. Prevent contamination
2. Access
3. Visual enhancement
Full Arch Dam Product List
1.Roeko Flexidam
2.Bite Registration material
3.Punch in 12, 22 positions - slit technique
4.Dry Tip
Haemastatic Agents
• Do not use Ferric sulfate (e.g.Viscostat, astringedent) as can cause
a grey-brown margin with the bonding agents
Viscostat - haemostasis
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Stops bleeding in seconds, saves chair time
•
Care with bonding as may cause staining
microleakage
•
Cannot use with polyether impressions
A viscous 20% ferric sulfate coagulative
haemostatic gel.
Viscostat Clear
(25% Aluminium Chloride)
•
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! Stops minor bleeding in the esthetic zone
! Transparent gel leaves no residue and rinses off with ease
OUTLINE
• Adhesive dentistry and isolation
• Composite restorations
• All-Ceramic types and preparation for bonding
• Cementation - adhesive
COMPOSITE
RESTORATIONS
Advanced Layering of Composites
• Muia (1993)
“ the dentine imparts all of the colour. Enamel like a
fiberoptic structure conducting light through it’s rods”
• Anatomic stratification with successive layers of
dentine, enamel and incisal composite
Optical Properties of Teeth
• DENTINE
• ENAMEL
• MAVERICK COLOURS
Optical Properties of Teeth
• DENTINE:
• basic colour (hue).
• high opacity and saturation
• more saturated with time, deposition of secondary
dentine.
Optical Properties of Teeth
ENAMEL
• high translucency, lack of colour
• may not contribute to colour, but may regulate value.
Clinically three types of enamel:
• young: white colour, thick and less translucent - higher value.
• adult: neutral in colour, not as thick, and intermediate translucecny
• old: yellowish/grayish colour, thinner, higher translucency - lower value.
ENAMEL
• Cervical third: thin (0.3mm) so can observe dentine
shade.
• Middle Third (1.0mm): increased light scattering
• Incisal Third (0.9-1.2mm): infinite characterisations
(varying degrees of translucency and opacities)
Dr Christopher C.K. Ho ©
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Optical Properties of Teeth
• MAVERICK COLOURS:
Characterisation colours located at DEJ or
at enamel surface i.e. craze lines,
hypoplastic areas.
Layering - “Simplified Approach for Ultimate Aesthetics”
• Anatomic stratification with successive layers of:
• Dentine: dentine (opaque) composite,
• Enamel: enamel and incisal composite
• Tints and effects
• Positioning of layers with right thickness and location
• Realistic depth of colour as well as surface and optical
characteristics that mimic nature
SHADE SELECTION
• Enamel shade – A, B, C, D
• Dentine Shade – A, B, mainly A shade is chosen as the artificial dentine shade.
Use of an opaque shade for block out. choose at gingival third where enamel
thinnest.
• Translucent shade – clear, amber, grey, super clear
Dr Christopher C.K. Ho ©
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SHADE SELECTION

Bleaching with peroxides can reduce adhesion strengths on both
enamel and dentine,

Bonding procedures delayed at least 2 weeks after completion of
bleaching to allow shade stabilisation as well as complete leaching
of peroxide remnants from the tooth structures.
1. Spyrides GM, Perdigao J, Pagani C, et al. Effect of whitening agents on dentine bonding. J Esthet Dent 2000;12:264-270.
2. Haywood VB. Achieving, maintaining and recovering successful tooth bleaching. J Esthet Dent 1996;8:31-38.
3. Roulet JF, Soderholm KJ, Longmate J. Effects of treatment and storage conditions on ceramic/composite bond strength. J Dent
Res 1995; 74: 381-387.
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SHADE SELECTION
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Clean teeth
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Colour chromatic map/photograph
Prior to rubber dam or isolation - dehydration
Optimal lighting conditions (Fluoro - green/white, Tungsten - yellow/
orange)
Trial mockup
Composite choice????????
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Sculpts well
Adaptability
Non-sticky, thixotropic
Chameleon effect
Good gloss retention
Use sparingly
Tints
Dr Christopher C.K. Ho ©
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Kerr Kolor + Plus TM
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TINTS (Colour Modifiers)
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Tints have high chroma, can dilute with unfilled resin
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Blue, grey – incisal 1/3 translucency
Yellow and yellow brown – cervical 1/3 and used on proximal surfaces can
create illusion of narrowness, can mask brown tetracycline discolouration
White – increase value, hypocalcifications, craze lines, mask yellow
Red, pink – simulate gingival tones, enhances vitality and can neutralize blue
tetracycline
Opaquers (blocking dark tooth)

By definition – blocks light, changing the optical charateristic.

