Composite Alternatives the Most USED

Uncommon, Daniel H Ward DDS

Common Sense: . What YOU need to know NOW about Graduated 1979 OSU Restorative Dentistry and Materials . Private Practice‐Columbus, Ohio . Assistant Clinical Professor The Ohio State University‐1996‐2009

Daniel H Ward DDS

Daniel H Ward DDS “I get by with a little help from my friends…” . Reviewer‐Journal of Prosthetic Dentistry . Reviewer‐Journal of Esthetic and Restorative .Dr Harry Albers .Dr Graeme Milicich . Dentistry .Dr Paul Belvedere Dr Buddy Mopper .Dr John Burgess .Dr Jeff Morley . Member and Evaluator for Catapult .Dr Mark Canon .Dr Brian Novy . Lecturer and Chief Examiner University of .Dr Gordon Christensen .Dr Jorge Perdagão Minnesota Post‐Graduate Program in Esthetic .Dr George Freedman .Dr Steve Rosenstiel . Dentistry‐20 years .Dr Galip Gürel Dr Robert Seghi .Dr Geoff Knight .Dr Irwin Smigel .Dr Doug Lambert .Dr Byong Suh .Dr Karl Leinfelder .Dr Ed Swift

Companies I Work With Patients are more

.AdDent .Kerr knowledgeable than ever .BISCO .Pulpdent .Caulk/Dentsply .Shofu .Centrix .SDI .Clinicians’ Choice .SSWhite .Coltene/Whaledent .Tokuyama .GC America .Triodent .Heraeus Kulzer .3‐M .Ivoclar .VOCO

1 We must listen more to We must provide our patients alternatives for our patients

…but the right Composite alternatives The most USED

and ABUSED Material in Dentistry

Uncommon, common sense

•What is the most important restoration that determines the long term prognosis of a tooth? •Are flowable composites always an inferior restoration? •Does fluoride present within the enamel of an un-prepared tooth margin result in a better bond between resin and tooth?

2 Uncommon, common sense Composite Direct Placement Challenges •Does the addition of fluoride to a resin result in efficacious fluoride release? •Should preparations for tooth to be Decay Removal restored with a composite be the same as for a tooth to be restored with amalgam? Thoroughly remove decay only •What is the effect of warming composite immediately prior to placement?

Amalgam Composite 15 Year Old Preparation Preparation

“Convenience” MID Lifetime of tooth often determined by first dentist Form intervention

Conservative Tooth Preparation How do you restore?

330 169L

201.3VF

Fissurotomy bur Low Viscosity Flowable Composite

3 G-aenial Universal Flo Beautifil Flow 00

 Homogeneous spherical particles  Unique glass ionomer filler particles

 Better wear resistance  Releases fluoride and other ions

 Higher flexural strength (167 MPa)  Neutralizes pH-Antibacterial

 Filled 50% by volume  Reduced plaque accumulation

 Good polishability  Good polishability

 Visibly blends in well Mean particle size 200 nm  Visibly blends in well S-PRG (Surface pre-treated Glass Ionomer)

Low Viscosity Flowable Composite Low Viscosity Flowable Composite

S PRG Fillers CALSET Thermal Assisted Light Polymerization Significantly reduced plaque accumulation

BEAUTIFIL Ⅱ Conventional Restorative Material W （） Containing S-PRG filler （Not containing S-PRG filler） A plaque R M

Less plaque Full-grown plaque Compule Tray E Dispenser Gun Intra-oral plaque formation R （24 hours W/O Brushing） Warmer Tray

ADVANTAGES CALSET Thermal Assisted Light Polymerization Thermal Assisted Light Polymerization  Improved flowability of composites

 Improved marginal adaptation

 Improved rate of polymer conversion

 Improved surface hardness/durability/polishing.

 Decreased curing time and increased depth of cure

 Increased sculptability and ease in shaping anatomy

Stansbury JW. Use of near-IR to monitor the influence of external heating on dental composite Comax Dispenser Dispenser Gun Tray photopolymerization. Dent Mat 2004; 20(8).

4 “Dentistry begets Dentistry” Completed Tooth Restorations

“The more dentistry you do for a Low Viscosity Flowable Composite & patient, the more dentistry they will Warmed Composite eventually need.”

