"The New Materials and the New Restorative Dentistry-Opportunities and Challenges” PRODUCT TRENDS 2015 Caries Diagnostic

"The New Materials and the New THE MAJOR CURRENT TRENDS PRODUCT TRENDS 2015 Restorative Dentistry-Opportunities OF TECHNOLOGY CHANGE NON-IONIZING DIAGNOSTICS MINIMALLY INVASIVE DENTISTRY (MID)/EARLY and Challenges” DIAGNOSTICS/EARLY TREATMENT REMINERALIZATION & REMINERALIZING MATERIALS BULK FIL RESTORATIVES Steven R. Jefferies, MS, DDS, PhD MORE STABLE ADHESIVE STRATEGIES THE LATEST EMERGINGCLASS OF ADHESIVES - UNIVERSAL Professor ADVANCES IN LASERS ADHESIVES Department of Restorative Dentistry BIOMIMETIC, BIOACTIVE MATERIALS NON-RADIOGRAPHIC DIAGNOSTICS Maurice H. Kornberg School of Dentistry REGENERATIVEPULP THERAPY & ENDODONTICS LASERS – SMALLER, LOWER COST, MORE “REAL” USES Temple University NEW RESIN CEMENTFORMULATIONS TISSUE ENGINEERING, ADVANCED IMPLANT SURFACES BIOACTIVE RESTORATIVES & LUTING AGENTS LEHIGH VALLEY HEALTH NETWORK ANTIMICROBIAL, MORE DURABLE COMPOSITES CONTINUING EDUCATION PROGRAM CAD/CAM GENERATED-FABRICATED RESTORATIONS ALLENTOWN,PENNSYLVANIA TECHNOLOGY FOR MINIMALLY INVASIVE DENTISTRY HIGH-STRENGTH ALL-CERAMICS OCTOBER 7, 2015 (MID) REPAIR & MAINTAINANCE OF EXISTING RESTORATIONS STRONGER ALL CERAMIC MATERIALS

DRIVERS/OBTACLES FOR INCIPIENT/EARLY ENAMEL MINIMALLY INVASIVE DENTISTRY DEMINERALIZATION TECHNOLOGY ADOPTION (MID) Early Interproximal Improved Performance More complex Lesions Smooth Surface Improved Efficacy Demineralization (Ortho High cost “White Spot Lesions”) Reduced treatment EARLY DIAGNOSTICS - EARLY Increased procedure time time TREATMENT Reduced procedure Limited/Poor Training cost “Too New” Less invasive Lack of efficacy data REMINERALZATION TECHNOLOGY New information forces Lack of effectiveness data change Limited or no clinical data Reasonable payback INFILTRATION TECHNOLOGY on investment

New Diagnostic Technologies in What’s new in caries diagnosis & Caries Diagnostic Caries Management & Treatment treatment? Technologies/Techniques Early diagnostics VisualVisual Transmission of organisms Radiographic ––ComputerComputer Assisted Caries Risk Assessment Interpretation --LogiconLogicon Caries Diagnostics Risk Assessment DiagnoDent Virulence factors Prevention SoproLifeSoproLife & Spectra (Caries NEW DIAGNOSIS DEVICES Detection/IntraDetection/Intra--OralCameraOral Camera)) Early Intervention - Remineralization Populations in need/access to care Conventional Translumination Patient Monitoring Individualized treatment planning DexisDexis CariVuCariVu REMINERALIZATION TECHNOLOGY The Canary System Intraoral Microscopy (Microscope)

1 Useful diagnostic? Laser-Induced Fluorescence of QLF contrast enhancement Carious Tissue

Sensitivity (false negatives?) Kutsch, in 1992, illuminated carious and non-carious tissue Specificity (false positives?) together with an argon laser together with dark field ReliabilityReliability photography.

 IntraIntra--examinerexaminer He reported that while illuminating, carious lesions in teeth  InterInter--examinerexaminer had a clinical appearance of dark, fiery, orange-red color.

Will discuss hard tissue fluorescence further in the section of new caries diagnostic devices. white light QLF

Caries Diagnostic Principle of operation Translumination & An Idea? Technologies/Techniques VisualVisual Contrast enhancement follows from Radiographic ––ComputerComputer Assisted scattering properties of tooth tissue Interpretation --LogiconLogicon enamel dentin DiagnoDent SoproLifeSoproLife & Spectra (Caries Detection/IntraDetection/Intra--OralCameraOral Camera)) Why not combine a Conventional Translumination quality transluminator early lesion DexisDexis CariVuCariVu with a high-resolution The Canary System intra-oral camera? Intraoral Microscopy (Microscope)

A NEW APPROACH IN CARIES DISCLOSING DYE AN UNMET CHALLENGE IN Operating Microscope GC Tri Plaque ID Gel CARIES DIAGNOSIS Advantages of the operating microscope WEDO NOT YET HAVE A are:are: DIAGNOSTIC METHOD OF homogeneous DEVICE THAT WITH illumination; ACCURACY OR PRECISION aa33--dimensionaldimensional view, INDICATION THE SIZE AND DEPTH OF THE CARIOUS togethertogether provide clear LESIONS.LESIONS. visualization of the examination sitesite..

2 ADVANCES IN THE FINAL CHALLENGE REMINERALIZATION FOR Caries Therapies

WE DO NOT YET EARLY CARIOUS LESIONS:LESIONS: HAVE A DIAGNOSTIC THE EMERGING QUEST IN TEST OR DEVICE •• EarlyEarly ––remineralizationremineralization techniquestechniques WHICH WILL TELL ORAL HEALTH •• LateLate ––restorativerestorative techniques US IF THE CARIOUS •• MidMid ––combinationcombination of above LESION IS “ACTIVE” NewNew Remineralization Technology OR “INACTIVE”!!! Treatment of Incipient Carious LesionsLesions Integration with Minimally Invasive Dentistry (MID)(MID)

The Oral Equilibrium Between Demineralization/Demineralization/RemineralizaRemineraliza FLUORIDE THERAPY New Calcium--Based,Based,Calcium tiontion Remineralization AgentsAgents Oral Microbes + Fermentable Carbohydrates Plaque Acids AMORPHOUS CALCIUM PHOSPHATE (ACP)

Remineralization Demineralization CASEIN PHOSPHOPEPTIDE (RECALDENT)

TRITRI--CALCIUMCALCIUM PHOSPHATE (TCP) Salivary Components: Calcium, Phosphate, pH Buffers, Fluoride PARTICULATE BIOGLASS (NOVAMIN)

RecaldentRecaldent®® Amorphous Calcium Phosphate ACPACP •• Recent developments by RecaldentRecaldent have made it possible to bring calcium and phosphate in an amorphous form to the mouth. •• A reaction product of dicalciumdicalcium phosphatephosphate AMORPHOUS Calcium Phosphate •• •• By means of caseinphosphopeptide, phosphopeptide, a complex is andandtetracalcium phosphate, developed by •• NO Structure created with the amorphous calcium phosphate and Ming S. Tung at the American Dental the resulting CPP--ACPCPP ACP molecule binds to biofilmsbiofilms,, Research Association’s Paffenbarger •• ACP is created through chemical reaction plaque, bacteria,hydroxyapatite and surrounding Research Center. soft tissue, thus localizing the bio--availablebio available calcium •• TCP is a crystal put into rosin medium and phosphate. •• The calcium and phosphate remain in a •• ACP dissolves into saliva and is delivered •• RecaldentRecaldentis available in a MI Paste and MI Paste relatively “amorphous” or “non“non--crystalline”crystalline” Plus (contains fluoride) from GC Dental. state, increasing their bioavailability. directly to teeth (4X and 2X) •• Numerous claims:remineralization, remineralization, desensitization, caries inhibition (MI Plus ––hashas Fluoride).

