Sealants, Preventive Resins and Posterior Composites

Department of Pediatric Dentistry University of Isfahan medical sciences 2009

Sealants
Indications
Recently erupted teeth Tooth can be isolated No, or only minimal pit and fissure staining No, or only minimal catches in the grooves No evidence of radiographic caries

Sealants
Material in Y/O Clinic
Ultraseal XT plus Manufacturer: Ultradent Advantages
High strength Filled resin sealant (approximately 60% ) Low shrinkage Clinically and radiographically opaque Fluoride releasing May be used for sealants and microrestorative (PRRs)

Sealants
Technique Prior to etching the tooth:
Isolate tooth (i.e. rubber dam, dry-angle, cotton roll) Pumice tooth with nonfluoridated pumice Wash and dry. Drag grooves with explorer to remove any remaining pumice. If necessary, wash, dry, and re-isolate.

Sealants
Etching: - 35% PA
Deliver to the tooth using the blue tip, or using a microbrush Etch the grooves and cuspal inclines Etch for 15 seconds Wash for 10 seconds Evaluate frosted enamel

Sealants
Apply PrimaDry for 5 seconds using the brush tip or microtip brush.
99% ethyl alcohol Acts as a drying agent and increases bond strength

Gently dry

Sealant
Apply sealant using the spiral brush tip, or using a microbrush. Sealant should flow into grooves and up cuspal inclines. Cure for 20 seconds

Sealant
Evaluate quality of sealant:
Marginal integrity? Pits or voids in sealant? Overhangs? Heavy occlusion?

Sealants
Areas of concern
Retention rates on buccal pits and grooves of mandibular molars and distolinqual grooves of maxillary molars Sealants need periodic maintenance
Moisture contamination secondary to incomplete eruption and difficulty in isolation - predicted 30% failure rate within 5 years in these areas. Marginal integrity and wear.

Preventive Resins Restorations

Indications
Tooth can be isolated. No, or only minimal pit and fissure staining Minimal catches in the grooves, or areas with distinct incipient enamel caries. No evidence of radiographic caries.

Preventive Resin Restorations

Type A
Caries is incipient and limited to enamel No radiographic caries
Many clinical situations can not be classified according to type until the operator has completed the required exploratory preparation

Type B
Caries extends minimally into dentin and is small and confined No radiographic findings

PRR A vs. PRR B

Type A

Type B

Preventive Resin
Isolate tooth (i.e. rubber dam, dry-angle, cotton roll) Pumice tooth with nonfluoridated pumice Wash and dry. Drag grooves with explorer to remove any remaining pumice. If necessary, wash, dry, and re-isolate.

Preventive Resin
Remove decalcified pits and fissures with a slow speed 1/4 or 1/2, or with a HS330FG Examine all margins for remaining caries. If caries remains, consider anesthetizing and placing conventional restoration; otherwise proceed in the following manner:

Preventive Resin A
Etch surface with 35% PA for 15 seconds Wash for 10 seconds and dry For lesions which are completely within enamel, restore in the same manner as described for sealants.

Air dry Place sealant Cure for 20 seconds Adjust occlusion if necessary

Preventive Resin B
If caries extends to dentin: Anesthesia? Etch for 15 seconds with 35% PA Rinse for 10 seconds and dry.

Preventive Resin B
Apply drying agent to pulpal floor of the prep for 5 seconds, then dry Apply thin layer of Ultraseal XT plus to base and along enamel walls Cure for 15 seconds
Depending upon the extent of dentin involvement, DBAs should be considered!

Preventive Resin B
Apply drying agent to gingival portion of the prep for 5 seconds, then dry Apply thin layer of Ultaseal XT plus to base and along enamel walls Cure for 15 seconds Place composite into prep, and cure

Preventive Resin B
Apply drying agent to gingival portion of the prep for 5 seconds, then dry Apply thin layer of Ultaseal XT plus to base and along enamel walls Cure for 15 seconds Place composite into prep, and cure Examine margins for integrity

Preventive Resin B
Apply drying agent to gingival portion of the prep for 5 seconds, then dry Apply thin layer of Ultaseal XT plus to base and along enamel walls Cure for 15 seconds Place composite into prep, and cure Examine margins for integrity Re-etch, seal, cure and adjust occlusion if necessary

Posterior Composite
Indications
Non-stress bearing area of the tooth - occlusal contacts in natural enamel High esthetic demand by the patient Conservative restoration in nature
Buccal linqual width not greater than 1/3 of occlusal table All margins must be free of caries/decalcification Rounded internal line angles

Posterior Composites
Materials
System must have compatable components Etch DBA Flowable composite (liner) Composite Sealant

Posterior Composites
Select teeth appropriately

Small confined lesions chasing grooves Decalcified grooves Minimal radiographic involvement Outline can avoid heavy occlusal contact

Posterior Composites
Anesthetize and isolate Open pits and fissures with 330HS Remove remaining caries with slow speed or spoon excavator Examine for clean margins

Posterior Composites
Utilize total etch technique In cases of deep caries, it may be beneficial to place a glass ionomer liner Etch for 20 seconds and rinse. Dry, but DO NOT desicate the dentin

Posterior Composites
Remoisten dentin slightly with a damp microbrush Place dentin bonding agent according to manufacturer instructions (critical step) on dentin and enamel . Cure
In this example, Prime and Bond NT , a onestep system, is being used

Posterior Composites
Place flowable composite on pulpal floor
Acts as a stress breaker during curing Minimizes shrinkage and gap formation

Cure

Posterior Composites
Place composite incrementally, beginning with eventual cuspal areas. Cure between increments minimizes overall shrinkage and gap formation

Posterior Composites
Adjust occlusion if required Finish composite in the usual manner with high speed finishing burs and polishing points

Posterior Composites

During the finishing process, some gaps at the margin will occur. These need to be sealed. Etch occlusal surface for 20 seconds with 35% PA. Rinse, and dry

Posterior Composites
During the finishing process, some gaps at the margin will occur. These need to be sealed. Etch occlusal surface for 20 seconds with 35% PA. Rinse, and air dry Apply unfilled resin sealant such as Fortify Cure Check marginal integrity Occlusal adjustment should not be necessary

Summary
All techniques are critically dependent upon adequate isolation. If you cant keep it dry, or keep it dry long enough, it wont work. Check for poor margins, overhangs, pits and voids - particulary on DLGs and buccal grooves. Failure to adhere to guidelines may result in a poor/failing restoration or post-op sensitivity for the patient

Summary
There is often no clear cut line between the different preventive resin restorations, and PRRs vs. a conventional posterior composite. When in doubt, be more aggressive. DBA systems and composites must compliment each other. With some brands of flowable composite, you need to use a DBA first