“Dentistry begets Dentistry” 15 Year Old

Re-Treatment Complete Notice the lower anterior teeth

Add dentin shade •Aura •Miris

BuildupBuildup dentin remaining Add A-2 replacementAdd translucentspecial witheffects toincisalform simulate with hybrid shade or opaquesimilar darker to desired •Venus Pearl hybridimperfectionsmicrofill –typically within final color with A3-A3.5tooth structure hybrid (typically •Kalore A1-A2) •TPH Spectra

5 Finish and polish Add A-1 restoration Restore adjacent tooth Shape, finish and polish restorations

Add Characterization Add Facial Surface

•Beautifil II Restore opposite Important-Junction •Aura Enamel teeth must be invisible •Kalore GT Optrasculpt •Esthelite Sigma Quick

Composite Direct Placement Pre-Operative Challenges

Post-Operative Sensitivity

Hydrodynamic Theory Finished Restorations

Hydrodynamic Theory Hydrodynamic Theory

SEM Dr Jorge Perdagão

Fluid flow within dentinal tubules causes PAIN Opened, unsealed dentinal tubules causes Brannstrom M. The Cause of post restorative sensitivity and its prevention. J Endod 1986;12:475- 481. PAIN

6 Dentin Dentin Bonding

 70% inorganic carbonate hydroxyapatite calcium phosphate  30% organic (collagen) and water  Dentinal tubules 0.06-3 microns in diameter  Most Bonding occurs between dentinal tubules  Hydrophilic

SEM Dr Jorge Perdagão

Oh NO, not another bonding Oh NO, not another bonding lecture! lecture! •What are MMP’s and what agents can •Is there a relationship between post- affect their effects? operative sensitivity and dentin bond strengths? •What is the effect of the width of the hybrid layer and dentin bond strengths? •What are the characteristics of alcohol, acetone and water based solvents of dentin •What new Self-Etching Primer Dentin bonding agents? Bonding Agent has bond strengths to un- etched enamel greater than 40 MPa ? •What are Universal Dentin Bonding Agents?

Etched Dentin

 Demineralize surface  Expose collagen fibers  Remove smear layer  Increase porosity of intertubular dentin SEM Dr Jorge Perdagão  Open up dentinal tubules  Increase surface area Etched Dentin

7 Total Etch Technique Bonding agent should not leave Placement of Etchant the dentinal tubules open Method #1-Reducing Post-Op Sensitivity •Total Etch Technique Fill and Occlude open dentinal tubules

Rinsing of Etchant Placement of Resin Primer “Moist” Dentin”

Apply multiple coats

“Overwet” Phenomenon Overdrying Placement of Resin Primer Collapsed collagen fibrils

Moist Moist

Tay FR, Gwinnett AJ, Wei Sh. The overwet phenomenon: a scanning electron microscopic study of Gwinnett AJ. Dentin bond strength after air drying and rewetting. Am J Dent. 1994;7(3):144-148. surface moisture in the acid-conditioned, resin-dentin interface. Am J Dent. 1996;9(3):109-114.

8 Overdrying Proper Moisture

Un-collapsed collagen fibrils Collapsed collagen fibrils

SEM Perdigao

Moisture Variability Bonding Agent Solvents

Acetone Alcohol Water

Evaporating the solvent with dry air Variability Air only syringe Warm air dryer

Sensitivity Bond Strength Air/water syringe Air/water syringe

9 Effect of Dentin Depth on Bond Strengths GLUMA Adhesive Single Optibond Clearfil System Bond Solo Liner Bond Superficial 22.1 18.9 21.0 Dentin (+/-2.8) (+/-4.1) (+/-7.4) Deep 14.2 18.4 17.6 Dentin (+/-7.0) (+/-4.8) (+/-5.9)

Mean shear bond strength in MPa •Occludes tubules

Lopez CL, Perdigao J, Lopes M et al. Dentin Bond Strengths of Simplified Adhesives:Effect of Dentin Depth. Compendium. 2006;27(6):340-345. •Anti-bacterial

Total Etch Technique Summary

 Most technique sensitive  Requires proper attention to detail  Use in ideal sized preparations