3 RecaldentRecaldent What isWhatis NovaMinNovaMin?? SO IS THERE CLEARLY A SUPERIOR PRODUCT FOR REMINERALIZATION AA phosphopeptide is a peptide NovaMin is the brand name of a particulate bioactive •• glass that is used in dental care products for incorporating one or more phosphate Remineralisation of teeth. It was developed and •• NOT CLEAR AT THIS TIME. groups, typically associated with protein patented by NovaMin Technology, Inc.. •• FLUORIDE IS STILL THE MAJOR phosphorylationphosphorylation.. COMPONENT ––BOTHBOTH IN RESISTENCE TO In aqueous solutions, •• Caseins are a special group of phosphophospho-- NovaMin consists of 45% DEMINERALIZATION & PROMOTION OF peptides found usually in milk and milk SiO2, 24.5% Na2O, 24.5% CaO and 6% P2O5. REMINERALIZATION. products.products. The active ingredient is called Calcium Sodium •• ALL CONTAIN THE MAXIMUM AMOUNT OF •• May enhance stability and transport of Phosphosilicate[1] calcium viacalciumvia phosphophospho--peptidepeptide group FLUORIDE (i.e. VARNISH ––5%).5%). NovaMin delivers an ionic interactions form of calcium, phosphorus, •• ONLY RCT CLINICAL DATA CAN SOLVE silica, and sodium which are necessary for bone and tooth THE ISSUETHEISSUE ––VERYVERY EXPENSIVE!!! mineralization.

New Approaches to the Management & Treatment of Assessment & Therapy Dental Caries •• New diagnostic technologies are emerging in dentistry & EXPLORING NEW will provide a wider range of treatment options. TECHNOLOGIES FOR: •• Legal, insurance, and standards of care will MINIMALLY INVASIVE DENTISTRY influence this trend. “MID”“MID” •• Treatment protocols and decisions will also be influenced.influenced. Steven R. Jefferies, MS, DDS, PhD •• THANK YOU!!

Clinical Uses ––DentalDental Lasers Dental Lasers Light Amplification by Stimulated Emission of Radiation “LASER”“LASER” Diode Laser Diode Laser  Caries Diagnosis -630nm-980 nm wavelength Uses  Cutting Soft Tissue -Laser vibrates tip molecules, -Gingevectomy Two Basic Laser Categories in Medicine/Dentistry -Gingivoplasty  Cutting Hard Tissue which are converted to heat -Crown preparation troughing 1) HARD LASERS  Wound healing  Longer wavelengths  Tooth whitening  Cuts by ablation of tissue  Used for tooth and bone applications  Removal of Porcelain Veneers ((Er:YAGEr:YAG))  Periodontal Therapy ((PerioLasePerioLase)) 2) SOFT OR LOW ENERGY LASERS  Endodontic Cleaning & Debridement (PIPS)  Low energy wavelengths  Cuts tissue by coagulation, vaporization, and carbonization

4 Dental Lasers Clinical Uses ––DiodeDiode Laser Other “MID” or Tooth Preparation Diode Laser Technology Advantages -Affinity for pigments in tissues hemoglobin bacteria -Little contraction and scarring -Little postoperative gingival recession -Compact size -Affordable -Reduced chance of tissue/tooth damage

Disadvantages -unable to cut bone or tooth (can be an advantage) -Cost - Slower cutting than electrosurgical

ADVANCES IN MATERIALS & Icon™ Resin Infiltration RESTORATIVE PROCEDURES SystemSystem

•Incipient caries indication still needs further clinical CAD/CAM & HIGH STRENGTH CERAMICS documentation & lacks AN OVERVIEW OF CAD-CAM reimbursement codes. ADVANCES IN COMPOSITE RESIN DIRECT DENTAL TECHNOLOGY •Fluoride Gel/Varnish RESTORATIVES interproximal application LAVA COS are alternative treatments. NEW MATERIAL CATEGORY ––BIOACTIVEBIOACTIVE Itero •Esthetic treatment of MATERIALS CEREC white spot lesions has E4D attracted more attention, especially in the US.

THE FABULOUS FOUR OF THE EVOLUTION OF SYSTEM OPERATING FACTORS DENTAL CAD-CAM CHAIRSIDE CAD-CAM - CEREC  First restorations placed in 1985  OPTICAL VS. LASER SCANNER  2D to 3D images  Separation of the imaging and milling units.  POWDER VS. NO POWDER

 STILL IMAGES VS. VIDEO IMAGES

5 EVIDENCE-BASED, LONG- TERM CLINICAL OUTCOMES

CEREC 1, 1a, & 2 CAD/CAM RESTORATIONS

CERAC 1 & 2 – LONG-TERM Occlusal forces on Proximal CLINCIAL DATA A CONUNDRUM? Box  Conclusion: AMALGAM COMPOSITE The long-term results (95.5% survival after TERRIBLE MARGINS nine years) are excellent, although CEREC 1  CS: 300 –  CS: 200 – and CEREC 2 did not achieve today’s level of 500 MPa 380 MPa clinical precision and quality of the marginal BUT  FS: 130 –  FS: 90 – integrity (however compensated for using 170 Mpa 150 MPa EXCELLENT, LONG-TERM macrofilled luting materials).  Modulus:  Modulus:  Posselt A, Kerschbaum T, Longevity of 2328 CLINICAL RESULTS? 15 – 55 2 – 12 GPa chairside CEREC inlays and onlays, Int J GPa Comput Dent; 6: 231–248 WHY?

6 CEREC: 3D INFRARED VS AC CEREC 3D LAVA C.O.S. BLUC CAM  The LAVA C.O.S. captures the 3- D surfaces of the teeth directly in the mouth using video capture.  This data is then used to create SLA resin models from which any restoration can be fabricated.

 Unique features:

a. Real-time Video Capture and feedback (3-D-in-motion)

b. Intuitive touch screen interface

c. LAVA (Zirconia) copings can be milled in the

d. laboratory direct from the capture data.

iTero iTero E4D System

 User interface.  What it does. The iTero captures the 3-D surfaces of the teeth  Workflow for E4D is similar to The iTero utilizes a directly in the mouth using a CEREC, but there are system confocal (laser and optical) differences. wireless foot pedal  E4D captures images from 3 image series (usually about 21 separate angles (buccal, during the image images). This data is then used lingual, and occlusal) for each capture process to to create CAD/CAM resin models tooth using a laser. This reduces any error that might allow the operator to (Figure rt) from which any be introduced by automated restoration can be fabricated. “patching” (filling in) of areas confirm or retake each that are below the height of image. The pre- and contour and cannot be picked  Features up from a top-down image post-capture input is alone. However, it does a. True powder-less image increase the number of images done with a wireless capture that must be taken. mouse and a sealed b. Talks user through each of the keyboard 21 images c. Geller-type (resin) models.

E4D System NYU Marginal Fit Study: E4D vs. Cerec  The E4D mill can produce all types of indirect restorations (inlays, onlays, crowns, veneers, etc) from a variety of materials (composite, leucite-reinforced and lithium disilicate ceramics.) 

7 Observations & Conclusions of the Critical Problem for Optical & Conventional NYU Marginal Fit Study Impressions – margins at or below the HOWEVER, THIS MARGINAL margin of the gingival sulcus

 E4D exhibited a reduced and more homogeneous fit based on assessment of fit at buccal, lingual, and center positions. This might be due to software FIT STUDY INDICATES THAT improvement and/or different machining approaches used in the E4D system. BOTH THE CERAC & E4D  The CEREC-produced specimens in this study fit least well at the center.

 Studies by the NYU group (Silva NR, de Souza GM, Coelho PG, Stappert CF, Clark SYSTEMS CAN PRODUCE EA, Rekow ED, Thompson VP. Effect of water storage time and composite cement thickness on fatigue of a glass-ceramic trilayer system. J Biomed Mater Res B Appl Biomater. 2008 Jan;84(1):117-23) suggest that increased cement MARGINAL FIT WELL WITHIN thickness reduces the load required to initiate a radial crack in this area of the crown, potentially making crowns with less precise fit more vulnerable to fatigue failure. CLINICALLY ACCEPTABLE

 The CAD/CAM technology has been considerably improved in the past years. VALUES (I.E. <80-100 MICRONS) However marginal accuracy of CAD/CAM restoration is still dependent upon adequate cavity preparation and equipment operation.

What’s New In What’s New in Impression Materials What’s New In Impression Materials Impression Materials? Imprint 4 – 3M ESPE – Aquasil Ultra Cordless?