May give a “flat” and “lifeless” appearance

Keep as deep as possible not to close to surface of composite. Too close
total light reflection and no diffraction or transmission of light

Use sparingly, enough to block out about 50-75% of discolouration and
follow with an opaque composite e.g. A2O (Premise)
Dr Christopher C.K. Ho ©
Class IV Restorations
Class IV Restoration
Class IV Restoration
Challenges
1. Avoiding “show-through” in the fractured space
2. Avoiding a line appearing at the fractured edge
3. Matching hue, chroma, and value of the restored
portion along with errant colors, characterisations,
and translucency in the incisal millimeter.
Invisible Margin
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1 mm 45° bevel, 40 micron bur (red band)
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Lingual chamfer – more bulk (P. Magne study)
Second cut was made to create a feathered edge
with an irregular shape
Plastic surgery principles - line angles, 3 plane
facial surface.
BEVELLING
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Blending of translucent
composite - chameleon effect
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Increased micromechanical
retention.
Diagnostic Waxup
Shade Selection
Moisture control + Putty
Key Matrix
Preparation
Etch and adhesive
Block colour/build dentine
Enhance colour - tints
Enamel buildup
Final cure
Contouring
Polishing
A3 Dentine
A2 Enamel
Yellow tints
Shade Selection
Moisture control + Putty
Key Matrix
Preparation
Etch and adhesive
Block colour/build dentine
Enhance colour - tints
Enamel buildup
Final cure
Contouring
Polishing
Shade
Moisture control
Preparation
Etch and adhesive
Block colour/build dentine
Enhance colour - tints
Enamel buildup
Final cure
Contouring
Polishing
Shade
Moisture control
Preparation
Etch and adhesive
Block colour/build dentine
Enhance colour - tints
Enamel buildup
Final cure
Contouring
Polishing
Shade
Moisture control
Preparation
Etch and adhesive
Block colour/build dentine
Enhance colour - tints
Enamel buildup
Final cure
Contouring
Polishing
Shade
Moisture control
Preparation
Etch and adhesive
Block colour/build dentine
Enhance colour - tints
Enamel buildup
Final cure
Contouring
Polishing
Shade
Moisture control
Preparation
Etch and adhesive
Block colour/build dentine
Enhance colour - tints
Enamel buildup
Final cure
Contouring
Polishing
Shade
Moisture control
Preparation
Etch and adhesive
Block colour/build dentine
Enhance colour - tints
Enamel buildup
Final cure
Contouring
Polishing
Shade
Moisture control
Preparation
Etch and adhesive
Block colour/build dentine
Enhance colour - tints
Enamel buildup
Final cure
Contouring
Polishing
Shade Selection
Moisture control + Putty
Key Matrix
Preparation
Etch and adhesive
Block colour/build dentine
Enhance colour - tints
Enamel buildup
Final cure
Contouring
Polishing
Shade Selection
Moisture control
Preparation
Etch and adhesive
Block colour/build dentine
Enhance colour - tints
Enamel buildup
Final cure
Contouring
Polishing
Shade
Moisture control
Preparation
Etch and adhesive
Block colour/build dentine
Enhance colour - tints
Enamel buildup
Final cure
Contouring
Polishing
A3 Dentine
A2 Enamel
White and Yellow tints
Shade
Moisture control
Preparation
Etch and adhesive
Block colour/build dentine
Enhance colour - tints
Enamel buildup
Final cure
Contouring
Polishing
Shade
Moisture control
Preparation
Etch and adhesive
Block colour/build dentine
Enhance colour - tints
Enamel buildup
Final cure
Contouring
Polishing
Shade
Moisture control
Preparation
Etch and adhesive
Block colour/build dentine
Enhance colour - tints
Enamel buildup
Final cure
Contouring
Polishing
Shade
Moisture control
Preparation
Etch and adhesive
Block colour/build dentine
Enhance colour - tints
Enamel buildup
Final cure
Contouring
Polishing
Shade
Moisture control
Preparation
Etch and adhesive
Block colour/build dentine
Enhance colour - tints
Enamel buildup
Final cure
Contouring
Polishing
Contouring and Polishing/Finishing
Proper finishing can:
•prevent plaque accummulation,
•resist stains,
•improve marginal adaptation and
integerity, longevity and aesthetics.
Finishing and Polishing
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Inherently destructive - formation of micro-cracks at and below
surface.
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Cracks may be exacerbated during mastication and can reduce
the fracture toughness. (Ferracane J et al 1987)
Finishing and Polishing
• Jet Burs – flame, needle shaped
• Fine Diamonds
• Finishing Discs e.g. Optidiscs, Soflex XT
• Finishing strips
