Please activate JavaScript!
Please install Adobe Flash Player, click here for download
ePaper created 2018-03-23, 14:41:46 | version 1.38.0
Labwork As described in Case No. 1, the assistant im- mediately poured the impressions in the lab with MACH-SLO (Parkell) after disinfecting them and basing them with a rigid, fast-set- ting bite registration material such as Blu- Mousse (Parkell) (Fig. 17). Within two min- utes, we had a working silicone model on which to build the onlay (Fig. 18). The under- cuts were then blocked out with an electric waxer (Ultra Water, Kerr Lab), paying special attention to avoid the margins (Fig. 19). Starting with the Premise Indirect (Kerr Den- tal) dentinal shades (A2 primary dentin and A1 facial dentin) and ending with incisal shades (Neutral incisal), the onlay was incre- mentally fabricated in layers using various composite instruments. The onlay was then placed in the BelleGlass curing oven for heat, pressure and light curing. In approximately 10 minutes, the onlay was ready to be finished with multiple finishing burs (Fig. 20) on the silicone models. The on- lay was polished for a high shine and then checked on the model to verify accurate inter- proximal contacts and margins (Fig. 21). Seatingtheonlay When seating the onlay, the Isolite was re- applied for isolation, ease of placement and the patient’s comfort during the cemen- tation stage. Before cementation, Expasyl (Kerr Dental) was gently packed into the sul- cus, creating a dry space between the tooth and tissue without any risk of rupturing the epithelial attachment (Fig. 22). The aluminum chloride in the Expasyl dried the tissue, re- ducing the risk of sulcal seepage and contam- ination. The FenderMate was then inserted beneath the interproximal floor to slightly separate and isolate the adjacent teeth and to help fa- cilitate seating the onlay (Fig. 23). The Ex- pasyl (Kerr Dental) was rinsed off thorough- ly and the FenderMate was adapted to the ad- jacent interproximal surface with a condens- er (Fig. 24). Once all of this was properly placed, the enamel and composite core were first micro- etched to remove any debris and increase me- chanical retention of the surface of the com- posite flowable liner. Then the surface was further prepared for bonding with 37 percent phosphoric acid for 15–20 seconds. A single-component, fifth-generation adhe- sive (OptiBond Solo Plus Unidose, Kerr Den- tal) was applied in two coats and air-thinned until there was no more movement. No cur- ing was done at this time. Flowable compos- ite (Premise Flowable, Kerr Dental) in the lightest shade was then dispensed into the prepped tooth before inserting the onlay into the tooth. Before curing, the FenderMate was removed and the onlay was further seated using a con- denser with gentle pressure. Complete seat- ing was facilitated using the contra-angle packer/condenser. An explorer was helpful in removing excess flowable before curing. Floss was applied between the involved in- terproximal surfaces before curing and left in place to remove excess interproximal cement and facilitate the cement removal step after curing. The restoration was cured from all angles, starting at the interproximal gingival floors where leakage is most likely to occur. Occlu- sal flash and excess flowable composite was “buffed” with a short flame carbide while the interproximal margins were adjusted with bullet or needle carbides. A Bard Parker #12 scalpel and Qwik Strip (Axis) were used to re- move interproximal cement and then the re- maining floss was used to floss out any re- maining cement and to ensure proper at- home flossing. Once the ideal occlusion was established, dia- mond-impregnated points and/or cups were used to polish the restoration, starting with the coarsest grit first and finishing with the finest grit for a smooth finish while a PDQ composite polishing brush (Axis Dental) with composite polishing paste (Enamelize, Cos- medent) made for a final high shine. Conclusion There are certainly clear advantages for both the patient and the dentist when doing indirect com- posite resin restorations. These restorations have helped us save patients’ teeth, time and mon- ey. Over the last 20 years, we have tweaked, up- dated and modified these restorations in terms of techniques, materials and equipment. These restorations not only save time and conserve healthy tooth structure, they are a valuable ser- vice to provide to our patients; and they appre- ciate it. Direct composites are an essential part of our ar- mamentarium. Nevertheless, indirect compos- ite restorations have many advantages, especial- ly when dealing with multiple restorations in- volving adjacent interproximal surfaces. There is simply no comparison between the strength of these materials made outside of the mouth with those cured in the mouth. Moreover, it is much easier to build, control, pol- ish and finish the occlusal, interproximal and fa- cial/lingual morphology in the laboratory. Pa- tients appreciate the numerous benefits of both direct and indirect composites, and they espe- cially appreciate not having to be in cumber- some temporaries or having an inconvenient second appointment. Perhaps the greatest advantage for the patient is being able to conserve the maximum amount of healthy structure while saving time and money — all at the same time. “The trend in dentistry today is clearly toward more esthetic and less in- vasive. Indirect resin and ceramic inlays and on- MEDIA CME Self-Instruction Program How to earn CME Credits? Contact CAPP: events@cappmea.com; +971 43616174 gently packed into the sulcus (Fig. 8). The alu- minum chloride dried the tissue, reducing the risk of sulcal seepage and contamination. The FenderWedges were then inserted beneath the interproximal floor to slightly separate and isolate