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Tips for successful posterior resin composite restorations

dentin, which is infected by bacteria and easily stained with caries detecting dye solution, is removed, the cavity floor dentin is not sensitive, even if it is very close to the pulp. Once the intact dentin is exposed in the cavity, it must be very sensitive because the dentinal tubules are open and transfer the stimuli to the pulp. Because of the development of material Bonding with perfect sealing of the tubules is science and cariology, it became very easy to essential for decreasing sensitivity. Furthermore, obtain successful results with posterior cutting of sound dentin may cause pulpal restorations using adhesive resin composites. inflammation or hyperemia. In most cases, The successful results include esthetics, long these pulpal changes recover with time, lasting function, and of course, no however, some cases requiring post operative sensitivity of the endodontic treatment may occur Bonding with tooth. At the same time, the because of irreversible pulpal procedures and manipulation of the perfect sealing changes. materials should be simple and The procedure of this of the tubules easy to reduce the operators technique established by Dr. is essential for technique sensitivity. Fusayama [New Concepts in Operative Dentistry, Quintessence 1. Cavity preparation decreasing Publishing, 1980] is as follows; 1. Cavity preparation for the sensitivity. opening the cavity with high speed adhesive restoration is extremely cutting (Figures 1&2), 2. excavation simple and easy. The most of the outer carious dentin according to the significant reason for the post operative guide of caries detector and natural discoloration sensitivity is over-cutting of dentin during the using slow speed steel burr or hand instruments cavity preparation. When the outer carious (figures 3-5), 3. repeating the staining of the lesion and its removal until staining becomes light pink or less (figure 6). In addition, the wetness of the cutting debris and the sensitivity of the tooth are very valuable information for diagnosing the amount Figure 1 Before treatment Figure 3 Discoloration is seen of dentin to be removed. Then the bonding and filling materials are applied without lining materials even when the cavity is
Dr. Junji Tagami Chairman and Professor Department of Cariology & Operative Dentistry Tokyo Medical & Dental University 5-45 Yushima 1 Chome Bunkyo-ku Tokyo 113-8549 Japan tagami.ope@tmd.ac.jp

very deep (Figure 7&8). When the outer carious lesion is removed according to the guide of staining with caries detector and natural discoloration, patients dont feel severe pain during the caries excavation (Figure 9). Clinical evaluation of the VAS (Visual Analogue Scale) value of the pain during the treatment of caries revealed that the younger patients tended to feel stronger pain than older patients. However, the pain was much less than the pain during a shot of local anesthesia [Terano et al., JDR 79 abst.#1162, 2000]. Though various methods for diagnosing dentin caries removal have been proposed, this technique is the most practical for achieving minimum invasive caries treatment. After removal of the outer carious dentin, the cavity floor consists of the so called inner carious dentin, which is also named as caries affected dentin. It is clearly shown that the caries affected dentin is not permeable (Figures 10-13). It means that the cavity floor dentin is not sensitive. The SEM picture exhibits the occluded dentinal tubules with mineral deposits even after the phosphoric acid etching (Figure 14). Thats why the lining is not necessary when this technique is applied. The lining is recommended when the intact dentin was cut or when the patients felt significant pain during the cavity preparation. When this minimal invasive technique for caries removal and cavity preparation is used, post operative tooth sensitivity seldom occurs. Even when the cavities are left as it is without any filling, the tooth is not sensitive because the cavity floor dentin consists of the caries affected

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Figure 2 Cavity is opened with high speed diamond point

Figure 4 Caries detector is applied

dentin with the occluded tubules.