•Occlusions

Total Etch Technique Total Etch Technique Materials-4th Materials-5th Generation Generation

Acetone solvent Alcohol solvent Acetone solvent Alcohol solvent

10 Bonding agent should not leave Self-Etching Primer the dentinal tubules open Method #2-Reducing O Post-Op Sensitivity O CH 2 COOH CH 2 O •Self Etch Technique O COOH Methacrylate-group Spacer-chain Acid-groups Hydrophobic end link between Hydrophilic end Never leave the connects to functional groups etches tooth polymer-network structure (self dentinal tubules open limiting)

“Self Etching” Primer Resin Tags do not Contribute to Dentin Acidifying Primer accompanies etch Adhesion in SE Adhesion

Lohbauer U, Nikolaenko SA, Petschelt A, Frankenberger R.. Resin Tags do not contribute to dentin Acid reaction is self-limiting adhesion in self-etching adhesives. J Adhes Dent. 2008;10(2):97-103 .

Self-Etch Technique Challenges

 Decreased bond strength to un-etched enamel  Marginal gap formation with un-etched Self etching Primer enamel  Bond incompatibility to self-cure and dual-cure resins  More susceptible to hydrolytic degradation resulting in significantly diminished bond strengths over time

11 37% H3PO4 etched Unprepared enamel surface for 15s. Popular SE primer etched Unprepared enamel surface

Effect of Enamel Etching-Bond Strength Effect of Enamel Etching-Bond Strength •Tests confirm that preparing the enamel •Tests show that etching uncut enamel with margin improves bond strength especially phosphoric acid increases bond strength to with self-etch dentin bonding agents enamel with 1- bottle dentin bonding agents

Substrate All-Bond Universal All-Bond Universal Substrate All-Bond Universal All-Bond Universal Self-Etch Total-Etch Self-Etch Total-Etch

Uncut Enamel 18.7±6.7 31.4±7.1 Uncut Enamel 18.7±6.7 31.4±7.1

Cut Enamel 29.0±5.5 35.6±3.6 Cut Enamel 29.0±5.5 35.6±3.6

55% improvement 67% improvement

Bisco in-house data.. Bisco in-house data.. Lee IS, Son SA, Hur B, Kwon YH, Park JK. The effect of additional etching and curing mechanism of composite resin on the dentin bond strength. J Adv Lee IS, Son SA, Hur B, Kwon YH, Park JK. The effect of additional etching and curing mechanism of composite resin on the dentin bond strength. J Adv Prosthodont. 2013;5:467-484. Prosthodont. 2013;5:467-484.

Effect of Enamel Etching-Bond Strength Effect of Enamel Etching-Marginal Gaps •Tests show that etching cut enamel with •SEM analysis found no marginal gap phosphoric acid increases bond strength to formation of enamel etched w phosphoric acid enamel with 1- bottle dentin bonding agents prior to application of a self-etching 6th generation bonding agent (Clearfill SE) following thermocycling •SEM analysis reported marginal gap formation

Substrate All-Bond Universal All-Bond Universal of enamel not etched w phosphoric acid prior Self-Etch Total-Etch to application of a self-etching 6th generation

Uncut Enamel 18.7±6.7 31.4±7.1 bonding agent (Clearfill SE) following thermocycling Cut Enamel 29.0±5.5 35.6±3.6

22% improvement

Bisco in-house data.. Souza-Junior EJ, Prieto LT, Araújo CT, Paulillo LA. Selective enamel etching: effect on marginal adaptation of self-etch LED-cured bond systems in aged Lee IS, Son SA, Hur B, Kwon YH, Park JK. The effect of additional etching and curing mechanism of composite resin on the dentin bond strength. J Adv Class I composite restorations. Oper Dent. 2012;37:195-204. Prosthodont. 2013;5:467-484.

12 Effect of Enamel Etching-Marginal Gaps Bond Incompatibility with Self and Dual Cured Resins Solution: “Etching prepared enamel w When the pH of a dentin bonding agent is too phosphoric acid promoted better marginal low (more acidic), tertiary amines (necessary integrity with self-etching bonding agents.” for the polymerization reaction) are deactivated resulting in bond incompatibility with self and dual cured resins.