Aquasil Ultra Cordless (Dentsply/Caulk) Imprint 4 (3M ESPE)

The PFM Restoration Winds of Change

ADVANCED LABORATORY • The gold standard for ceramic restorations is clearly • However, recent years have seen dramatic porcelain-fused-to-metal (PFM). With PFM, it is FABRICATED CERAMIC reasonable to expect a 10- to 15-year survival rate of increases in the basic price of gold and other 95%, with the incidence of porcelain chipping around 4 noble metals used with porcelain bonding MATERIALS to 10%. alloys, which has resulted in a significant • With the use of porcelain facial margins and proper increase in laboratory costs. Steven R. Jefferies, MS, DDS, PhD tooth preparations, good to excellent esthetic results can be anticipated. • This increase in cost, coupled with society’s • PFM restorations have been popular for decades obsession with esthetics, has resulted in because they provide a combination of reasonable increased interest in ceramic restorations. esthetics coupled with maximum longevity.

8 Dental Ceramic Classification by Ceramic Materials - 2015 Composition PressablePressable CeramicsCeramics ––22ndnd GenerationGeneration

• Thereare four (4) groupsof ceramicmaterials that have • Material type: Lithium disilicate glass ceramics a sufficientlevel of clinical testing and/or anecdotal Heavily Filled Glassy Ceramics Empress 2 now evidencethat clinicians should investigateand consider eMax •Strength ~ 350 MPa for use with their patients: •Toughness ~ 2.0 • Brand examples: Empress 2 –NOW Polycrystalline Moderately Ceramic Filled eMAX Materials Glassy 1) Leucite-reinforced glass-ceramics Ceramics • Advantages: Highly esthetic, 2) Lithium disilicate glass ceramic restorations translucent, slightly stronger • Indications: Single crowns, 3) Layered zirconia crowns anterior 3 unit bridges (large Glassy Ceramic Materials 4) Monolithic zirconia restorations 4x5mm connectors) • Bonding & conventional Lithium Disilicate ~ 85% cementation

eMax Table 1. Properties of IPS e.max Press. Table 2. Properties of IPS e.max CAD. Microstructure – Lithium Silicate Crystals CTE (100-400°C [10-6/K] 10.2 CTE (100-400°C [10-6/K] 10.2

Lithium Disilicate Reinforced Ceramic -6 CTE (100-500°C) [10-6/K] 10.5 CTE (100-500°C) [10 /K] 10.5

Flexible strength (biaxial) 360 Flexible strength (biaxial) 400 [MPa] [MPa]

Fracture toughness [MPa 2.75 Fracture toughness [MPa 2.25 m0.5] m0.5

Modulus of elasticity [GPa] 95 Modulus of elasticity [GPa] 95

Vickers hardness [MPa] 5,800 Vickers hardness [MPa] 5,800 Chemical resistance 40 [µg/cm2 Chemical solubility [µg/cm2 40

Press temperature EP 600 915 to Crystallization temperature 840 to [°C] 920 [°C] 850

Clinical Results: eMax Press Crowns Clinical Results: eMax CAD Crowns

ZirconiaZirconia ––FrameworkFramework RestorationsRestorations

StatusStatus --20152015

Meets the “500 Units/5 Years” criteria! Encouraging, but doesn’t yet meet the “500 Units/5 Years” criteria!

9 CRA Zirconia Study Data & Specific NYU In-Vitro Fatigue Study: IntroductionIntroduction --20012001 Framework Recommendations Zirconia vs. eMax •• Limited clinical data was available. •• Nevertheless, use of CAM and CADCAD--CAMCAM was a considerable driving force; ••As was the possibility of a high--strength,strength,high metalmetal--freefree alternative; •• As was laboratory efficiencies in production; including overseas production.

Possible Solutions to the Zirconia Problem? Possible Solutions to the Zirconia Problem? Clinical Data on All Zirconia

Limited – But now available ALL ZIRCONIA vs Emax Two Sources Choices • Strength vs Durability? •Esthetics?  Trac Research (Formerly CRA) •Clinical Data (of any kind)?  The Dental Advisor

Retrospective Clinical Evaluation: Clinicians Report – TRAC Research BruxZir Monolithic Zirconia Drs. Gordon & Rella Christensen TRAC Conclusions: • “BruxZir and e.maxCAD full-contour crowns on molars have demonstrated clinical service superior to all other tooth-colored materials studied clinically by TRAC over 39 years. To date, their service record resembles that of cast metal.” • “Clinical service over three plus years has begun to answer many critical clinical questions, but important questions remain on possibility of phase change of zirconia in 100% humidity of the oral cavity, glaze use, service life, and failure mode.” • “Status reports will be forthcoming as answers to these and other pertinent questions emerge through this This is the only prospective, controlled clinical trial study.” yet reported for monolithic zirconia crowns!!

10 Surface Contamination - Zirconia

• Salivary Phospho-Proteins Major Clinical Issue – Zirconia • Ivoclean Bruxzir Clinical Video Frames/All - Zirconia

https://www.youtube.com/watch?v=f2-sWcSPlbk RETENTION Why???

Comparative Unit Costs of Metal- Partial List of A SILENT REVOLUTION??? Currently Available based & All Ceramic Crowns Zirconia Crowns RESTORATION SO IF THERE WASN’T A 2007 2012 PROBLEM WITH PORCELAIN- TYPE VENEERED ZIRCONIA SUBSTRUCTURES, WHY DID THE MAJOR COMPANIES DEVELOP THEIR OWN VERSIONS OF MONOLITHIC PFM ~72% ~24% ZIRCONIA??????

FOR EXAMPLE:

ALL CERAMIC ~22% ~73% (~50-70% Lava Plus – Monolithic as all zirconia) zirconia Cercon ht – Monolithic OTHER ~6% ~3% zirconia

Ahmed & Donovan.EvaluationofContemporaryCeramicMaterials.2015;JournalofEsthetic and RestorativeDentistry. 27(2)59–62.

Partial List of Currently Available Update & Key Facts: Zirconia Layered Zirconia Crowns Zirconia Crowns Restorations • One problem with layered zirconia crowns, which has been seen in almost all clinical trials, is the cohesive chipping of the veneering ceramic. • Monolithiczirconia restorations have only been in use for a few years, so no long-term clinical trials are available. • This chipping, which occurs approximately five times more frequently than with PFM restorations, does not always necessitate • Most authorities are optimistic regarding survival rates replacement of the crown, but it has been a persistent problem. based on the fact that so few zirconia cores have fractured • Causes of the chipping may be lack of support of the veneering in clinical trials, and a monolithic or full-contour zirconia ceramic by the core and the low thermal conductivity of the core crown is essentially an unveneered zirconia core. material. • They have very high ﬂexural strength (1200–1400 MPa) and • The latter problem may have been resolved by utilization of slower have been used experimentally with large multi-unit cooling cycles, and the former issue has been resolved with restorations. improved software programs to insure optimum support by the core. • Because of these excellent properties, more conservative tooth preparations are possible compared with those used with PFM, lithium disilicate, or layered zirconia crowns.

Ahmed & Donovan.EvaluationofContemporaryCeramicMaterials.2015;JournalofEsthetic and RestorativeDentistry. 27(2) 59–62.

11 Update & Key Facts: Zirconia Update & Key Facts: Zirconia Update & Key Facts: Zirconia Restorations Restorations Restorations • Zirconia cannot be etched with hydrofluoric acid • It should be noted that the internal surface of • Another advantage of monolithic zirconia crowns is that when polished well, they are very kind to opposing tooth structure, and because their molecular structure is different from zirconia crowns is usually contaminatedwith saliva multiple in vitro studies have shown much less wear of enamel than with other types of ceramic. glass ceramics. and possibly blood during try-in, and has a strong • These restorations are relatively opaque, resulting in reduced • Protocols involving airborne particle abrasion affinityto salivary proteins that are not easily esthetics compared with layered restorations. removed. If these are not removed, crowns can be • They are also relatively inexpensive with an average cost of $171. bondingwith MDP primers and resin cements have • The major indication for monolithic zirconia crowns is for posterior been tested in vitro, but they generally form prematurely dislodged. teeth where esthetics is not critical, especially for second molars relatively weak bonds that deteriorate with aging and • The best protocol for cleaning the internal surface is when patients decline cast gold restorations. • Because zirconia crowns can be fabricated with signiﬁcantly less run the risk of transformationof the entire crown or to use a solution of zirconium oxide (zirconia) in tooth reduction, another indication is for crowns on mandibular core as a result of particle abrasion. sodium hydroxide (Ivoclean, Ivoclar Vivadent) for 20 anterior teeth. • In the opinion of the authors, zirconia crowns are seconds followed by rinsing with water. best used with retentive preparations and cemented.