2. Selection of the adhesive resin High quality adhesive provides good sealing and reinforcement of the tooth substance and filling material. Adhesive resin which exhibits strong bonding, low technique sensitivity and durable bond to both enamel and dentin should be selected. Figure 9 VAS value of pain during the caries Figure 12 Occlusal view after preparing the SE Bond is very well known as extremely removal and cavity preparation LA: VAS flat surface. Lesion with the discoloration is value during the shot of local anesthesia excellent adhesive resin for both enamel and removed according to the clinical procedures. dentin. SE Bond consists of two steps, which is selfetching primer application Figure 10 Extracted molar with cavitated lesion and bonding resin Figure 5 Lesion to be removed is clearly Figure 7 Bonding procedure is applied Figure 13 After the etching, the red dye indicated solution infiltrated from the pulp. The dye application. was seen only at the area of the intact It does not dentin, indicating the cavity floor dentin is not sensitive. require the wet bonding technique Especially in the since the water rinsing cases of posterior Figure 11 The occlusal surface was ground is not and the root was also removed. The crown restorations, the wet segment was bonded to a plastic plate and necessary. connected to a syringe to be able to apply a bonding technique is Wet bonding Figure 6 Removal of the outer lesion, and Figure 8 After filling and polishing pressure from pulpal side. The pulp the prepared cavity chamber was filled with a red dye solution. technique is very difficult to apply, well known because as a resin. However, the configuration of Though various technique sensitive bonding high consistency resin posterior cavities is procedure, since both the over-wet methods for composites may have and over-dry condition result in very complicated. diagnosing disadvantages such as decrease of the bond. Especially in the difficulty of dentin caries the cases of posterior restorations, spreading, especially in obtaining good removal have the wet bonding technique is very a very small and adaptation between difficult to apply, because been proposed, complicated cavity, incremental layers. The at configuration of posterior cavities is this technique is and poor adaptation to Figure 14dentindentinal tubuleswiththe caries affected were occluded mineral Even the very complicated. deposits even after the phosphoric acid both cavity walls and the most consistency is very thin Operator technique sensitivity etching. the incremental before polymerization, practical for with SE Bond is much lower than interface. flexural strength, Vickers with the all-in-one type adhesive, achieving When the cavity wall hardness, and tooth brush wear resistance of which consists of only the selfminimum adaptation and voids in Class I resin Clearfil AP-X are very high. This is mainly etching adhesive. Because of the composite restorations were invasive caries because of the high filler content of 85.5 weight extremely simplified bonding investigated, it was revealed that % (Figure 15). Barium glass is used as the filler treatment. procedure of the all-in-one type thick-consistency composite had particles and this glass is relatively soft adhesives, both performance of more problems related compared to silica filler bonding and technique sensitivity are generally to voids and wall adaptation than particles. Because of sacrificed. the medium and thin consistency this relatively soft filler, composites [Opdam et al., Dental 3. Selection of the resin composite polishing of this resin is Materials 12:230-235, 1996]. Clearfil AP-X, which is a heavy filled semi very easy. Thus, Clearfil AP-X, which can hybrid type resin composite, was developed for be classified as a mediumboth anterior and posterior restorations. 4. Long term clinical consistency resin composite, can The consistency of Clearfil AP-X must be performance be said to be very easy to fill into felt relatively thin compared to most posterior In most of the Figure 15 SEM of the AP-X, showing the cavities of posterior teeth and to resin composites. However, Clearfil AP-X is not papers reporting the heavily filled with various sizes of fillers. obtain excellent wall adaptation sticky to the instruments. This unique property longevity of posterior was achieved by an original technology, named without voids. This property is also resin restorations, the advantageous when the incremental filling interfacial boundary control between filler wear of the composite resin was not a technique is applied to deep cavity restorations, significant reason for the replacement of that particle and matrix resin. It is very easily

recognized when you compare with any of the composite resins which are used in your clinic. This is one of the most unique characteristics of Clearfil AP-X. Stickiness of the resin pastes to filling instruments is reduced by increasing the consistency of the paste in the resin materials so called packable or condensable