Souza-Junior EJ, Prieto LT, Araújo CT, Paulillo LA. Selective enamel etching: effect on marginal adaptation of self-etch LED-cured bond systems in aged Suh BI, Feng L, Pashley DH, Tay FR. Factors contributing to the incompatibility between simplified-step adhesives and chemically-cured or dual -cured Class I composite restorations. Oper Dent. 2012;37:195-204. composites. Part III. Effect of acidic resin monomers. J Adhes Dent 2003;5:267-282.

Bond Incompatibility with Self and Dual Bond Incompatibility with Self and Dual Cured Resins Cured Resins Solution: Use of a higher pH (>3.0)self-etching Solution: Use a dual-cure activator dentin bonding agent does not inactivate the tertiary amines and allows for polymerization.

pH=3.2

Suh BI, Feng L, Pashley DH, Tay FR. Factors contributing to the incompatibility between simplified-step adhesives and chemically-cured or dual -cured composites. Part III. Effect of acidic resin monomers. J Adhes Dent 2003;5:267-282.

Hydrolytic Degradation Hydrolytic Degradation

“The cured layer of 1-step self-etching Solution: Use 2 layers-a hydrophilic layer adhesives is hydrophilic and a permeable covered with a hydrophobic layer membrane.”

Tay F, Suh B, Pahsley D, Carvalho R. Single Layer Adhesives are Permeable membranes. J Dent 2002;30:371-382. Yoshida Y, Yoshihara K, Nagaoka N, Hayakawa S, Tori Y, Ogawa T, Osaka A, Van Meerbeek B. Self-assembled nano-kayering at the adhesive interface. J Dent Res 2012;9:376-381.

13 Hydrolytic Degradation Self Etch Technique

Solution: Use MDP containing bonding agents  6th generation DBA that effectively etches which become hydrophobic upon enamel polymerization due to high amount of cross- linkage. “MDP-containing adhesives form nano-layering at the adhesive interface. Stable MDP-Ca salt deposition along with nano- layering may explain the high stability of MDP-based bonding.”

Yoshida Y, Yoshihara K, Nagaoka N, Hayakawa S, Tori Y, Ogawa T, Osaka A, Van Meerbeek B. Self-assembled nano-kayering at the adhesive interface. J Dent Res 2012;9:376-381. OptiBond XTR

Unprepared enamel surface Self Etch Technique OptiBond XTR

Etched with 37% Phosphoric Acid OptiBond XTR 6th Generation DBA

Popular 6th Generation DBA Popular 7th Generation DBA

Swift E, et al. J Esthet Restor Dent. 2011;23(6):390-398.

Self Etch Technique Self Etch Technique OptiBond XTR OptiBond XTR

 2 component self-etch  Primer contain acetone, alcohol and water  15% filled by volume solvents  Hydrophilic acidic self-etching primer with  Low film thickness (5 micron) enhanced etching capabilities  Bonds to gold, non-precious metal,  Hydrophobic adhesive to maximize zirconia, porcelain material compatibility, increase strength  Direct and indirect restorative procedures and promote bond durability

14 Seventh Generation DBA Self Etch Technique Beautibond Materials 6th & 7th  Dual acidic monomers Generation  Low film thickness (5 micron)  Radiopaque  Easy to use-single application 10 sec

Sixth Generation Seventh Generation All-Bond SE Clearfil SE Optibond BeautiBond G-Bond Protect XTR

Long Term Dentin Bond Stability Long Term Dentin Bond Stability MMP-Matrix Metalloproteases Cysteine Proteases (Cathepsins)

 MMPs are naturally occurring proteases  Lysosomal enzymes that become activated in involved in dentin formation and trapped lysosomes by a low pH during odontogenesis  Secreted by osteoclasts in bone resorption  Not bacteria but proteolytic enzymes found  Regulated by chondroitin within dentin capable of degrading collagen within newly created adhesive hybrid layers  Collagenase activity breaks down collagen and hydrolyzes collagen into small peptides  Low pH causes dentin to release these inherent MMPs which attack exposed collagen fibrils

Osorio R, Yamauti M. Osorio E., et al. Effect of dentin etching on metalloproteinase- Terasariol Il, Geraldeli S., ,Minciotti Cl., et al., Cysteine catepsins in human dentin pulp mediated collagen degradation. Eur J Oral Sci 2011;119:79-85. complex. J Dent Res 2011; 90:506-11.