SUMMARY & CONCLUSIONS: SUMMARY & CONCLUSIONS: ULTRA-HIGH DENSITY, PROCESSED THEN MILLED COMPOSITE/CERAMIC INDIRECT ALTERNATIVES TO PFMS ALTERNATIVES TO PFMS MATERIALS SUMMARY AND CONCLUSIONS SUMMARY AND CONCLUSIONS • Clearly PFM is the gold standard for esthetic crowns restorations, but the price of noble metals has driven • Monolithiclithium disilicatecrowns are indicated laboratory costs to unprecedented levels. for premolars and first molars, whereas layered • Advances in materials and technology have resulted in lithiumdisilicatecrowns can be used with the development of four ceramic systems that can be considered as economic alternatives to PFM, which maxillary incisors. provide good to excellent esthetic results and have • Layered zirconia cored crowns can be predictably demonstrated adequate clinical longevity. • Layered leucite-reinforced crowns provide excellent used on anterior teeth and premolars. esthetic results on maxillary anterior teeth and • Monolithiczirconia crowns are best used for premolars when etched and bonded in place. molars and mandibular anterior teeth.

CAD/CAM NANOFILLER COMPOSITE: LAVA ULTIMATE (3M)

New Composite Advances in Composite Resin Developments Technology --NEWNEW MONOMERS --NANOTECHNOLOGYNANOTECHNOLOGY Steven R. Jefferies, MS, DDS, PhD (NANOFILLERS)

12 HistoryHistory Midi -filler – Composition 2 um 19621962 ––BisBis--GMAGMA (beachball) ––strongerstronger resin Resin matrix Bis-GMA CH Mini -filler – 19691969 ––filledfilled composite resin ––monomermonomer O 3 O CH2=C-C-O-CH2CH-CH2O -C- OCH2CHCH2O-C-C=CH2 0.6 um ––initiatorinitiator ––improvedimproved mechanical properties CH3 OH CH3 OH CH3 (canteloupe) ––lessless shrinkage ––inhibitorsinhibitors ––pigmentspigments ––paste/pastepaste/paste system Microfiller – Inorganic filler 1970’s1970’s ––acidacid etching and microfillsmicrofills .04 um ––glassglass (marble) 1980’s1980’s ––lightlight curing and hybrids ––quartzquartz 1990’s1990’s ––flowablesflowables andand packablespackables ––colloidalcolloidal silica Nanofiller – .02 um (pea) 2000’s2000’s ––nanofillsnanofills Coupling Agent 2010’s2010’s ––NewNew monomers, low shrinkage Relative Particle Sizes Rueggeberg, J Prosthet Dent 2002 Phillip’s Science of Dental Materials 2003 (not to scale)

NanofillNanofill vs.vs.NanohybridNanohybrid NanofilledNanofilled CompositeComposite Nanoparticles &&NanoclustersNanoclusters/3M/3M

NanofillsNanofills FiltekFiltekSupreme (3M ESPE) ––nanometernanometer--sizedsized particles throughout matrix Filler particles Nanohybrids ––filled: 78%filled:78% wgtwgt ––nanometernanometer--sizedsized particles combined with ––nanomersnanomers more conventional filler technology 0.020.02 ––0.070.07 microns ––nanoclusternanocluster act as single unit ––0.60.6 ––1.41.4 microns

Swift, J Esthet Restor Dent 2005

Filler Improvements in FiltekFiltek™™ Supreme Ultra Universal Comparative Retention of Restorative CURRENT “NANO” COMPOSITES PolishPolish

NANONANO--HYBRIDS:HYBRIDS:

Grando (Voco) Synergy (Coltene/Whaledent) Kalore (GC Dental) NANOFILLED: As the particles are not as strongly sintered, the MI Flow (GC Dental) Filtek Supreme (3M(3M--ESPE)ESPE) cluster size range could be Tetric EvoCeram (Ivoclar(Ivoclar--Vivadent)Vivadent) broadened (vs. Filtek Supreme Venus Diamond (Heraeus Kulzer) Plus restorative) without CeramCeram--X(Dentsply/DeTrey)X (Dentsply/DeTrey) affecting physical properties. Premise (Kerr USA)

13 MICROSTRUCTURAL OTHER INOTHERIN--VITROVITRO DATA: CLINICAL DATA: NANOFILL VS. CHARACTERIZATION: FILTEK NANOCLUSTER REINFORCEMENT? MICROMICRO--HYBRIDHYBRID COMPOSITE Cyclic preCyclicpre--loadingincreasedloading increased the SUPREME VS. ZZ--250250 WeibullWeibull Modulus of both FiltekFiltek •• Clinical Wear Performance of “Mechanical properties of Supreme Body (FSB) and FiltekFiltek FiltekFiltek--SupremeSupreme and Z100 in Supreme Translucent (FST) Posterior Teeth: 5 YR CLINICAL No statistical RodriguesRodrigues Junior,Junior, nanofillednanofilled resinresin--basedbased compared to other composites. composites: Impact of dry & BiaxialBiaxial fleuralfleural strength of both FSB WEAR PERFORMANCE difference in volume ScherrerScherrer,, FerracaneFerracane,, Fracture toughness, wet cyclic preloading on bibi-- and FST was maintained or axial flexure strength” increased after cyclic loading •• S. PALANIAPPAN, D. BHARADWAJ, D. wear between the Della Bona. Dental compared to other composites MATTAR, M, PEUMANS, and B. VAN Flexural Strength, Curtis, Palin, Fleming, tested.tested. Materials 24 (2008) 12811281-- ShortallShortall,, Marquis. Dental MEERBEEK, & P. LAMBRECHTS materials, but WeibullWeibull Modulus,Modulus, Nanoclusters appear toappearto KatholiekeKatholieke UniversiteitUniversiteitLeuven, Department 88.88. Materials 25 (2009) 188188--197197 provide distinct of Dentistry, BIOMAT Research Cluster, nanofillnanofill was lower.lower.was Characteristic Materials Tested: reinforcing mechanism BelgiumBelgium HeliomolarHeliomolar,, Z100, Z250, compared to microfilmicrofil,, 3636--6060 Month steady Strength, and Critical FiltekFiltekSupreme (body and microhybridmicrohybrid, or,or nanonano-- •• Dental Material 27 (2011) 692692--700700 Crack Strength ––VeryVery translucent), GrandioGrandio,, hybrid systems. state vertical wear GrandioGrandio Flow.Flow. SilaneSilaneinfiltration of was lower for the SimilarSimilar nanoclusters may enhance damagetolerance in the nanofillnanofill (0.263(0.263 vsvs composite, with the potential for improved 0.486 microns per clinical performance. month).month).

