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By
Hisham Abdelwahab Mostafa
Professor Of Operative Dentistry
Faculty Of Dentistry, Ainshams University
Important Notice
Copy&/or modification of all or part of the
following text is prohibited by law
Contents
- The recent concept in restorative dentistry
- Aspects in which restorative dentistry is modernized
- Recent advances in diagnosis and treatment planning
Computerized Radiography:
Radiovesiography
Wave length dependent fiber optic transillumination
Argon laser fluorescence
Computerized occlusal analysis
Electrical Caries Monitor ECM
Caries detection dyes
New concepts in treatment planning
Prevention, Minimal intervention vs drill and fill, ART,
Ultraconservative preparation, ozone therapy.
- Recent advances in cavity preparation
Recent classification of cavities based on site and size Si/Sta
Use of air abrasion technique
Use of lasers in tooth preparation
Use of ultrasonics in tooth preparation
Stepwise excavation
Chemomechanical caries removal (Caridex&Carisolv)
Management of smear layer(Concept of hybridization)
- Recent advances in restorative materials and adhesives
Gallium based silver alloy
Bonded amalgam restorations (Amalgam bond)
Novel adhesive systems
Packable and flowable composites
Microhybrid non shrinking composites
Glass ionomers, Compomers, Giomers and Smart restoration
Ormocers and Ceromers
Tooth colored inlays:
-Fabricated (direct, indirect)
-Machine ground (CAD/CAM, Celay)
-Ready made inserts
(size matching: sonic-sys, cerana)
(non-size matching: megafil beta quartz inserts)
- Recent advances in manipulation techniques and equipments
Ultrasonic condensation
Incremental packing, c-factor, decoupling technique
2
Guided polymerization:
Soft start polymerization ( stepped, ramped and pulse delay)
High intensity QTH polymerization(Turbo curing), PAC and LED:
Recent technology in Hand pieces and rotary instruments:
3
Recent Concept Of Restorative Dentistry
4
The procedure of recognition of disease and its extent for achieving the
plan of treatment is termed diagnosis. Apart from the traditional methods
for patient examination and diagnosis, the new restorative dentistry is
currently dependent on many recent methods and techniques that not only
help in reaching to a prompt diagnosis for the case but also facilitate the
plan of treatment and helps in explaining it to the patient to participate
positively in the process of decision making to proceed during the steps
for treatment.
Computerized Radiography:
According to many investigators (Richardson,1981 and Jackson,etal,1985),
the digitized radiography proved to be superior than the traditional
radiograph in disclosing the defects affecting the hard tooth tissue,
undoubtedly, caries is of primary concern in this respect.
5
contrast. This would be usefull in particular in detection of incipient
caries at the inter-proximal areas.
Recent technological developments have produced a new generation
of software with computer aided image analysis making it possible to
drive a variety of objective measurements from approximal enamel
radioluscencies corresponding to natural lesions depicted in clinical bite
wing radiographs which were regularly employed for the purpose of
detecting early proximal decay. Moreover, the ability of the digital
radiograph to generate a scale plot of the lesion boundary as well as the
estimate for the depth of penetration of the lesion enables the operator to
accurately estimate the progression of decay and by follow ups, he can
judge the regression or the arrest of the carious procedure (Pitts,1984).
Furthermore, the ability to perform an accurate radiograph while
minimizing the exposure time and omitting the procedure of film
processing adds to the benefits of the technique in addition to the
possibility of repeating the shots and save only of the best quality of them
as a record. The filing system incorporated helps the operator to bring
back the desired image in the touch of a button.
On the other hand, numerous barriers still need to be overcome in
the use of computers in dental radiography mostly in the part of its
software. In many instances, the alteration of an image to remove artifacts
or scratches needs to be documented and can not be relied on as an
evidence in the legal sense (Pickens,1986).