MMP-Matrix Metalloproteases Long Term Dentin Bond Stability In-vivo 12 m w/PBNT (Acetone) Potential MMP Inhibitors  Chlorhexidine (CHX)  w/CHX in 12 m  Benzalkonium Chloride  MDPB ((12-methacryloxydodecalpyridinium bromide)  Galardin (mimics MMP-binds Zn atom) (inhibits tumor growth and metastasis) Immediate (MPa) 14 mo (MPa) Control 29.3 (9.2) Control 19.0 (5.2)  Epigallocatechin-3-gallate (green tea CHX 32.7 (7.6) CHX 32.2 (7.2) polyphenol) Carrilho et al., JDR 2007; 86; 529 Perdigao J, Resi A, Loguercio AD. Dentin Adhesion and MMPs: A Comprehensive Review. J Brackett et al.,Operative Dentistry; 2009;34(4):381-385 Esthet Restor Dent 2012: 25:219-241.

15 Long Term Dentin Bond Stability Long Term Dentin Bond Stability Disinfect to prevent MMPs Disinfect to prevent MMPs

MDPB (12-methacryloxydodecalpyridinium bromide) Use Etchant containing 1% TE-ApplySE-Apply 2% 2Chlorhexidine coats 2% Benzalkonium Chloride afterChlorhexidine acid etching priorfor 30 to sec Pashley DH, Tay FR, Imazato S. Hot to Increase the durability of Resin-Dentin Bonds. Compend. application of primer 2010;32(7):60-64.

Dentin Bonding Challenges Dentin Bonding Solutions Most simplified one-step adhesives were shown to be the least In order to overcome these problems, recent studies indicated that durable, while three-step etch-and-rinse and two-step self-etch (1) resin impregnation techniques should be improved, particularly adhesives continue to show the highest performances, as reported for two-step etch-and-rinse adhesives; (2) the use of conventional in the overwhelming majority of studies. In other words, a multi-step adhesives is recommended, since they involve the use simplification of clinical application procedures is done to the of a hydrophobic coating of nonsolvated resin; (3) extended curing detriment of bonding efficacy. Among the different aging time should be considered to reduce permeability and allow a phenomena occurring at the dentin bonded interfaces, some are better polymerization of the adhesive film; (4) proteases inhibitors considered pivotal in degrading the hybrid layer, particularly if as additional primer should be used to increase the stability ofthe simplified adhesives are used. Insufficient resin impregnation of collagens fibrils within the hybrid layer inhibiting the intrinsic dentin, high permeability of the bonded interface, sub-optimal collagenolytic activity of human dentin. polymerization, phase separation and activation of endogenous collagenolytic enzymes are some of the recently reported factors that reduce the longevity of the bonded interface.

Breschi L, Mazzoni A, Ruggeri A, Cadenaro M, Di Lenarda R, De Stefano Dorigo E. Dental Breschi L, Mazzoni A, Ruggeri A, Cadenaro M, Di Lenarda R, De Stefano Dorigo E. Dental adhesion review: aging and stability of the bonded interface. Dent Mater. 2008 Jan;24(1):90-101. adhesion review: aging and stability of the bonded interface. Dent Mater. 2008 Jan;24(1):90-101.

Dentin Bonding Solutions Selective Etch Technique

• SE 1-step adhesives are too hydrophilic and permeable  Apply etch to enamel only for 15 seconds even after polymerization  Wash thoroughly • The best way to minimize these weaknesses is to apply  Place self-etching primer a neutral-pH, hydrophobic adhesive resin layer in a separate step • Acidic components cause incompatibility with self- cured composites. • 3-step, etch-and-rinse adhesives remain the “gold standard” in terms of adhesive durability.

De Munck J, Van Landuyt K, Peumans M, Poitevin A, Lambrechts P, Broem M, Van Meerbeek B. A Critical Review of the Durability of Adhesion to Tooth Tissue: Methods and Frankerger R, Lohbauer U, Roggendorf MJ, Naumann M, Taschner M. Selective enamel etching Results. J Dent Res. 2005;84(2):118-132. reconsidered:better than etch-and-rinse and self etch? J. Adhes Dent. 2008;10:339-344.