CLINICAL DATA: NANOFILL CLINICAL DATA: NANOHYBRID VS. CAD/CAM NANOFILLER COMPOSITE ––ANTERIORANTERIOR TEETH FINE PARTICLE HYBRID COMPOSITE: LAVA ULTIMATE (3M)

•• Three Year Clinical Evaluation Conclusions: At the 33--YearYear Nanohybrid ((GrandioGrandio,,VocoVoco)) ofof FiltekFiltekSupreme in Anterior recall:recall: TeethTeeth •• 1) Retention, surface vs. fine hybrid composite •• J. DUNNJ.DUNN11, C. MUNOZ22, A.WILSON11, M.,M. NO DIFFERENCE IN ARAMBULA11, and R. RANDALL33,, 11Loma Linda staining, and secondary ((TetricTetric Ceram,Ceram, IvovlarIvovlar) in)in University, CA, USA, 22SUNY at Buffalo, NY, USA, CLINICAL PERFORMANCE 333M ESPE Dental, St. Paul, MN, USA caries were unchanged from extended Class II cavities •• IADR/AADR ABSTRACT baseline;baseline; after six years BETWEEN NANOBYBRID •• 2) Surface polish remained high throughout study as N.N. KrKräämermer, F. Garcia,F.Garcia--Godoy,Godoy, AND FINE HYBRID; the composite appeared to C.C. ReindtReindt, A.J.,A.J. FeilzerFeilzer, R.,R. SUCCESS RATE WAS display a "self"self--polishing"polishing" Frankenberger..Frankenberger effect.effect. 100% FOR BOTH •• 3) Overall clinical Dental Materials, 27 (2011) MATERIALS AND NO performance is high and is 455455--464464 acceptable for routine SUBJECT DROPOUTS. clinical use. •• Study partially funded by 3M ESPEESPE

FiltekFiltek LS (Low(LowLS Shrinkage)Shrinkage) N’DuranceN’Durance --SeptodontSeptodont The DuPont Monomer

New “New“DimerDimer Acid”Acid” DX-511 Monomer (New Monomer Technology from DuPont) Monomer system The long rigid core helps reduce polymerization shrinkage. The flexible side arms help increase monomer reactivity. High molecular weight (895) and low number of C=C double bonds help reduce Improves Conversion polymerization shrinkage. ––75%75% The monomer is compatible with current adhesive and composite products. Reduced volumetric shrinkage (1(1--1.5 %)1.5%) High compressive SiloraneSiloranechemistry (right) has a ring--openingring opening reaction, thus strength & toughness reducing polymerization shrinkage to 0.6 to 1 %. Good clinical Requires separate chemistry for bonding agent. Long Rigid Core evidenceevidence Flexible Uses quartz filler, which modifies esthetics. Arm Flexible Arm Good documented clinical performance up to 3 yrs.

Version Edited 01/10/2010 6

14 Increasing the size and molecular weight Class I Direct Restoration of monomers reduces overall shrinkage

“Single Shade KALORETM A2 Universal Only” Direct, Tooth Colored

Polymerization Low Molecular Before After Restoratives weight

BULK FILL RESTORATIVES

High Molecular weight Shrinkage

Dentistry by Dr. Mark Pitel, NY

Version Edited Version Edited 01/10/2010 8 01/10/2010 54

BULK FILL Materials NationNationaallInstiInstittuteute forfor DDeentalntal andand “BULK FILL” RESTORATIVE Craniofacial ResearchResearch COMPOSITE RESINS Advantages of “New Class” of materials “… Studies have shown that Saves Time? dental resin composites DEFINITION – 2015: Easier? have an average Better adaptation to tooth? replacement time of 5.7 Light-cured composite resin Reduce chance for air entrapment materials for direct restoration of Better conformity to cavity walls years due to secondary posterior teeth, which can be Better marginal integrity decay and fracture of the restoration.” placed and cured in bulk Less shrinkage stress? increments of 4 – 5 mms thickness. GreaterDepth of Cure? 4-5 mm

Why do we need bulk fill?

PRIMARY MODES OF OTHER FACTORS FAILURE OF POSTERIOR CONTRIBUTING TO COMPOSITES FAILURE

• SECONDARY • MARGINAL BREAKDOWN CARIES • RESTORATION WEAR Why incremental filling? • RESTORATION • INADEQUATE - Limited depth of cure POLYMERIZATION FRACTURE - Reduce shrinkage stress • PULPAL DEATH • TOOTH FRACTURE

15 U nUn ddes ir aes abbl ele CCoonsenseqqueuenncesces ooff InaInaddeeqquuaat ete PPoollymymeer i zriz aat i o nti n BULK FILL Materials

- Inadequate physical properties They are NOT all the same! - Reduced bond strengths - Increasedbreakdown at margins with use • Increment thickness - 4mm, 5mm - Decreasedbiocompatibility - Potentially increased DNA damage due to leachates • Single increment use vs. “capping layer” - Increasedbacterial colonization of resin

J Can Dent Assoc 2010;76:a23 • Sculptable (paste-like) or flowable (syringe)

BULKBULK FILL MateriaMateriallss Thermal Manipulation of Composite Resin Questions / Concerns VISTA DENTAL • Depth of cure [degree of conversion] ThermaTherma--FloFlo™ • Adaptation – microleakage Composite Warming Kit Sonic Delivery of Benefits of HEAT: • Strength IncreasedIncreased flowabilityflowability == CompositeComposite • Mechanical properties Easy extrusion Improved polymerization= Kerr Dental (Danaher))(Danaher • Wear Reduced voids • Contraction force and rate Reduced curing time • Handling • Durability – clinical performance over time

So Where Did the Idea Come From SONICFILL ––TECHNICALTECHNICAL DATA

16 Comparative Strength ––Bulk FillFillBulk Restoratives WHAT’S THE SONICFILL 2 DIFFERENCE?

BULK FILL MATERIAL SONICFIL 2 VSVS SONICFIL (1)

From: Open Journal of Composite Materials, 2014, 4, 117-121

According to the Kerr Are there other options for bulk--fillbulk fill restorations??? Product Manager GlassGlass IonomersIonomers??? Maybe ––inin selected situations?

Better color matching JADA, Vol. 130, September 1999 ;1347–1353 Better esthetics Localized and Generalized Simulated Wear of Resin Composites

Operative Dentistry, 2015, 40-3, 322-335

WW Barkmeier T Takamizawa RL Erickson A Tsujimoto M Latta M Miyazaki

Clinical Relevance Wear is an important parameter for the selection of resin composite materials .

ANOTHER CONCEPT IN BULK FILL RESTORATIVES: EQUIA™ GC’s New Product Self-Adhesive, Aesthetic Posterior Restorative EQUIA PHYSICAL PROPERTIES Clinical Case clinical images courtesy of Dr. Lassocinski & GC Dental Description for Equia

“Bulk fill, Self-adhesive, Rapid Restorative System”

17 CLINICAL DATA – GC EQUIA – 2 YEAR RESULTS GC EQUIA • CONCLUSIONS: Within the limitations of this study it can be concluded that EQUIA can be used as a permanent restoration material for any sized Class I and in smaller Class II cavities. However, results of ongoing prospective studies shall provide a more exact indication definition in Class II GC EQUIA situations.

• SIGNIFICANCE: Modern glass ionomer systems may not only 2 & 4 YEAR CLINICAL DATA serve as long-term temporaries, but also as permanent restorations in posterior teeth.

• What about interproximal contacts?

FriedlK, Hiller KA,Friedl KH. Clinicalperformanceofa new glass ionomerbasedrestoration system: a retrospectivecohortstudy.Dent Mater.2011 Oct;27(10):1031-7.

A NEW IDEA GAINING TRACTION: CURING A EQUIA FORTE CLINICAL DATA – GC EQUIA – 4 YEAR RESULTS CONVENTIONAL GIC WITH AN LED LIGHT AN IMPROVED GC EQUIA? • Objective: The aim of this study was to evaluate the clinical performance of a glass ionomer restorative system compared with a microfilled hybrid posterior composite in a four-year randomized clinical trial. • Methods: A total of 140 (80 Class 1 and 60 Class 2) lesions in 59 patients were either restored with a glass ionomer restorative system (Equia, GC, Tokyo, Japan), which was a combination of a packable glass ionomer (Equia Fil, GC) and a self- adhesive nanofilled coating (Equia Coat, GC), or with a microfilled hybrid composite(Gradia Direct Posterior, GC) in combination with a self-etch adhesive (G-Bond, GC) by two experienced operators according to the manufacturer's instructions. Two independent examiners evaluated the restorations at baseline and at one, two, three, and four years postrestoration according to the modified US Public Health Service criteria. • Results & Conclusions: The use of both materials for the restoration of posterior teeth exhibited a similar and clinically successful performance after four years.