incomplete removal of water from the hybrid Miyazaki et al. [American layer and insufficient penJournal of Dentistry 13:101-104, etration of the resinous 2000] also reported the larger variamaterial into the collagen tion in bond strength of an adhesive layer are considered to be with total etching and wet bonding main causes of the degratechnique than a self etching adhedation of the hybrid layer. sives (Figure 4). In the case of the As the result, the quality Figure 4 Dentin bond strengths(MPa) of wet bonding technique, both over adhesives with a self-etching primer and of the hybrid layer should wet and over dry conditions result in phosphoric acid, obtained by the well be inferior in the case of the decrease of the bond. experienced operators, untrained clinicians total etching technique attended a continuing education program, and A new type of bonding materithe dental students. and/or wet bonding techal, an all-in-one type adhesive, connique. sists of a real one-step bonding proThere might be a cedure. The self-etching adhesive is concern if it is safe to applied and cured. The adhesive has leave the acidic primer on to include some amount of water to the tooth surface, since be acidic, and it has to be polymerwater rinsing is not ized with dissolved smear layer. applied after the applicaAlthough the bonding procedure is tion of the self etching simplified, the technique sensitivity primer. Fortunately, a Figure 5 Long term dentin bond strengths and bonding performance seem to (MPa) of a conventional adhesive with acidic Concept of SE Bond seven-year clinical evaluabe sacrificed. In fact, these all-in-one conditioner and adhesive, and a product with The technology of self etching primers was tion of an adhesive using adhesive resins demonstrated lower the self-etching primer. developed by Kuraray Medical Inc. This was the self-etching primer, bonding than adhesives with a twoachieved by the development of the so called adhe- step self-etching primer [Nakaoki et Clearfil Liner Bond 2, sive resin monomers, named MDP or Phenyl-P revealed excellent results al., 79th IADR, Abst.#1815, 2001]. (Fig. 1). The adhesive resin monomers includes the Another recent study revealed that without any de-bonding, acidic part, that is phosphate. Because of this nor pulpal response SE Bond showed the most stable acidic part, the primer solution containing the [Akimoto et al., Japanese and strong bond when compared MDP becomes acidic, and can etch the enamel Journal of Conservative with an adhesive with phosphoric and dentin surface. Dentistry 2001]. Enamel acid etching (Single The wet bonding and dentin are very strong Bond) and an adhetechnique is required only buffers against the acid. sive of all in one syswhen the acid is applied After application of the tem (Touch & Bond) Figure 6 Phosphoric acid etching provided and rinsed with water. In primer for 20 seconds, the [Nikaido et al.,31st the typical etching pattern of the the case of the bonding acidity of the primer must longitudinally cut enamel prisms AADR, 2003]. Even procedures using the self be decreased dramatically. when students withetching primer, the uncerThe excess of the primer out the experience of tain method of wet bondsolution is also removed using adhesive resins ing technique is not by air blasting. If it is prepared the specideveloped required since the collagen Figure 1 Adhesive resin monomers Phenyl-P, harmful to the dentin/pulp mens, the best by Kuraray Medical Inc., MDP and fibers are already incorpocomplex, the excellent which include the phosphate bases. Because results were obtained of the acidic part, they are named to be acidic rated with the resin clinical performance withwith SE Bond. Also, monomer, which enables to reduce the pH of monomers in the primer out post operative sensitivSE Bond exhibited the primer solution. Figure 7 Self-etching primer of SE Bond solution. The bonding proity cannot be obtained. less technique sensiprovided relatively weak etching effect cedure of Clearfil SE Bond The dissolved and tivity than the other compared to phosphoric acid. (Figure 2) is, application of softened smear layer can bonding materials. self etching primer for 20 be blown away from the The only probseconds, drying the sursurface when the excess lem with this adheface with air blast removsive system is the consistency of the of the primer is removed. Also, the primer is ing the excess primer soluknown to show some antibacterial effect. Even if self etching primer, which is very tions from the surface, some bacteria and smear layer remained, excellent thin. The primer flows very easily application of the bonding down the cavity walls, however, this clinical performance and durable bonding prove Figure 2 Clearfil SE Bond consists of one resin, and light curing. problem is easily solved by applying that it would not be a problem. bottle self-etching primer and one bottle light With this extremely simple cured adhesive the primer 2 or 3 times during the Enamel bonding bonding procedure, very application time [Ogata et al., Another concern may be the bonding to strong bonding to both Operative Dentistry 24:81-88, enamel, since the acidity of the self etching primer enamel and dentin, as 1999]. is considered to be much lower than that of phoswell as to various dental phoric acid. Actually, etching effect of the self-etchLong term bond durability materials can be obtained ing primer is much less than that of the phosphoric The bonding durability of the (Figure. 3) [Harada et al., acid etchant (Figure 6, 7). However, a recent study adhesive with a self etching primer Dentistry in Japan 36: 47revealed that SE Bond showed more stable bonding has been reported to be superior 53, 2000]. SE Bond is than the adhesive with total etching to both cross-cut enamel prisms and longitudinallyused in the clinic for not technique even after 6 years (Figure cut enamel prisms than the adhesive with phosonly restorative procedures 5) [Burrow et al., Adhesive Dentistry phoric acid etching (Figure 8) (Shimada et al., but also intraoral repairs Figure 3 Bond strengths (MPa) of the SE Operative Dentistry, 28:20-27, 2003). The phos19:254, 2002]. It is because of the of fractured restorations, Bond to enamel, dentin, metal, and porcelain. phoric acid etching may be too strong to etch the very stable hybrid layer formation, Alloy Primer (Kuraray Medical) and Activator secondary caries and (Kuraray Medical) were used for the bonding longitudinally cut prisms, which resulted in the septhough it is very thin. Effects of so on.