16 Selective Etch Technique Selective Etch Technique

 High Viscosity allows precise placement  Allows total etch or self etch of enamel  Contains BAC and/or dentin

G-aenial Bond

Selective Etch Technique Total, Self or Selective Etch

 Precursor to “Universal” Bonding agents Universal Bonding  Bond strength same to total vs self etch Materials Dentin Bond Strength

Self-Etch Total Etch Total Etch Moist Wet

Total, Self or Selective Etch Total, Self or Selective Etch Universal Bonding All-Bond Universal Materials  Total-etch, self-etch or selective-etch  Single bottle for direct and indirect  Total-etch, self-etch or selective-etch technique restorations  Can be used for direct and indirect restorations  High bond strengths to metal, ceramics,  Bond to all indirect substrates-metal, ceramics, zirconia, porcelain & lithium disilicate. zirconia, porcelain and lithium disilicate.  Compatible with light-cured, self-cured  Compatible with light-cured, self-cured and and dual-cured composite and luting dual-cured composite and luting cements. cements since pH is 3.2  Becomes hydrophobic upon setting

17 Total Etch vs. Self Etch Total, Self or Selective Etch Shear bond strength of Universal Adhesives on Tooth Structures MPa* Universal Bonding Materials

*Manufacturer supplied data

Total, Self or Selective Etch Total, Self or Selective Etch Universal Bonding Universal Bonding Materials Materials

Light Cured Dual Cured

Bonding agent should not leave Resin-Modified Glass Ionomer the dentinal tubules open Method #3-Reducing Post-Op Sensitivity •Total Etch Technique Never open the dentinal tubules

18 RMGI Base RMGI Liner Reprepare

No dentin conditioner Dentin conditioner needed due to self-etch preferred to achieve primer component optional dentin bond

TOP TEN REASONS: TOP TEN REASONS: GI isn’t used under every restoration GI isn’t used under every restoration

10. It’s not necessary 5. I don’t know how to use 9. It takes more time 4. Not as strong: I “bond” everything-holding tooth together and making it stronger 8. It costs more money 7. I don’t understand which product to use 3. It doesn’t bond as well to dentin as resin 6. Not necessary with today’s Hundredth 2. Fluoride release is transient generation bonding agents 1. Old fashioned: used before better bonding agents were available

Clinical Class I Clinical Class I Restoration Restoration

•Make initial access opening w small bur •Use high speed to refine preparation •Use slow speed to remove decay •Smooth margins with a football diamond.

19 Clinical Class I Clinical Class I Restoration Restoration

•Glass ionomer base/liner •Completed Preparations •Etch enamel then dentin, wash and dry

Clinical Class I Clinical Class I Restoration Restoration

Ivoclar P-1

•Place & scrub multiple coats bonding agent, wait, evaporate solvent and cure •Cure thoroughly •Place composite and adapt to sides

Posterior Occlusal Anatomy Occlusal Buccal/ lingual Finishing Burs Secondary Anatomy gingival-IP

12 fluted carbide burs

SS White Ivoclar Caulk Enhance/POGO Jazz Astropol Procedure Trim and shape composite Define secondary anatomy Restore buccal/ lingual Adjust occlusion Restore occlusal fissures contour Blend margin between Reduce and smooth tooth and composite composite surface •Blend margins with finishing carbides Interproximal shaping at gingiva and above contact •Adjust occlusion

Popular Instruments Football or egg-shaped Flame-shape Needle shape 7406 H-274 Safe-end SE6 •Finish and polish H379 5379-5 7901 15106-5 15121-5

20 Clinical Class I Restoration

•No metal in the center •Very Flexible-now more durable •Double Sided •Etch, wash/dry and apply surface sealant •Available in Unit Dose •Etch, wash/dry and apply surface sealant

Total Etch with RMGI Liner/Base “Fill me” in on the latest in Direct Restoratives! Summary •What’s new in composite technology?  Best reduction of post-operative sensitivity •What’s all the buzz about bulk fill  Insurance of fluoride release composites?  Best bond to enamel  Long term stable bond to dentin •To achieve good Class II interproximal  Use in majority of posterior preparations contacts with composite, you just use the same armementarium as amalgam?

