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Dental Tribune Middle East & Africa Edition | May-June 2015 11restorative Your practice is our inspiration.™ Herculite® XRV Ultra™ Kerr, making history again < Page 10 After discussing the alternatives, the patient opted for an indirect ceramic inlay. At the treatment visit, after anaesthetizing the area, the old composites were removed and the tooth prepared to remove recurrent caries and staining at the old margins (Fig. 5). A digital impression was taken of the preparation (Fig. 6) and opposing arch using an E4D digital scanner, the proposed inlay form examined (Fig. 7), and the scans transferred to the laboratory where the ce- ramic inlay was fabricated us- ing CAD/CAM. At the patient’s seating appointment, the fit of the inlay was assessed. In this case, I selected OptiBond XTR (Kerr) 2-bottle self-etch uni- versal adhesive with separate etch/primer and bonding agent, which is suitable for direct com- posite and all types of indirect restorations. I chose this adhe- sive system for 2 main reasons. Due to its unique chemistry, the high bond strength obtained with this adhesive is as high as that obtained with a traditional total-etch adhesive, and it offers high shear bond strength with both enamel and dentin. The OptiBond XTR adhesive system primer etches enamel and den- tin, and its hydrophilic nature lets it better penetrate the dentin to help provide increased bond- ing to dentin. OptiBond XTR also has a thin film thickness, allow- ing for proper seating of the final restoration. A distinct consideration in choosing OptiBond XTR, par- ticularly since the preparation was large and deep, was the lack of post-operative sensitivity found with this adhesive. Post- operative sensitivity is a rela- tively frequent occurrence fol- lowing restoration placement, and some studies have found this more likely to occur with a total-etch adhesive than with a self-etch adhesive,1 although this may be due to overdrying of the dentin and its desiccation leading to transient sensitivity. Self-etch adhesives inherently leave less room for sensitivity to occur. OptiBond XTR has a mild pH of around 4 (versus a pH of around 2 for phosphoric acid etchants); it does not remove the smear layer or open dentinal tu- bules, instead preventing tubule exposure while still allowing for hybridization. OptiBond XTR contains proprietary chemistry that helps to prevent sensitivity, and its hydrophilicity ensures that the primer and adhesive can penetrate well into the den- tin and seal off the surface of the dentin, helping to prevent sen- sitivity. Before placement of the ceramic inlay (LAVA Ultimate), it was first air-abraded at 15 psi and ultrasonically cleaned. It was then put aside while the preparation was treated. The primer was applied to the enamel and dentin for 20 sec- onds with a gentle scrubbing motion then air-dried for 5 sec- onds to remove the solvent. Next, the bonding agent was applied (Fig. 8), agitating the brush gently over the enamel and dentin surface for 15 sec- onds. The adhesive was then gently air-dried (Fig. 9) and light-cured for 10 seconds. The bonding agent was then applied to the intaglio surface of the indi- rect ceramic inlay (Fig. 10) and gently air-dried for 5 seconds and light-cured for 10 seconds. NX3 Nexus (Kerr) resin-based cement was then applied to the intaglio surface, the inlay care- fully seated, and excess cement removed before light-curing all surfaces for 20 seconds each. NX3 Nexus resin-based cement is fully compatible with Opti- Bond XTR, making it a superior choice compared to other resin- based cements. The interproxi- mal areas were checked for any residual cement, and the occlu- sion was checked before the pa- tient left. The result was an aes- thetic, durable restoration with excellent marginal integrity, excellent bond strength, and a satisfied patient (Fig. 11). Summary Our current adhesive system op- tions are total-etch and self-etch variants. Without a patent and durable bond with high bond strength, restoration failure will occur with the breakdown of the bond even if all other aspects of therestorationaresound.Select- ing a clinically proven adhesive ensures that you are choosing a material capable of perform- ing under real-life conditions. Fig. 8. Application of the bonding agent to enamel and dentin after primer had been used. Fig. 9. Moderately air-drying the bonding agent. Fig. 10. Applying bonding agent to the inlay’s intaglio surface. Fig. 11 Final restoration seated and cemented. Dr.WalterG.Renne,DMD,USA Dr. Walter runs the CAD/CAM clinic at MUSC in addition to treat- ing patients in faculty practice where Dr. Renne maintains an active general dentistry practice utilizing both the CEREC AC and E4Dsystems. About the Author The adhesives used in the cases presented offer reliable, durable high-strength bonds, marginal integrity, easy clean-up, and ease of use. Reference 1. Blanchard P, Wong Y, Mat- thews A, et al. Restoration vari- ables and postoperative hyper- sensitivity in Class I restorations: PEARL Network Findings. Part 2. Compend Contin Educ Dent. 2013;34(4):E62-8.v