restoration. The main cause of failure for composite restoration is usually secondary caries around the restorations. To increase the longevity of the restorations, the refurbishing of the restorations is believed to be very effective [Mjor, Adhesive Dentistry 19:236, 2002]. The survival rate of the composite restoration in posterior teeth was reported to be higher than that of cast restoration [Kubo et al., Japan J Conserv Dent.44:802-809, 2001]. The calculation was based on the results of 19 years clinical assessment. This result is enough to assure the propriety of the Fusayamas technique. The recent materials can be expected to exhibit much better results than the reported survival rate at 19 years, approximately 80 %, because of the improvements of the materials.

Technique sensitivity

What is Clearfil SE Bond?

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aration of enamel prisms just beneath the bonding Opdam et al. (American Journal of Dentistry interface (Figure 9, 10). In the clinical situation, the 11:229-234, 1998) evaluated the post operative cavity walls consist of mostly longitudinally cut sensitivity with class I restorations. Post operative enamel prisms. As shown in the Figures 7, sensitivity was the SEM of the enamel after the self-etching observed with 25% primer application does not look great, howof the cases reever, we etch the tooth for the bonding, but stored with the adnot for the SEM. hesive using phosUnfortunately, the uncut enamel surphoric acid etching, face is much more acid resistant than whereas none of ground enamel, and the self-etching primer the cases restored is not strong enough for strong bonding using a self etching (Kanemura et al., American Journal of primer, Clearfil Figure 8 Enamel bond strengths (MPa) of SE Dentistry, 27:523-530, 1999). In the cases Liner Bond 2. Bond and Single Bond to horizontal and axial sectioned surfaces with the longitudinally cut of the bonding of fissure sealant and direct The desensienamel prisms, and to tangentially sectioned composite veneer without cutting the tizing effect of the surface with cross-cut prisms. enamel surface, phosphoric acid etching is adhesive resin recommended. monomers is considered to conPost operative tribute to decrease In fact these sensitivity the post operative According to a tooth sensitivity. all-in-one adhesive clinical evaluation of The desensitizresins demonpost-operative tooth ing effect of sensitivity after resin adhesive primer strated lower composite restoraapplication to bonding than tions, teeth restored Figure 9 Laser scanning microscopic image of hypersensitive with the materials uti- the bonding interface between enamel and adhesives with teeth was conSingle Bond showing the crack propagation lizing self-etching firmed in clinical along the prisms under the interface. two-step selfprimer showed the studies (Tagami etching primer. less post-operative et al., Dental sensitivity than bondMaterials Journal ing materials using 6:201-208, 1987, phosphoric acid etching (Figure 11, Suda et al., Dental Unemori et al., Journal of Dentistry, 29:7Materials Journal 13,2001). It is considered that adhesive 9: 163-166, materials with self-etching primer have the 1990). The mechaadvantage of better bonding performance nism of the desenFigure 10 Laser scanning microscopic image of and less technique sensitivity in the bondsitizing effect was the bonding interface between enamel and SE ing procedure compared to those materials Bond showing the tight bonding without crack postulated due to propagation. with phosphoric acid etching. the coagulation of

dentinal fluid or precipitation of protein in dentinal fluid, such as globulin and albumin, resulting in a reduction in dentin permeability (Tagami et al., Arch oral Biol 39 suppl: 146S, 1994). Self etching primer is expected to show the desensitizing effect since the self etching primer shows the coagulation of protein. Based on our work, SE Bond is believed to have the best advantage in preventing post operative sensitivity, as compared with the adhesives using phosphoric acid. After the phosphoric acid etching, Figure 11 Incidence (%) of post-operative tooth the primer sensitivity after composite resin restorations self-etching primer, application using the adhesives withwith light cured phosphoric acid etching has a pos- adhesives, or chemical cured adhesives. sibility of decreasing the sensitivity; however, the etching increases dentin permeability by enlarging tubule diameters. SE Bond, which does not require any strong acidic treatment, and is not technique sensitive as compared to the wet bonding technique, provides a successful restoration. s

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