SGurgan,ZB Kutuk,E Ergin,SS Oztas,andFY Cakir(2015) Four-yearRandomizedClinicalTrialto Evaluatethe ClinicalPerformanceof a Glass Ionomer RestorativeSystem.OperativeDentistry: March/April2015,Vol. 40, No. 2, pp. 134-143.

EQUIA FORTE – EQUIA FORTE CLINICAL TECHNIQUE THE TECHNOLOGY AN IMPROVED GC EQUIA?

18 Currently Available Generations Classification of Newer Systems •• Fourth Generation ––ThreeThree--stepstep Etch & rinse Interaction with tooth surface •• Fifth Generation ––TwoTwo--stepstep Etch & rinse Number of clinical application steps •• Sixth Generation ––TwoTwo--step SelfstepSelf--etchetch 1) Etch & rinse (i.e., totaltotal--etch)etch) Steven R. Jefferies, MS, DDS, PhD ––OneOne--step SelfstepSelf--etchetch 2) Self--etchetchSelf2) •• mixmix Department of Restorative Dentistry •• Seventh Generation 3) Resin3)Resin--modifiedmodified glass ionomerionomer ––OneOne--step SelfstepSelf--etchetch •• no mixnomix Van Meerbeek, Oper Dent 2003

Prime & Bond NT ––ModifiedModified Clinical Application Etch & Rinse (Three--Step)Step)(Three Technique Can Improve Bond Strength & Clinical Adhesive Categories Performance Etch & Rinse ConditionerConditioner 1515 ––2020 second enamel etch; 4etch;4--77 second dentin ––ThreeThree--StepStep PrimerPrimer etch.etch. conditioner,primer, adhesive Wet or Moist Dentin is ––TwoTwo--StepStep Adhesive resin Optimal; Dry Dentin conditioner,(primer & adhesive) Problematic (acetone). SelfSelf--EtchEtch Apply copious amounts, let ––TwoTwo--StepStep ExamplesExamples stand 5stand5--1010 secssecs, then,then (conditioner& primer), adhesive “light” air dry. ––ScotchbondScotchbond MultiMulti--PurposePurpose ––OneOne--StepStep Cure 20 seconds ––thenthen ––OptibondOptibond FLFL (conditioner& primer & adhesive) repeat for a second coat and second cure. GlassGlass IonomerIonomer ––TwoTwo--StepStep conditioner,conditioner,resin resin--modifiedmodified glass--ionomerionomerglass mixturemixture

AFTER ALL THESE YEARS ––TONSTONS OF RESEARCH: WHY IS Is The Oral Environment Excessively THE PERFORMANCE OF ADHESIVE RESIN MATERIALS IN An Emerging Concern: BiofilmBiofilm-- QUESTION? Bacterial Challenge; Specific to “Corrosive” to Resins & Adhesives? LongLong--TermTerm Clinical ResinResin--BasedBased Materials? Performance of Class II Posterior Composites “The enzymes in saliva degrade dental Demarco , et.al. Dent Mater. 2012 RoumanasRoumanas ED. JED.J EvidEvid Based Dent PractPract. 2010.2010 composites and may enhance tooth decay. AbtAbt E. The Journal of EvidenceEvidence--BasedBased Dental Practice. 2008 ……………………………………………………… Bernardo, et.al. J Am Dent Assoc. 2007 PulpalPulpal Biocompatibility? Pressure? Especially in areas …………….. There is strong evidence to SonciniSoncini , et.al. J Am Dent Assoc.Assoc.2007 2007 with low remaining dentin thickness (RDT)! suggest that biofilmbiofilm formation contributes to the Stability of the “Hybrid Zone”? chemical and mechanical degradation of dental Absence of real bioactivity or ability to actively composites.” remineralizeremineralize/BIOLOGICALLY/BIOLOGICALLY integrate with adjacent tooth tissue. Quote from 1. Research Objectives, Background: Increasing the Service Life of Different amounts of pathogenic bacteria underneath Dental Resin Composites; (R01); Announcement Type: New; Request for composite resin vs. amalgam? Ref: 2003, QuintQuint. Int..Int. Applications (RFA) Number: RFA--DEDE--1010--004004RFA Enzymatic Degradation of composite resins?? SRJ, 10-4-13

19 Questions About The Adhesive BUT THERE ARE OTHER THREATS ANOTHER MAJOR Resin Interface? TO MARGINAL STABILITY! CHALLENGE PLUSPLUS ––OTHEROTHER DEGRADATIVE ENZYMES COMPOSITE RESINS MAY BE MORE PRONE FROM MULTI--SPECIESOFMULTI SPECIESOF TO BACTERIAL CHALLENGE /ENZYMATIC BACTERIA DEGRADATIONDEGRADATION.. PLUSPLUS ––ACIDACID DEMINERALIZATION & LOW pHpH&LOW DENTIN BONDING IS STILL PROBLEMATICPROBLEMATIC..

NANOLEAKAGE BELOW & WITHIN THE NANOLEAKAGE BELOW & WITHIN THE HYBRID ZONE HYBRID ZONE NOW IS RECURRENT ANTIMICROBIAL RESINS AND COMPOSITES CARIES (I.E. – A GINGIVAL WALL LESION MIGHT BE USEFUL TO RESISTANCE SECONDARY/RECURRENT CARIES Stability of the “Hybrid Zone”/Enzymatic Degradation? Growing Evidence of the Role of Enzymatic Degradation? .. Brackett, et.al. J Dent. 2011; PashleyPashley &&TayTay, et.al.,et.al. Dent Mater. 2011; CarreraCarrera, et.al.,et.al. ActaActa BiomaterBiomater. 2013 ;;.2013 ToledanoToledano, et.al. Caries Res. 2012; NeelakantanNeelakantan, et.al. JJ,et.al. ClinClin PediatrPediatr Dent. 2009;Hsu, et.al. Dent Mater. 2008; ZouZou, et.al.,et.al.J Biomed Mater Res A. 2010 Reis, et.al.Reis,et.al. Dent Mater. 2007;Yuan, et.al. Dent Mater. 2007

ClearfilClearfilProtect Bond TOTAL ETCH/SELF ETCH? SelfSelf--EtchEtch Components

AcidicAcidic MDPMDP WHAT’S THE DIFFERENCE? DiDi--HEMAHEMA--PhosphatePhosphate monomersmonomers MA 154154MA PhenylPhenyl--PP TWO BOTTLE VS ONE BOTTLE? MACMAC--1010 44--MET(A)MET(A)

BisGMABisGMA MDBPMDBP ADDED “SELECTIVE” ETCH FOR Crosslinking UDMAUDMA monomersmonomers TEGDMATEGDMA ANTIMICROBIAL ENAMELENAMEL GDMAGDMA MONOMER HEMAHEMA usually water based SolventSolventSolventSolvent

OPTIBOND FL (3 – STEP; ETCH, PRIMER, ADHESIVE) – NEW “UNIVERSAL” LONG TERM CLINICAL STUDY – DR. ALAN BOGOSHIAN NEW UNIVERSAL ADHESIVES ADHESIVES • ONE BOTTLE • SCOTCHBOND UNIVERSAL • SELECTIVE ETCH; • XP BOND – NOW PRIME & BOND XP • TOTAL ETCH • PRIME & BOND ELECT • SELF ETCH • IS IT POSSIBLE??? 2 Years 13 Years5 Years

20 What Do These Three Adhesives Share in Scotchbond Universal XP Bond Common That May Enhance Their Performance? • OPTIBOND FL • XP BOND – NOWPRIME & BOND XP • SCOTCHBONDUNIVERSAL

 Phosphate – MDP  Phosphate – PENTA  Carboxylic Acid – Vitrebond Co-polymer  Carboxylic Acid - TCB

THEY HAVE COMBINATION ADHESION PROMOTERS!