The high cost of the computerized radiograph does not encourage
many of the practitioners. However, some of the equipments are
introduced with a reasonable price so that a transition from traditional to
computerized radiography is currently taking place.( Hess,1986)
Radiovesiography:
The radiovesiograph is a multi-component system advocated by Dr
Francis Mouyen in 1989 ( Mouyen etal,1999). It enables the operator to
capture colored images from the patient mouth via an intra oral camera
and the transfer of this image to the computer to be saved there so that
many options and applications could be carried out by that image. The
image can be zoomed, rotated, cut or edited in the same manner as
pictures captured from the computer scanner. Further manipulation of the
image is possible, it includes enhancement, contrast stretching and
reversing. The appearance of the image on the computer monitor and the
possibility of file reopen enable the operator to share the process of
decision making during planning of treatment of the case, taking in
consideration the possibility of informing the patient about the existing
condition and explaining the steps of treatment to be proceeded. On the
other hand, alarming the patient from the unfavorable consequences that
6
could occur if such treatment is neglected . Again, as digital radiography
could be an adjunct to the same equipment, a sensor for radiography can
be attached instead of the intra-oral camera for radiographic purposes
(Snow, 2002). The sensor can be cold sterilized and for infection control,
disposable latex sheaths are used to cover it when it is in use inside the
mouth.
The newer versions of intra-oral cameras are very light in weight (less
than 50 Grams) and the illumination for image capture is no longer a
fiber-optic which is affected by aging but it became light emitting diodes
which give adequate white illumination to comply with darkness inside
the mouth. The focusing of the camera lens is automatic and the image
could be transferred either to pc or to any other video compatible system.
Some devices include a defogging feature to prevent the effect of intra-
oral humidity from altering the image quality. Moreover, there is a
capability of freezing the images up to four images at the same timing.
7
high intensity light is shone through the tooth and the transilluminated
image of the tooth is captured by the above mentioned intra oral camera,
then it is displayed on the computer screen for diagnosis.
8
patented 60 microns thickness disposable sensor to record instantaneously
the patient bite in terms of location, timing and force of every tooth in
contact. This record is transferred to a computing system which can make
an actual simulation of the patient occlusion on a monitor assuming the
different situations possible during centric, eccentric and functional
movements. Thus, providing both qualitative and quantitative assessment
of occlusion instead of the former messy only qualitative carbon marks
and presenting this in a moving show. The movie can be replayed in
frame by frame manner to study the occlusion. The system was termed T-
Scan and has got many advantages as being simple to operate, dynamic
viewing of occlusion, timed analysis of force during various positions of
teeth contact and the possibility of permanent documentation and
monitoring of the occlusal condition after carrying on the various
treatment protocols. The T-Scan not only presented a valuable method for
clinical evaluation and understanding of the occlusal problems but also it
offered an important tool for teaching purposes as explained by Dr
Maness, the inventor of the system. (Maness,1988).
Dr William Maness
9
Electrical Caries Monitor ECM :
The existing clinical methods for caries diagnosis are unable to
discriminate between lesions with or without a remineralized surface
layer. The idea is that the electrical conductivity of a tooth changes with
demineralization, even when the surface remains macroscopically intact.
A major advantage of the ECM is to present reliable objective reading .
Thus, it becomes suitable for early detection of lesions and to monitor
lesion progression or recession, arrest or remineralization.(Ashley P, 1997).
The ECM measures the electrical resistance of a site on the tooth ; high
measurements indicating well mineralized tissue and low values are
indicative of demineralized tissue. Electrical resistance measurements
have demonstrated accuracy in detecting occlusal caries (Albrektsson etal,
2001)
Ricketts etal .( Ricketts etal, 1995), reported the benefits of utilizing the
ECM in diagnosis of early occlusal and cervical carious lesions. Baysan
etal, (Baysan etal,2000) recently in 2000, showed the definite correlation
between ECM readings and th clinical findings during caries assessment
as texture, hardness, size, cavitation. The researchers concluded that the
ECM is a valuable method to detect incipient lesions. One of the
marketed appliances is the ECM III, Lode diagnostics BV, Groningen,
Netherlands.
10
in a more biological look and summarized the conservative technique in
two man steps, the first was to use the caries detection dye and the second
was stepwise excavation to remove only the infected irreversibly
denaturated dentin and leave the deeper non infected reversibly denatured
remineralizable dentin.