• #12 Scalpel
• Silicon carbide brushes
Jet/Kerr burs
Carbide burs:
•12 and 30 fluted
•used dry to visualise
•light pressure to avoid overheating
Jet Bur #7406
Jet Bur #7408
Jet Bur #7214/9214
Jet Bur #7406
Jet Bur #7408
Smile Design
“An artist works not with the hands but with the eyes”
Contouring: Tooth Form
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Basic Shape - oval, square, triangular
Transitional Line angles: determine appearance - 3D appearance
Incisal Edges, embrasures
Basic Tooth Shapes
“Natures Morphology: An atlas of tooth shape and form.” Shigeo Kataoka and Yoshimi Nishimura.
Square
Ovoid
Triangular
Transitional Line Angles
Axial inclination
 Aesthetic
smile has teeth with a slight mesial inclination of
the vertical axis
–(centrals straightest with gradual increase in inclination
posteriorly)
 Posterior
teeth should flow with the inclinations creating
smooth transition from anterior to posterior
Lip line vs. Incisal edge line
 Incisal
edge positions of the
upper teeth should follow the
curvature of the lower lip in a
convex shape
 Older smile – wear with
flattened incisal edge line
99
Which rectangle appears smaller????
The teeth can be made to look
smaller and narrower by
tapering the incisal angles
toward the tooth and the
opening of the embrasure.
Incisal Embrasures
Age
Sex
Finishing Strips - S shape use
• Polishing
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Silicon points e.g Hi Luster points (Kerr Hawe)
Opti 1 step (Kerr Hawe), Enhance cups (Denstply)
Silicon carbide brush: Optishine (Kerr Hawe)
Felt mops and diamond polishing pastes (Enamelize - Cosmedent)
Polishers
Surface roughness and bacterial retention
Threshold)surface)roughness)for)bacterial)reten3on)(Ra=0.2)µm))
)))))))))))))))))))))))))))))))))))))))))))))))))))))))))(Curd)M.L.)Bollen)et)al,)1997)
Creating surface texture - lobes
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Reb band flame diamond
Rubber points
Shofu Ceramiste KN-7 rubber
points
Surface Texture
1.
Vertical ridges
5.
Perikymata
2.
Vertical Grooves
6.
Enamel pits and irregularities
3.
Horizontal ridges
4.
Horizontal grooves
From: Sulikowski and Yoshida. Surface Texure: A systematic
approach for accurate and effective communication. Quintessence
Dent Tech 2003;26:10-20
Optishine (Hawe-Neos)
• Silicon carbide coating
• Gold handle to differentiate
Finishing and Polishing: Summary
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Contouring and Finishing:
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Discs
Burs (multifluted carbides or fine diamonds)
Polishing
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Discs
Hiluster Rubber Points (Kerr Hawe)
Interproximal finishing strips
Silicon Carbide Brush - textured surface
Diamond polishing paste - felt mop, goat hair brush
“The White Line”
Pictures courtesy of Lou Graham
“The White Line”
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Traumatic finishing, coarse burs for finishing
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Solution: Rebonding or remove and composite placement
Overheating margins e.g. rubber points
Adhesive layer too thick
Inadequate polymerisation
Polymerisation shrinkage causing microfracture of unsupported enamel
Repairing voids in composite
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Done prior to final
polishing
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saucer shaped prep
Etch, bond, no LC
Add composite
Blocking Discolouration
Use of dentine composite and
opaque tints
The “Ditch”
Class II composite resin
• Difficulty
• Open contacts/food trap
• Voids/porosity
• Shrinkage/sensitivity
• Open margins
• Larger restorations - indirect treatment of choice (e.g. cusp replacement
or restoration larger than 1/3 B-L width of tooth).
Getting that Tight Contact
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Bitine ring and sectional matrix – burnish margins
Contact Pro 2 with tofflemeire
Optracontact with tofflemeire
Indirect
Problem & Solution
Conventional Matrix
Sectional Matrix System
www.triodent.com
V"Wedge
Wave)Wedge
V3 system
Metafix (KerrHawe)
NEW DEVELOPMENTS
DYAD FLOW
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Self-adhering composite powered by OptiBond®
Class I, PRR, Fissure sealants
Porcelain repair (approx 34MPa)
Undercuts, core buildup refinement,
DYAD FLOW
DYAD FLOW
((((SonicFill™(Kerr)
(Sonic(Ac#vated(BulkDfill(Composite
Segmental Placement – Historical Composites
Materials before
year 2000
> 4% shrinkage
5mm
Press(and(Wipe
Press(and(Wipe
High(Output(LED
(>(1000(mW/cm2)
10(seconds