Faculty of medicine, Dpt of restorative dentistry, ass.prof. L. Roubalikova1 Restorative dentistry III. Reconstruction of posterior teeth using adhesive materials CLASS I. All pit and fissure restorations . R. on occlusal surface of premolars and molars R. in foramina coeca – usually on occlusal two thirds of the facial and lingual surfaces of molars and on palatal surface of maxillary incisors ▪ Infractions of marginal ridge ▪ Corrosion ▪ Bad aesthetics Amalgam - disadvantages ▪ Easier to place ▪ Good mechanical properties esp. ▪ Price Amalgam - advantages Indications ̶ Moderate to large restorations ̶ If there is heavy occlusal loading (alternative onlay) ̶ Oral hygiene is not optimal (alternative dense glassionomer as middle term temporary) ̶ When ihe proper isolation is not possible ̶ Price Contraindications ̶ Aesthetically prominent areas of posterior teeth ̶ Small - moderate classes I. that can be well isolated Amalgam ? Pertinent material qualities and propeties Strength Longevity Ease of use Clinically proven sucess BUT! GIC only? ̶ Primary dentition ̶ Resin modifies GIC preferable 8 Composite - benefits ̶ Non metallic materiál ̶ Adhesion – no gap ̶ Less amount of hard dental tissues that is necessary to remove ̶ Good resistency of the treated tooth ̶ Aesthetics 9 ▪ Good isolation is necessary ▪ Technique sensitive treatment ▪ Price Composite - disadvantages Indications ̶ Aesthetically prominent areas of posterior teeth ̶ Small - moderate classes I. that can be well isolated ̶ Good level of oral hygiene is necessary Contraindications ̶ Moderate to large restorations ̶ Restorations that have heavy occlusal contacts ̶ Restorations that cannot be well isolated ̶ Restorations that extend onto the root surface ̶ Abutment teeth for removable partial dentures Composite and cavosurface margin ̶ Outline includes the caries lesion only ̶ The fissures that go to the caries lesion should be opened Retention principles ̶ Prepare the box or deep dish – the bottom is in dentin ̶ Do not prepare any undercuts! ̶ Do not bevel enamel, finish the border with the fine diamond bur only. Pre –gel Gel point Post -gel Polymerization shrinkage and polymerization stress Postoperative sensitivity ditching marginal discoloration gap cracks Versluis 2000 Secondary caries Risks – high C-factor Adhesives ̶ Acid etching technique ̶ Selfetching adhesive systems Marginal adaptation depends on the ̶ mode of the placement of composite material ̶ dry operating field ̶ adhesive systems Flowables - importance 1. Excellent marginal adaptation 2. Protection of the adhesive 3. Elastic layer ? 1 2 3 Placement of the material Adhesives ̶ Acid etching technique Etching Washing Priming Bonding Adhesives ̶ Selfetching adhesive systems Priming Bonding Adhesives ̶ Active and passive bonding Active – rubbing with microbrush - selfetching Passive – without any rubbing – acid etching Adhesive preparation in a fissure Pit and fissure sealing indications ̶ Teeth soon after eruption with deep fisures ̶ Disabled patients ̶ Adults - hyposalivation Definujte zápatí – název prezentace nebo pracoviště30 Pit and fissure sealing - cointraindications ̶ Shallow fissures, good oral hygiene DMF = 0 ̶ High caries risk (DMF high) – risk of proximal caries ̶ Proximal caries, occlusal caries (ICDS – 3 and more) Definujte zápatí – název prezentace nebo pracoviště31 Adhesive preparation Preparation of enamel borders The beveling dependens on the orientation of enamel rods Preparation 45° Next to cusp 50-60°, Preventive filling - indications ̶ Primary molars ̶ Premolars ̶ Permanent molars (D3 and more) Definujte zápatí – název prezentace nebo pracoviště35 Preventive filling - contraindications ̶ High caries risk, DMF ˃ 5 ̶ Large dental caries (more than 1/3 intercuspidal distance, underminig chronic caries ̶ Proximal surfaces must be intact or max D1 ̶ Proximal cavitated lesions Definujte zápatí – název prezentace nebo pracoviště36 37 Preventive filling – GIC + composite Preventive composite filling Preventive glassionomer filling Sealant filling The composite material is built cusp by cusp Isolated cavities Preparation of fissural complex CLASS II. Proximal caries in posterior teeth Direct restorations - Amalgam - Composite - Glassionomer - Indirect restorations –inlays, onlays Composite Ceramics Metal alloy40 Indications: Amalgam ̶ Moderate to large restorations ̶ If there is heavy occlusal loading (alternative onlay) ̶ Oral hygiene is not optimal (alternative dense glassionomer as middle term temporary) ̶ When ihe proper isolation is not possible ̶ Price Contraindications: Amalgam ̶ Aesthetically prominent areas of posterior teeth ̶ Small - moderate classes I. that can be well isolated Indications: Composite ̶ Aesthetically prominent areas of posterior teeth ̶ Small - moderate classes I. that can be well isolated ̶ Good level of oral hygiene is necessary Contraindications: Composite ̶ Moderate to large restorations ̶ Restorations that have heavy occlusal contacts ̶ Restorations that cannot be well isolated ̶ Restorations that extend onto the root surface (subgingival – margin relocation or lenghtening of the crown is necessary) ̶ Abutment teeth for removable partial dentures Composite - possibilities ̶ Conventional cavity (oclusal and proximal cavity) ̶ Adhesive slot ̶ Tunnel preparation ̶ Cusp replacement – direct, indirect. Definujte zápatí – název prezentace nebo pracoviště45 Interproximal borders Yes No Composite Amalgam Preparation 30 - 40° ? Cervical borders In enamel No bevel Cervical borders In dentin Preparation technique Oscillating instruments Class II. and contact point Importance of the correct restoration of the contact point: ̶ Prevention of retention in the proximal space ̶ Prevention of secondary caries ̶ Prevention of irritation of interdental papilla and resorption of alveolar bone ̶ Prevention of changes in position of the teth Class II. and contact point ̶ Matrix band + matrix retainer - Metal band (in primary teeth) Without matrix retainer Plastic band (polyester – e.g. Lucifix matrix) Sectional matrices with separator Contact point Contact area Matrix band and matrix retainer Sectional matrices ̶ Sectional matrices with separator Good adaptation Separation using wedge and separator 55 Sectional pre-contoured metal matrix system provided the highest contact tightness with the highest length of contact arc. Restorations with circumferential precontoured metal matrix system provided higher LCA than those with circumferential straight metal matrix with Tofflemire retainer and circumferential pre-contoured transparent matrix system“ Kampouropoulos D, Paximada C, Loukidis M, Kakaboura A. The influence of matrix type on the proximal contact in class II resin composite restorations. Oper Dent 2010; 35; 454-462 56 Use of the sectional matrix system in twosurface Class II cavities resulted in statistically significantly tighter proximal contacts than the use of the circumferential matrix system. For the three-surface no statistically significant differences in contact tightness were found between the different matrix systems.“ Wirsching E, LoomansB A, Klaiber B, Dörfer C E. Influence of matrix systems on proximal contact tightness of 2-and 3-surface posterior composite restorations in vivo. J Dent 2011; 39: 386–390 58 Step 1: Pre - wedging The wedge is inserted before preparation: Compression of gingiva Separation of teeth Together with the matrix protection of damage of neighbouring tooth Matrix for the filling can be inserted easier. 59 Step 2: preparation ̶ Preparation with the protection of neighbouring tooth using the metal strip or matrix. Definujte zápatí – název prezentace nebo pracoviště60 Step 3: adaptation of wedge, matrix and separator ̶ The wedge can be new or the same as previous, inserted from oral or vestibular side ̶ The matrix is 0,5 mm below the gingival wall ̶ Separator separates teeth Definujte zápatí – název prezentace nebo pracoviště61 Step 4 Making filling Definujte zápatí – název prezentace nebo pracoviště62 Custom ring technique 63 Historically, there were already similar techniques that can be confused with the “custom rings” technique, in 1981 form the book “textbook of Operative dentistry” by Baum/Phillips and Lund called “the non yielding matrix”, this technique had the objective of creating a super hard support for the matrix with acrylic in order to achieve extra contention for the amalgam condensation. Custom ring technique ̶ The group Styleitaliano developed the Custom Rings technique taking advantage of the simpliest materials regarding wedges, rings and matrices in order to be able to personalize the ring embrasures to adapt the matrices in an anatomical and personalized way. Definujte zápatí – název prezentace nebo pracoviště64 Custom ring technique ̶ The technique consists then on taking an impression with a photo-curing material (any light curing gingival material, block-out resin or flow composite) of the proximal embrasures of the teeth to restore and integrate them into the ring in order to be able to shutter perfectly wedge, matrices with a ring that will seal perfectly taking into advantage the anatomy of the healthy structures. Definujte zápatí – název prezentace nebo pracoviště65 Custom ring technique indication ̶ Larger cavities with axial wall exceeding the proximal surface Definujte zápatí – název prezentace nebo pracoviště66 Liquid dam is placed into the proximal space, cured 67 Sandblasted ring is placed and portion of liquid dam added, cured Definujte zápatí – název prezentace nebo pracoviště68 Customized ring Definujte zápatí – název prezentace nebo pracoviště69 Matrix with wedge and customized ring Definujte zápatí – název prezentace nebo pracoviště70 Kompozitní výplň II. třídy Kompozitní výplň II. třídy Kompozitní výplň II. třídy Sedelmayer Adhesive slot Vertical Horizontal Miniinvasive class II. cavities Adhesive slot Adhesive slot Approximal Caries Approximal Caries Tunnel preparation Open Closed Success? Low caries risk Special smal instruments Magnification BW post op Composite or GIC