11
portable apparatus includes a source of oxidizing gas and a dental hand
piece for delivering the gas/water to the target tooth. A cup attached to
the hand piece is provided for receiving the gas and exposing a selected
area of the tooth to the gas action. The tightly fitting cup includes a
resilient edge for sealing the margins to prevent escape of the gas. The
procedure should be followed by rinse and suction (Ebensberger etal, 2002)
to eliminate gas residues since some reports indicated that excessive
exposure to ozone may result in complications as eye, lung or
subcutaneous emphysema.
12
Recent classification of cavities based on site and size
Si/Sta:
The traditional Black,s classification which served for identification
and standardization of cavities for many years is currently debated for
inefficiency in specifying the size and extent of the lesion. Mount and
Hume in 1998,( Mount and Hume, 1998.), proposed a new classification that
is based on site and size and was termed Si/Sta classification. It includes
site1 for pits and fissures and enamel defects on the occlusal surfaces of
posterior teeth and smooth surfaces on anterior teeth. Site 2 involves
approximal enamel immediately below the contact areas with adjacent
teeth. Site 3 refers to the cervical one third of the crown or exposed root.
The four sizes are size 1 , which indicates minimal dentin involvement,
size 2 indicates moderate dentin involvement , size 3 designates
involvement beyond moderate and the restoration is designed to support
the remaining tooth, while in size 4, there is an extensive involvement
and bulk loss of the tooth structure and hence, a more radical form of
restoration will be designed.
13
adhesive dentistry and the application of bonded restorations. It is a
precise, gentle, time saving , painless as it reduces thermo-genesis and
omits the vibration of the ordinary rotary tools. It is recommended for
treatment of children, pregnant women and other medically compromised
patients.
14
Special Handpiece for laser application from Kavo
15
Various tips for ultrasonic preparation of the tooth structure
16
Ultrasonic equipment used to attach preparation tips
Stepwise excavation:
The carious process passes by periods of activity in which there is
increased rate of demineralization and proteolysis with resultant tooth
destruction and other periods of rest in which recovery takes place and
there is reparative mechanism causing remineralization by deposition of
sclerotic dentin. In cases of acute caries, the activity of the lesion is
enhanced due to increase of the rate of acid production while in chronic
decay, there is an enhanced reparative mechanism due to decrease of
virulence of the microorganisms, less production of acid and greater tooth
resistance. In many instances, during management of deep carious lesions
by complete one step eradication, the pulp is often approximated and may
be involved by minute undetected or frank exposures. The idea of
stepwise excavation is to perform peripheral dentin excavation first to
change the ecology of the lesion and arrest the spread of decay so that
repair can take place. This should be followed by removal of the central
cariogenic biomass and the superficial necrotic dentin in a separate
session as late as 2-4 months. Doing this, many pulps could be saved
from injury and the removal of the minimum amount of tooth structure as
a part of ART is achieved.( Bjorndal and Larsen, 2000 and Ricketts,2001).
The maximum outcome of the stepwise excavation procedure can be
established in combination with caries detection dyes which are able to
distinguish the infected from the affected dentin such as acid red dye
( fuchsin dye) or the more recent blue dye ( Quadrant CariTest) . Thus,
what is removed would be only the amount of dentin necessary to be
removed. Numerous researches indicated the benefits of stepwise
excavation which includes; reduced risk of pulp exposure, decreased CFU
counts, an alteration of the typical cariogenic microbiota, and an increase
of remineralization and repair evidenced by the formation of hard less
penetrable sclerotic dentin which adds to the quality and protective
capacity of the remaining dentin bridge (Leksell etal,1996,Bjorndal and
Thylstrup, 1998, and Banerjee etal, 2000).
17
Chemomechanical caries removal (Caridex&Carisolv) :
The ART involves the removal of only the infected carious dentin and
remineralization of the reparable only affected dentin. Mchanical removal
of decay using hand excavators or rotary tools would not satisfy the
objectives. The original chemomechanical agent for caries removal was
based on N-Monochloro-DL-2aminobutyrate (NMAB) and is currently
marketed under the name Caridex. (Watson and Kidd, 1986 and Romand-
Roeloffs etal, 1991). The system acts by altering the secondary and /or
quaternary structure of collagen in carious dentin by chlorination of the
collagen. The hydrogen bonding in the collagen is disrupted rendering it
more friable and easier to remove by scrapping the carious fragments
away. Studies have shown that the system is efficient in eradication of
more than 90% of carious dentin in 98% of cases (Albrektsson etal, 2001).