the adjacent teeth and to help fa- cilitate seating the onlay. After rinsing the Expasyl (Kerr Dental) thor- oughly, the enamel and composite core were gently micro-etched with aluminum oxide (EtchMaster, Groman Dental) to increase re- tention and remove any debris. Then the enamel and composite core were etched for 15–30 seconds. A single component, fifth- generation adhesive (OptiBond Solo Plus Unidose, Kerr Dental) was applied in two coats and air-thinned until there was no more movement. The enamel should be glossy (Fig. 9). Flowable composite (Premise Flowable, Kerr Dental) was dispensed into the prepped tooth and then the inlay was inserted into the tooth. The FenderWedges were removed and the on- lay was further seated using the Titaniu- coat- ed #21 Acorn with gentle pressure. Complete seating was facilitated using the contra-angle packer/condenser while an explorer was help- ful in removing excess flowable before cur- ing. When dealing with onlays involving in- terproximal surfaces, it is a good idea to floss after seating the onlay and before curing. The restoration was cured from all angles, start- ing at the interproximal gingival floors where leakage is most likely to occur. Occlusal flash and excess flowable composite were then “buffed” with a short flame carbide while the interproximal margins were adjust- ed with bullet or needle carbides. Sometimes a Bard Parker #12 scalpel and Qwik Strip (Axis) are used to allow for easier removal of interproximal cement. Once the proper occlusion was established, a diamond-impregnated point and/or cup was used to polish the restoration. Polishing was further enhanced through the addition of pol- ishing paste. In just one appointment, an esthetic and con- servative interproximal onlay replacing a me- siobuccal cusp was prepped, placed and pol- ished (Figs. 10, 11). CaseNo.2 This patient also came in with a dental emer- gency. The filling had fallen out of his bro- ken, lower right molar the day before he was going overseas for three weeks on business. He wanted a “quick and permanent solution” (Fig. 12). First the tooth was anesthetized. Next, a FenderWedge was used to isolate the in- volved tooth, protect the adjacent inter- proximal surface and pre-wedge the teeth for optimal contacts (Fig. 13). The Iso- lite was placed to obtain a dry and illumi- nated field. We used caries detector to en- sure complete decay removal (Fig. 14). The tooth was then microetched, etched and de- sensitized with HemaSeal and Cide (Advan- tage Dental Products). Two layers of self- etching bonding agent (OptiBond All-In-One Unidose, Kerr Dental) were applied to pro- vide reduced postoperative sensitivity and high dentin bond strength. This was then air- thinned and light-cured. Flowable composite (Premise Flowable, Kerr Dental) was added to the internal walls and floor, creating an even floor and filling in un- dercuts that were originally prepared for car- ies removal and amalgam retention (Fig. 15). After the tooth was insulated, the prep was refined with a flat-end cylinder, fine-grit, short shank diamond. Two Identic hydrocolloid impressions (Dux Dental) were then taken as before. These im- pressions were handed to the assistant to be poured in the lab (Fig. 16). During the time between the onlay prep and seat, a small fill- ing was done on another tooth to make the most of this appointment time slot while the onlay was being fabricated in the lab. Dr. Lorin Berland, a fellow of the AACD, pioneered the den- tal spa concept in his multi-clinician practice in the Dal- las Arts District. His unique approach to dentistry has been featured on televi- sion (‘20/20’) and in national publications and major dental journals, including Time magazine. In 2008, he was honored by the AACD for his contributions to the art and science of cosmetic dentistry. For more in- formation on The Lorin Library Smile Style Guide, www.denturewearers.com and the Biomimetic Same Day Inlay/Onlay 8 AGD Credits CD/ROM, call (214) 999-0110 or visit www.berlanddentalarts.com. Dr. Sarah Kong graduated from Bay- lor College of Den- tistry where she has served on the facul- ty in the department of restorative den- tistry. She was voted a Texas Super Den- tist and Texas Best General Dentist for general dentistry by her peers. Kong is part of a unique multispecial- ty private practice group in Dallas, www. berlanddentalarts.com, where she focuses on preventive, cosmetic, restorative and pe- diatric care as well as oral appliance thera- py for TMJ, snoring and sleep apnea. Kong is an active member in numerous professional organizations, such as the American Acade- my of Cosmetic Dentistry, American Dental Association, Academy of General Dentistry, Texas Dental Association and Dallas Coun- ty Dental Society, where she has served on the membership committee and the peer-re- view board. Contact Information Fig. 20 Expasyl prior to seat. Fig. 21 Expasyl and FenderMate prior to seating. Fig. 22 Adapting FenderMate. Fig. 23 Seating onlay. Fig. 24 Final onlay. Fig. 14 Caries detector. Fig. 15 Prep with liner. Fig. 16 Identic Hydrocolloid impression. Fig. 17 Basing the poured impression. Fig. 18 Silicone model. Fig. 19 Mod- el with undercuts waxed. Fig. 14 Fig. 15 Fig. 16 Fig. 17 Fig. 18 Fig. 19 Fig. 24Fig. 23Fig. 22Fig. 21Fig. 20 lays are not only compatible with this trend, but fulfill very nicely the restorative void between fillings and crowns,” said Ronald D. Jackson, DDS, FAGD, FAACD (Cosmetic Tribune, Vol. 1, Nov. 4, Dec. 2008). Regarding durability, esthetic inlays and onlays are not new anymore. They have a record of ac- complishment, and it is good. Wherever you practice, and however you practice, these res- torations are durable, esthetic, economical and very much appreciated! 7MEDIA CMEDENTAL TRIBUNE Middle East & Africa Edition | Jan-Feb 2013