OcclusalOcclusal forcesforces on Proximal MORE EVIDENCE ––WHYWHY BoxBox MODULUS MATTERS! AMALGAM BUT IS IT REALLY ALL COMPOSITE “Fatigue resistance and crack propensity of ABOUT ADHESIVES AND CS: 300CS:300 –– CS: 200200CS: –– 500 MPa500MPa 380 MPa380MPa large MOD composite resin restorations: ADHESION TO TOOTH FS: 130FS:130 –– FS: 90FS:90 –– direct versus CAD/CAM inlays.” STRUCTRE?? 170 Mpa170Mpa 150 MPa150MPa Modulus:Modulus: Modulus:Modulus: Dent Mater. 2013 Mar;29(3):324--31.31.Mar;29(3):324 OR ARE THERE OTHER 1515 ––5555 22––12 GPa12GPa FACTORS???? GPaGPa BatalhaBatalha--SilvaSilva S , de AndradaAndradaMA, Maia HP, MagneMagne P.P.

BatalhaBatalha--Silva, et al.al.Silva, SO, WHAT DO WE DO ABOUT THE GINGIVAL WALL AREA IN TOOTH “CAD/CAM MZ100 inlays increased the COLORED RESTORATIONS???? accelerated fatigue resistance and OpenOpenSanwichSanwich/Closed/Closed decreased the crack propensity of large PREPARATION & CASE SELECTION: AVAILABLE ENAMEL & CARIES RISK. SandwichSandwich MOD restorations when compared to ADHESIVE TECHNIQUE: SELF--ETCHSELF ETCH W/ ENAMEL direct restorations.” REBOND; OR SELCTIVE DENTIN ETCH (“BACK TO THE “While both restorative techniques yielded FUTURE”)FUTURE”) Liner/BaseLiner/Base excellent fatigue results at physiological CONTROL OF AXIAL WALL LENGTH/DEPTH OPEN SANDWICH: BUT WITH WHAT MATERIAL??? VsVs masticatory loads,loads, CAD/CAM inlays INDIRECT CERAMIC OR LAB--PROCESSEDLAB PROCESSED COMPOSITE: No Liner or Base seem more indicated for highhigh--loadload MAYBE? BUT TIME & EXPENSIVE!! patientspatients.”.” OTHER OPTIONS??? STIFFER, HIGHER MODULUS CR

21 Closed vs Open Sandwich Closed vs Open Sandwich Do we know if an open sandwich technique works clinically?

Clinical Research of Professor Jan van DijkenDijken:: Moderate to LongLong--termClinicalterm Clinical Studies with:

1) GlassGlass1) IonomerIonomer 2) Resin2)Resin--modifiedmodified Glass IonomerIonomer 3)3) CompomerCompomer ––PolyacidPolyacid Modified Composite Resin

SOME IMPORTANT ANCILLARY Chlorhexidine &&GlumaGluma PRODUCTS IN ADHESIVE Consepsis®Consepsis® --2.0%2.0% chlorhexidine gluconate solution used WHAT ABOUT SLOT PREPS? DENTISTRY!! to clean/disinfect before bonding (a disinfectant) GlumaGluma®®--5%5% GlutaraldheydeGlutaraldheyde,,35% 35% HEMA, 60 % WaterWater(a (a WHY THEY ARE IMPORTANT collagen crosslinking agent) Major Functions: Antimicrobial Activity & Inhibition of PREVENTING DENTIN & ADHESIVE Metalloproteinases BOND DEGRADATION • Reduces risk for recurrent caries? WHAT’S THE EVIDENCE? • Reduces potential for post operative sensitivity caused by residual bacteria? • Slightly higher bond strengths with many dentin MIMIMIZING TOOTH SENSITIVITY bonding agents DOES IT WORK WITH LONGEVITY? • Lower risk of bond strength compromise (Chlorhexidine hand soaps can adversely affect bond strength with dentin bonding agents. Consepsis contains no surfactants or emolients that interfere with bond strength.)

Final Thoughts ––Adhesives/DentinAdhesives/Dentin ALDEHYDES & “CHX” ALTERNATIVE METHODS BondingBonding TO FORM A BOND TO CHEMICALLY STABILIZING DENTIN WITH CROSSLINKING AGENTS (ALDEHYDES), TOOTH STRUCTURE? ENZYME INHIBITORS, ANTIMICROBIALS; INTEGRATION TO TOOTH STRUCTURE WITHOUT USE OF ADHESIVE MONOMERS USE AN ADHESIVE THAT COMBINES A PHOSPHATE ANDAND CARBOXYLIC ACID NECESSITY? MONOMER; FEASIBILITY? BENEFIT?BENEFIT? USE OF SELECTIVE ETCH OR “LIMITED”LIMITED” TOTAL ETCH MAY BE THE PREFERRED TECHNIQUE.

22 Reducing New Bioactive ––“Interactive”“Interactive” EXAMPLES OF CERAMIC Compositions of Portland & Materials to Practice BIOMATERIALS PORTLAND CEMENT calcium aluminate cements

Ceramic Classification Examples of BioceramicBioceramic .. New variations on the “classical” theme of .. Traditional Ceramics Dental Porcelain, LeuciteLeucite .. Special Ceramics AlAl--,,ZrZr, and Ti--OxidesOxidesTi,and the acidtheacid--basereactionbase reaction cement may yield CALCIUM SILICATE “unanticipated” benefits..benefits .. GlassGlass BioglassesBioglasses .. GlassGlass--ceramicceramic ApatiteApatite--WollastoniteWollastonite CALCIUM ALUMINATE .. Chemically Bonded CaCa--PhosphatesPhosphates .. Interactive materials, which are structurally Ceramics CaCa--Silicates,Silicates, CaCa--AluminatesAluminates more “analogous” to native mineralized tissuetissue;; may present new opportunities for restorative and prosthetic treatment in CALCIUM ALUMINATE – GLASS IONOMER dentistry.dentistry.

CURRENTLY AVAILABLE BIOACTIVE MATERIALS Calcium-Based, Bioactive Mineral Trioxide Aggregate Cements: The Potential (MTA) Composition

 Bioactivity via apatite formation at the  Calcium Oxide cavity interface leading to true microstructural integration with the tooth  Silicate Oxide substrate  Tricalcium Silicate  If above property is proven, potential to  Tricalcium Aluminate eliminate need for adhesive bonding  Bismuth Oxide agents. Torabinejad M, Hong CU, McDonald F and Pitt Ford TR. J Endod 1995; 21(7): 349-53

Biodentine WHAT MAKES THESE CALCIUM- CONTAINING MATERIALS UNIQUE? BIOACTIVITY

Pt 4: MTA #1 X10 H&E

23 BIOACTIVITY & NANOSTRUCTURAL Bioactivity: Hydroxyapatite crystals (HA) on the INTEGRATION cement surface CeramirCeramir®® Crown & Bridge Bioactivity materials, when immersed in physiologic .. CeramirCeramir®® C&B is a material that combines phosphate buffered saline solution, form calcium GlassGlass ionomerionomertechnology with Calcium phosphate and hydroxyapatite. AluminateAluminate Chemistry.Chemistry. In-vivo, interaction with tooth structure is .. The GI contributes to: .. Low initial pH, short duration manifested through the precipitation of nanocrystals .. Flow and Setting characteristics (<0.2 microns/200 nanometers) at the interface of .. Early strength the prepared tooth resulting in mechanical .. The CA contributes to: .. Increased strength and retention interlocking, and surface energy-based attachment .. Biocompatibility .. Sealing of tooth material interface of the hydrated cement nanocrystals with the tooth .. Apatite formation structure. .. Sustained long term properties, no degradation .. Basic end pH

MICRO CT ANALYSIS –– NanoNano structural integration ? INTEGRATION VS ADHESION SURFACE APATITE LAYER .. Inherent properties of Bioactive Reactions .. A “seamless” interface, which could reseal .. Crystallites precipitates from solution, wetting and itself over time ––lessless risk of secondary penetrating tooth surface; caries?caries? .. Basic pH (biocompatibility), chemical .. AsAsnanonano--sizedsized crystallites and the gibbsite gel precipitates on the tooth interface and within the stability, and no shrinkage (unlike resinresin-- cement matrix, the cement integrates within the based materials) gives a stable interface dentin and enamel matrix; Enamel Dentine .. The material is constituted of nanonano--sizedsized katoitekatoite Ceramir crystals in a gibbsite gel matrix bonded together by TEMs means of surface energy and mechanical interlocking.