The advantage of the Caridex system is that it provides painless and
efficient removal of carious dentin and thus preferred than conventional
mechanical removal which requires the administration of local
anaesthesia. However, it was reported that it is a time consuming
technique which precluded its universal adaptation.
More recently, a new gel Carisolv was introduced from ( Medi-
Team Incorporation, Gothenburg, Sweden). It is a combination of 0.5%
sodium hypochlorite and 0.1 M amino acids ( glutamine, leucine and
lycine). It comes in the form of two gels, one is transparent, and the other
is red. The two gels are mixed together or brought out from the tube
mixer supplied and applied into the cavity. The carisolv works on the
tooth substance to remove the decay evidenced by a cloudy vapor coming
after action. The application of gel takes 5-8 minutes in an average case
to remove the decay. The procedure is ceased when no cloud comes out
on gel application then, the supplied scrappers are used to eradicate the
softened dentin. The material selectively acts on denaturated collagen,
that is the collagen which has lost its cross striations by the action of the
cariogenic organisms and is considered as being irreparable or not liable
to the process of remineralization. By applying the carisolv, only dentin
decayed beyond repair is removed which matches the objectives of ART.
18
Management of smear layer(Concept of hybridization):
The state of art in the management of smear layer is to totally
remove it using phosphoric acid etching as a part of the total etch
procedure before application of adhesives to both enamel and dentin.
Whether total etch in a separate step or self etching adhesives are
better employed remains a controversial issue. The etching time suitable
for total removal of the smear unit ranges from 10-60 seconds with most
of the recommendations favoring the 30 seconds. This is of quite
importance to assure adequate etching effect on enamel at the same time
.(Nakabayashi and Pashley, 1998)
19
There are two requisites necessary for hybridization to occur. The first
is the preparation of dentin substrate by removal of the smear layer and
the smear plugs provided that no denaturation or deformity or collapse of
collagen occurs. The second requisite is the use of a suitable resin
monomer that can easily impregnate and wet the dentin to infiltrate into
the tubules and encapsulate the collagen fibrils projections. The process
of resin impregnation is critical in the success of hybridization.
( Nakabayashi, 1996 and Nakabayashi and Pashley, 1998).
On the other hand, the presence of a non resin impregnated zone of
dentin i.e. intertubular dentinal collagen non infiltrated with resin is
termed hybridoid layer. The hybridoid presence is thought to adversely
affect the bond, however, later studies have shown that this zone is later
on remineralized( Akimoto etal, 2001).
20
The search for an ideal restorative material is still going on. None of
the available restoratives is free from either biologic, esthetic or
mechanical limitations (Sturdevant ,2002). The evolution of new materials is
very rapid and the competition in the market is too high. I would say that
there is a weekly outcome in the field of restoratives to the dental
profession. Some materials proved superiority while others just survived
for short periods of time. All I can say is that the search is still going on.
21
Bonded amalgam restorations (Amalgam bond):
This is a resin adhesive used with amalgam restoration after etching of
enamel and conditioning of dentin. Its chemical composition is essentially
4 META (Methacryloxy chloride trimellitic dianhydride) . This is
particularly useful in extensive cavities in premolars to decrease
microleakage and to limit the tendency of tooth fracture. The possibility
of bonding a resin composite to the facial aspects of amalgam restoration
makes the system applicable to increase esthetic qualities by covering the
surface of amalgam restoration. Some products are supplied with an
oxyguard to counteract the oxygen inhibition of polymerization at the
margins (Al-Moayad etal, 1993 and Saiku etal, 1993).
22
(Swift etal, 1997). However, to ensure adequate resin impregnation and
hybridization, more than one application was recommended. The research
continued to eliminate the need for acid etching before application of the
dentin bonding agent until a bonding agent with self etching qualities
containing phosphate ester was produced under the name of (Prompt L
Pop, Espe) to constitute a single bottle self etching primer/adhesive
6th. generation bonding system (Perdigao etal, 2000).
The self etching system proved to produce a strong adhesive bond to
both enamel and dentin together with an excellent marginal seal and
possess a very simplified unique 2 steps application which are the
application for 15 seconds followed by gentle spread with air stream. The
simplicity and superior results has urged many clinicians to utilize the
material.(Breschi etal, 1999, Nunes etal, 1999 and Frey, 2000). The self etching
primer adhesive systems were blamed for the incorporation of smear
layer within the hybrid layer if the primer is not agitated during
application and that its highly acidic monomers incorporated to penetrate
smear layer to underlying dentin can cause hypersensitivity and can
interfere with polymerization of auto-polymerizable resins since this high
acidity deactivates the more basic amines incorporated as catalysts in auto
or dual cured resins. Moreover, as the newer generations of adhesives are
becoming more hydrophilic, the adhesive may absorb water from
underlying dentin(dentin perfusion) which can cause an interference with
the overlying composite polymerization (Tay and Pashley, 2003, Ahmad, 2003,
Ozok etal, 2004 and Tay etal, 2003).
23
More recently, in 2002, a 7th generation of adhesives has erupted .
The system is quite similar to the 6th generation but a desensitizing agent
was added to overcome the problem of hypersensitivity (Freedman and
Leinfelder, 2002). An example of this generation is the recently introduced i
bond.. The material is claimed to decrease hypersensitivity in addition to
the similar other properties compared to the 6th generation adhesives.
(Dunn, 2003 and Van Meerbeek etal, 2003).
24
Packable and flowable composites:
The invention of a condensable composite satisfied the operators due
to their excellent handling characteristics. They are non sticky and
moldable and easily released from the hand instruments, thus, less they
are time saving and less frustrating. The material possess advanced
physical and mechanical properties (Suzuk , 2001). However, the marginal
adaptation of such materials suffers from a shortcoming and there is a
possibility of interfacial debonding due to lack of adequate flexibility.
Shrinkage during polymerization can break the established interfacial
bond. The application of a flowable composite prior to the placement of
packable composite will provide a stress breaking effect to prevent this
debonding.(Miranden etal, 1999). The flowable composite usually has low
viscosity due to decrease of its filler content.
25
Microhybrid non shrinking composites:
The search for a universal composite to be suitable for use in both
anterior and posterior regions has emerged a consensus that hybrid
composites which has got high filler loadings up to 90% by weight of
both microfined silica , borosilicate glass and quartz are suitable for use
as anterior and posterior restorations. They possess excellent mechanical
properties due to high filler content, polishable and has got high wear
resistance and adequate translucency to produce the desired esthetics.
Numerous products are available in the market with different shades.
Each manufacturer claims superiority of his product. The incorporation of
non shrinking monopolymer systems has added to the high performance
of the materials by decreasing the resultant shrinkage of polymerization
which is reflected to better bonding and reduced marginal gap formation.
(Davidson, 2001).
26
primary teeth and when its anticariogenic potential is required (Powis etal,
1982 and Thornton eal, 1986).
Due to the cement nature of the material, it suffers from disintegration
in the mouth and susceptible to hydration and /or dehydration. Moreover,
it is a technique sensitive material during manipulation and its properties
are markedly affected with imperfect handling (Teo,1986, Walls etal, 1988
and Knibbs,1988). This has led to the incorporation of resin polymers to the
structure of polyalkenoates to develop the compomers (Antonucci and
Stansbury, 1989 and Mitra,1991).
Compomers possess better handling characteristics, more
translucent, less disintegrable and has got a better marginal adaptation
compared to glass ionomers. Moreover, the pattern of fluoride release has
been found to be equivalent to that of the original glass ionomers.
Furthermore, the possibility of light polymerization adds to the
advantages of the material (Elbadrawi, and McComb, 1998).
Giomers are another addition to the glass ionomer technology by the
incorporation of pre-reacted glass ionomer filler to the powder of the
glass ionomer. This was performed to obtain enhanced mechanical
properties. However, unlike the compomers it was noticed that this
category of glass ionomers significantly release less fluoride compared to
conventional glass ionomers (Yap etal, 2002).