500 nm

Intended Use Test program Net setting time, compressive .. CeramirCeramir®® Crown & Bridge is intended for .. The material is tested according to: permanent cementation of: strength, and film thickness all .. ISO 9917:2007, both internal and external conform to the International Standards tests, NIOM Norway .. Porcelain Fused to Metal Crowns and Bridges Organization (ISO) values for water--water .. FDA guidelines .. Metal (gold etc.) crowns and bridges basedbased lutingluting agents.agents. .. Gold inlays and onlaysonlays .. Biocompatibility testing ISO 7405 .. Cast or prefabricated metal posts .. External testing at Temple University , Prof .. Strengthened core AllAll--ZirconiaZirconia, All,All--Alumina,Alumina, Steven Jefferies and Lithium DisilicateDisilicate ((eMaxeMax)) ceramic crowns .. External testing with Prof C. H. PameijerPameijer and bridges .. Additional internal tests

24 CERAMIR MAY FILL A Shear Bond Strength Crown retention CRITICAL NEED FOR ALLALL-- .. Tests conducted by ProfessorsProfessors PameijerPameijer && .. Shear Bond strength to different substrates CERAMIC CROWNS/BRIDGES JefferiesJefferies Substrate Calcium Calcium Glass Ionomer .. Gold orGoldor ZirconiaZirconia crowns , 3mm prep height with Aluminate/Glass Aluminate/Glass Luting Cement BOND STRENGTH LEVELS TO ALUMINIA Ionomer (MPa) Ionomer (MPa) (MPa) 32 degree taper. AND ZIRCONIA SUGGEST: Manufacturer’s Independent Testing Data* Lab Manufacturer’s Data* A POSSIBLE UNIQUE & NEW BONDING Dentine 11 8.6 (range 5.3-11.9) 4.7 MECHANISM FOR CERTAIN BIOACTIVE, Enamel 8.4 Not Tested 8.4 Gold Alloy 10.2 16.2 (1.4) 2.8 CHEMICALLY-BONDED CERAMIC CEMENTS Alumina 7.5 12.0 (2.9) 6.6 (LIKE CERAMIR) TO HIGH-STRENGTH, Zirkonia 8.2 10.4 (3.0) 3.7 POLYCRYSTALLINE SINTERED CERAMICS

In all tests the standard deviation was about 2 MPa

Crown Retention Vs. Type of Cement CROWN RETENTION DATA Clinical study (all values in KgsKgstensiletensile force to displacement, Cement Results: Gold Results: Zirconia Results: eMax crowns crowns (in Kg f) crowns (in Kg f) (lithium disilicate) .. The study is performed at Temple University using gold crown copings) (in Kg f ) Philadelphia by Prof Steven. R. Jefferies Ceramir 38.3 ± 8.5 32.1 ± 6.3 29.48 + 9.99 Crown & (Cr-Co Die) A total of 38 crowns and bridges were cemented .. PolycarboxylatePolycarboxylate: ~ 9:~9 KgsKgs Bridge .. .. Zinc Phosphate: ~14 KgsKgs (Doxa) in 17 patients of which 31 were on vital and 7 on Rely X 39.8 ± 15.3 27.8 ± 11.3 Not tested nonnon--vitalvital teeth. There were 6 bridges cemented Unicem .. GlassGlass IonomerIonomer: ~24:~24 KgsKgs (3M in the study, consisting of 13 prepared abutment ESPE) teeth (12 vital/1 nonnon--vital).vital). .. RMGI: ~25RMGI:~25 ––4545KgsKgs Glass 26.6 ± 4.4 Not Tested 27.7 ± 12.73 Ionomer (Ketac Cem , 3M (Cr-Co Die) .. The clinical handling was part of the evaluation .. Resin Cement(w/DBA): ~30 ––6060KgsKgs ESPE) (Vivaglas, Ivoclar) Zinc 13.9 ± 4.5 Not Tested Not Tested .. The study was made with a hand mixed version Phosphat of the cement .. Self Adhesive RC: ~16 ––4545KgsKgs e (Flecks Cement, .. ZOE or Non--ZOETempNon ZOE Temp Cements:< ~9 KgsKgs Mizzy)

Measurement Parameters for Clinical Study

CEMENT MEASUREMENT CLINICAL MEASUREMENT Clinical study Cement Removal & CleanClean--upup DATADATA DATADATA CleanClean--upup and removal of Ceramir® waswas DispensingDispensing Sensitivity (Categorical --PatientPatient .. Results of the clinical handling deemed to be very easy. The cement Perception)Perception) reached a “crispy” state at the end of MixingMixing RetentionRetention workwork--timetime at the marginal areas of the Result clinical handling parameters restoration(s), which facilitated easy and Working Time Gingival Inflammation Index (GI) Dispensing Material now available in straightforward excess cement removal. Complete Seating Marginal Integrity capsules Mixing Easy Adverse Taste Marginal Discoloration Working-time 2 minutes Ease of Cement Removal CariesCaries Setting-time 4 minutes Visual Analogue Scale (VAS) -- Seating characteristics Very good SensitivitySensitivity Ease of cement removal Very easy

25 Porcelain Fused to Metal (PFM) Crowns CEMENTATION OF LITHIUM on Right and Left Lateral and Central Incisors; CeramirCeramir®® C&B Cement; ONE YEAR RECALL PHOTO DISILICATE ALL-CERAMIC CROWN

Clinical digital photograph of maxillary anterior, ceramo -metal restorations (right and left lateral and central incisors) cemented with Ceramir® at two year clinical evaluation.

Clinical study EVERYDAY ISSUES SO WHAT DOES Results What constitutes good handling in a BIOACTIVITY DO FOR ME Clinical parameters followed in the study were: lutingluting cement?cement? Sensitivity (Categorical) CLINICALLY?? RetentionRetention Soft Tissue Reaction Results of cement performance Summary Data & Conclusions from a field trial UNIQUE PULPAL BIOCOMPATIBILITY & Marginal Integrity up to three years recall have been CAPACITY FOR REGENERATION Marginal Discoloration excellent and quite clinically CariesCaries acceptable. 1.1. Easy to use. UNIQUE CAPACITY FOR REGENERATION Visual Analogue Scale (VAS) -- SensitivitySensitivity 2.2. Robust seating procedure. OF PERIODONTAL/PERAPICAL TISSUE Gingival Inflammation Index (GI) 3.3. Low viscosity ––easyeasy seating. FOR ROOT REPLACEMENT

1 Year results published in: Jefferies SR, Pameijer CH, Appleby D, BostonD, Lööf J, Glantz P-O. “One year clinical 4.4. Easy to clean up. performance and post-operative sensitivity of a bioactive dental luting cement – A prospectiveclinical study. Swed OK WHAT ELSE ––ESPECIALLYESPECIALLY FOR THE Dent J. 2009;33:193-199. RESTORATIVE DENTIST??? 2 Year results published in: Jefferies SR, Pameijer CH, Appleby D, BostonD, Galbraith C, Lööf J and Glantz P-O. Prospective Observationof a New Bioactive Luting Cement: 2-Year Follow-Up. Journal of Prosthodontics 21 (2012) 33–41

WHAT ARE THE NEW DISCLOSURE Physical & Clinical Properties of an PARADIGMS? In the interest of full disclosure, this Experimental Bioactive LutingLuting CementCement .. Bioactive vs. Inert research was supported, in part, by DoxaDoxa Acknowledgments Dental ABDentalAB .. Molecular Integration David C. Appleby, DMD, MScDMScD, FACP,FACP vs. “Physical –– Colin Galbraith, BS (MIT) Chemical” Adhesion Daniel W. Boston, DMD Kornberg School of Dentistry, Temple University .. Nanomolecular CornelisCornelis H.H. PameijerPameijer,, DMD, DSc, PhD StructureStructure University of Connecticut School of Dentistry vs.vs. JesperJesper LööfLööf,,M.Sc.EM.Sc.E, PhD,PhD Traditional, “Filler“Filler-- DoxaDoxa Dental ABDentalAB Matrix” Composite StructureStructure