The attempts for combining composite resin and glass ionomer has
led to the development of ion-releasing polyacid modified composite
known as smart restoration (Van Dijken, 2002). The smart restoration
elutes fluoride, calcium and hydroxyl ions when pH value drops in the
oral cavity. Consequently, the material may be able to reduce plaque
formation, remineralize the tooth structure, inhibit caries and neutralize
acids (Heintze, 1999)
27
Ormocers and Ceromers:
The ormocer stands for an organically modified ceramic composite
restoration. The restorative material is considered a new material that
substitutes the organic fraction of resin composites (Bis GMA & UDMA)
with another component which possesses an inorganic component of
modified silicon dioxide in an organic methacrylate group forming a
highly cross-linked matrix. The physical properties of ormocer
restorative is improved, but the marginal approximation is compromised
and can be decreased by utilizing a flowable composite liner better than
one bottle adhesive system.(Manhart etal,2000)
The ceromer is a ceramic optimized polymeric composite restoration
or fiber reinforced ceramic polymeric restoration ( Targis/Vectris) where
ceramic fillers are incorporated to substitute the quartz fillers. They got
an improved wear resistance and excellent esthetic qualities. The material
is available in LC direct restoration or LC followed by heat curing
fabricated inlays which are cured in a special furnace and cemented in
place with an adhesive resin cement supplied in different viscosities. The
material possesses enhanced mechanical properties, excellent esthetics.
Its marginal quality is optimized by utilizing a flowable composite and/or
a resin cement. Undoubtedly, the inlay form can compensate for the
polymerization shrinkage and is able to attain and maintain better
relations with neighboring and opposing teeth (Fahl and Casellini, 1997).
28
physical properties ground to produce the desired inlay. Undoubtedly,
direct, indirect or machinary inlays are able to produce better anatomical
landmarks, occlusal and proximal contact relationships with better
accuracy compared to the direct restorations.(Wassel etal, 1995). Apart from
the material of construction of the inlay, three types of tooth colored
inlays are currently available.; Fabricated inlays, either by direct or
indirect technique, machine ground inlays and Ready made inlays
(inserts). Repeatedly, the inlays are inserted into the corresponding
preparations and luted with adhesive bonding systems and/or flowable
composite or with a dual cure adhesive resin cement The ceramic inlays
should be etched with hydrofluoric acid and sialanated before insertion.
(Craig and Powers, 2002).
Direct inlays can be fabricated from composite resin, ceromers or
ceramic. The prepared inlay cavity is lubricated, the material is packed
incrementally, the increments of composite or ceromer are light cured
until the preparation is filled to the margins. The inlay is removed to
receive secondary polymerization by light, or by light and heat in a
special polymerization apparatus for 8minutes at 110oc.. Alternatively,
the indirect inlays can be constructed in the same way after an accurate
impression of the preparation and the inlay is constructed on a die in the
lab. The ceramic inlays are fabricated similarly as all ceramic full
coverage crown (Lutz, 1996, Burke etal, 1996 and Goracci and Andreasi
Bassi,1999).
29
the restoration is adjusted with manual grinding and finally the inlay is
polished and cemented in place. The main advantage of the system is to
provide the inlay in clinic in one session.(Christensen, 2001). The ceramic
blocks for making the restoration are mainly constructed from feldspathic
porcelain produced by Vita company. However, there is a newer version
for use with Cerec III CAD/CAM (Dicor MCG) which is a glass ceramic
with fluoromica crystals in a glass matrix. It has high wear resistance and
possess more flexural strength. In Cerec III system, the milling machine
is able to construct not only an inlay or onlay with all fine details of
occlusal anatomy, but also can fabricate venners , crowns and full
bridges. Moreover, the milling machine should not be placed aside of the
dental unit but can be stationed away in a separate room and connected
with or without a cable(remote radio control) to the computer unit.
The Celay copy milling technique fabricates the ceramic inlay
after constructing a pattern from composite resin or similar material on a
die. Then, a grinding machine similar to that which duplicates house keys
takes part in producing the restoration from the ceramic ingot. It is
important to note that as long as the ceramic blocks (ingots) do have the
same color, the produced restoration will always suffer from imperfect
esthetics.
30
Ready made inlays (inserts):
This group of inlays come as prefabricated inlays in different sizes.
They are used to restore cavities in posterior teeth, however, the rest of
preparation should be restored with packable and/or flowable composite.
The inserts have the advantage of standardizing the preparation, desirable
mechanical properties, efficient control of the polymerization contraction
and a reduction in time of the procedure.
Sonic Sys approx & sonic sys micro.
These are ready made size matching prefabricated ceramic inserts for
the proximal box cavity supplied in three different sizes produced by
Vivadent company corresponding to the ultrasonic tips of the Sonic sys
produced by Kavo. The inserts fit exactly the prepared proximal box
cavity and restores the proximal contact with the neighboring tooth to
produce the desired embrasures. The occlusal part of the preparation can
be restored with packable and flowable composites if necessary. In case
of small proximal cavities, a smaller size insert is available ( Sonic sys
micro) while he occlusal part of the preparation may be restored with
flowable composite or cavifils which are produced in compules of either
0.25 or 0.50grams. The fitting surface of ceramic inserts is usually
silanated to increase the wettability by the remainder composite
restoration.
Cerana inserts.
The cerana inserts are tapered cylindrical ready made size matching
ceramic pieces of different sizes. After cavity preparation, the proximal
part of class II preparation is drilled with the supplied corresponding
cylindrical diamond point, then, the insert is fitted in place via the plastic
tweezer supplied not to disturb the silanated fitting surface of the insert.
Another insert is selected to fit another preparation at the occlusal surface
and so on , the remaining parts of the occlusal preparation are either fitted
with smaller inserts in between the previously inserted inserts or with
flowable composite. The occlusal anatomy is finally adjusted after
removal of the inserts handles with abrasive stones. Finally, polishing is
performed for the final restoration.
31
Cerana inserts
32
The clinical performance of the final restoration is greatly dependent
on its technique of manipulation, instrumentation and tools utilized,
knowledge of the operator about the recent developments and concepts,
in addition to the employment of the most updated equipments. The
introduction of new materials to the field of restorative dentistry is
usually accompanied by a recent technology in insertion and
manipulation in an attempt to optimize the clinical utilization and the
functional performance of the restorations.
Ultrasonic condensation:
The ultrasonic condensation of amalgam restoration has increased the
hazards of mercury vapor in clinics since the procedure entails a process
of thermo-genesis ( Haley, 2003). On the other hand, ultrasonic packing of
conventional or condensable composites was found to increase its flow
and adaptation to cavity walls and margins, in addition to enhancement of
polymerization due to thermo-genesis encountered (Mohsen MMA and
Gilbert L, 1991). Various forms and sizes of ultrasonic tips are currently
available for ultrasonic condensation of composites. They are routinely
supplied with the newer forms of ultrasonic equipments.
33
the restoration., hence, it is advisable to separate between walls during
polymerization as much as possible ( Peutzfeldt and Asmussen, 2002). Some
authors recommend the use of a gingival auto-polymerizing increment in
class II cavities to separate the initial increment from the body during
polymerization, decoupling technique was advocated by Wilson etal in
2000, but it was debated for creating a new interface which may decrease
the outcome of mechanical properties of the restoration.
Guided polymerization:
In photo-activated composite, unlike the chemical, shrinkage vectors
travel towards the light source . This is explained on basis of the high
intensity of light at the surface which causes a rapid start of
polymerization that pulls the rest of the polymerizing chains towards the
site of initial polymerization.(Victor and Lyjan, 1994 and Yoshikawa etal, 2001).
Manufacturers have introduced various shapes of curing tips to be utilized
to guide the polymerization contraction, while in the critical gingival
margin, the use of a light reflection wedge will be helpful to concentrate
the light on the gingival area of the restoration to achieve such guidance
effect.( Lutz etal, 1986 and Victor and Lyjan, 1994). The technique was termed
three sited polymerization where curing is performed for buccal, lingual
and gingival to effect concentration of light at the proximal cavity.
( Pereira etal, 2002). Guiding polymerization by the three sited technique
proved an improvement in the adaptation of class II cavities when
compared with the conventional curing. However, Loesche in 1999
attributed the improvement in case of three sited polymerization to the
reduction of light intensity rather than to guided polymerization
34
Soft start polymerization:
Slowing down the initial intensity of polymerization by soft start
polymerization at a lower intensity 180 mw/cm2 for 10 seconds followed
by full intensity polymerization at 800 mw/cm2 will cause a slow down in
the conversion of double bonds of the resin monomer. Two steps of
polymerization are carried out by this technique (stepped
polymerization). Another method to apply the soft start polymerization
is the ramped curing in which the irradiance is gradually increased from
a low value to maximum intensity over a 10 seconds period after which it
remains constant for the duration of exposure. The third method to apply
soft start is the pulse delay in which there is an application of 10 seconds
conventional curing followed by an interruption of curing for one or two
minutes before completion with the same light intensity. Slowing down
the initial polymerization results in a decreased pull at the margins of the
restoration. The full intensity polymerization follows to complete the
conversion to the maximum to attain the desired mechanical properties.
Goracci and Casa de Martiniz,1993, explained the effect of reducing the
intensity of light source to slow down the speed of conversion and to
prevent the rapid increase of viscosity ( Trommsdorff effect ) which is
likely to occur by massive emission of light intensity. Thus, it is possible
by utilizing low intensity initial polymerization to obtain a slow and
gradual conversion at the beginning which facilitates flow of the resin
composite.
Pulse delay controls the process of polymerization for sake of
decreasing the contraction and improving the adaptation, yet, attaining
adequate mechanical properties for the restoration. The given time
probably allows for securing the established bond while the material is
adequately flowy. This will prevent the forceful pull of the material from
the bonded margins prematurely ( Yap etal, 2002). Moreover, the pulse
delay polymerization may be in favor of attaining high mechanical
properties by more cross linking of the pendant chains occurring as a
result of the presence of a ceased polymerization period ( Ruggeberg etal,
1999 and Sahafi etal, 2001).
35
Elipar trilight curing apparatus for soft start polymerization
36
1196mw/cm2 , that is almost double that of conventional QTH appliances
giving about 600mw/cm2.
37
products that may not polymerize with LED appliances. Some companies
shifted the emission spectrum of their LED appliances to suit a variety of
photo-initiators by combining two different diodes with a wide range of
spectral emission to allow the curing of all the materials(second
generation LED appliances).
The advantages of LED devices are; the less power necessary to
operate the unit because of their unfiltered narrow emission spectrum.
Consequently, they may be powered with rechargeable batteries, making
them available in light weight, cordless units. The diodes have a potential
lifetime of several thousand hours instead of the range of a hundred with
halogen systems. Ninety nine percent of the original energy of emitted
from QTH lamps is a useless energy that must be filtered out. Noisy fans
are required to help eliminate this unwanted heat, but, the LED devices
have very little wasted energy and require minimum cooling.(Leonard etal,
2002 and Soh etal, 2003)
38
Modern models of high and conventional speeds hand pieces are
fabricated with a more advanced technology. The body is constructed
from titanium alloy which prevents rust and provide light weight and
stability and to withstand repeated autoclaving. An anti-retraction
technology is also supplied to prevent regurgitation of fluids for infection
control purposes. Moreover, the fiber-optic illumination supplied comes
out from a compacted glass nozzle which does not hinder the passage of
light by repeated autoclaving. Ceramic ball bearings are also incorporated
to prevent wear and damage of the internal rotating parts by the extensive
use or repeated sterilization. The air/water spray coolant is designed in a
triple way burst for effective control of the generated heat and clearance.
Maintenance of the hand pieces is also given great attention since the
performance of the hand piece affects the quality of work. It is becoming
very simple to just fitting the hand piece in its place in the Assisstina
machine to be effectively cleaned and then lubricated with the specified
cleaner and lubricant.
39
The most recent outcome is the Neulite technology introduced by
Bien Air in which a single fiber-optic module can be plugged with either
a rotary high speed or conventional contra-angle hand piece, meanwhile,
the same module can be plugged with a high efficiency light curing tip to
be utilized for polymerization of various resin restoratives.
40
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