New Filler Technology New Filler Technology Giomer Fillers Giomer Fillers Surface modified layer Glass Ionomer phase

Glass Core Beautifil Flow Plus Beautifil II

Set Glass Ionomer Material Surface Modified Pre- Reactive Glass Ionomer Filler

 Unique Filler particles made of set glass ionomer with special surface coating BeautiSealant BeautiBond

21 Giomer Technology Giomer Technology 8 Year Results 13 Year Results 19 of 26 Class I, and 22 of 35 16 of 26 Class I, and 25 of 35 Class restorations were observed. II restorations were observed. Retention rate 66% (27 of 41)  – 52% of retained noted as excellent No failures – 41% of retained noted minor changes No secondary caries Secondary caries rate 3.27% (2 of 61) Overall positive results and low secondary  Alpha or Bravo aesthetics caries attributable to Giomer technology No post-op sensitivity noted

Gordan VV, Mondragon E, Watson RE, Garvan C, Mjör IA. A clinical evaluation of a self-etching primer and a giomer restorative material: results at eight years. J Am Dent Assoc. 2007;138(5):621-7 Gordan VV, Blaser PK, Mjor IA, Sensi L, Watson R, McEdward DL, Riley III J. Clinical Evaluation of a Giomer Restorative System: Thirteen-Year Recall 2013 IADR #3104:University of Florida

New Filler Technology Low Shrinkage Composites

Agl Microfill Micro-Hybrid Heliomolar Miris, Point4, EsthetX, Venus

Nanocluster Nano-Hybrid Filtek Supreme Venus Diamond, Tetric Evo-Ceram, Nano/Hybrids in green Kalore, Esthelite Q

Open Margin Cracked Enamel New Filler Technology (white line) Nanofill/Hybrid Prepolymerized Filler

Average Size 17 µm 400 nm Strontium Glass

100 nm Lanthanoid fluoride

Glass Fillers 700 nm Strontium Glass 700 nm Fluoroaluminum Silicate Glass Fractured Cusp Non-aggregated nano silica filler

16 nm Silica filler

Effects of polymerization shrinkage STRESS Kalore

22 New Filler Technology New Filler Technology Spheroidal Fillers Spheroidal Fillers

Estelite Sigma Quick Estelite Sigma Quick Tetric Evo-Ceram Venus

1μm 1μm

 Easy polishing and retention Filtek Supreme Premise 4 Seasons

 Blends well into tooth structure Nano Clusters  Esthelite Sigma Quick-1 layer  Omega-2-3 layers (5,000 Magnification)

New Resin Technology New Resin Technology Nanofill/Hybrid Nanofill/Hybrid DX-511 DX-511 MW 895

BIS-GMA Concern about bis-GMA MW 512 Shrinkage of bis-GMA,TEGMA UDMA Higher molecular weight-less shrinkage MW 470 TEGMA New advances possible through resin MW 286 technology MW=Molecular Weight

New Resin Technology Nanofill/Hybrid Pre-Operative Increasing the size and molecular weight of monomers reduces overall shrinkage Polymerization

Low Molecular weight

High Molecular weight

Shrinkage Completed Preparation Less Shrinkage Kalore-Clinical Case

23 New Resin Technology Non bis-GMA Composites Fuji II LC Resin Modified Glass Kalore Ionomer Base Kerr products Venus Pearl

Kalore

Bulk Fill Composites Bulk Fill Composites

 Allow many posterior restorations to be built up  Modes of Action in 1 segment – Improved initiators  Descriptions – Greater translucency allows better light transmission – Delayed gel state formation – “Stick the stuff in the hole and cure” – Increased elasticity – Evolutionary – Monolithic  Materials  Physical Advantages – Flowable – Conventional – Deeper depth of cure – Less Polymerization Shrinkage  Advantages – Less Polymerization Shrinkage Stress – Quicker, easier – Reduced likelihood of air voids between layers – Less chance of enamel and cusp fractures – Increased likelihood of adequate resin polymerization

Bulk Fill Flowable Composites Surefill SDR Low Shrinkage Stress •Reduced polymerization shrinkage stress • Bulk fill to 4mm •Surefill SDR •Increased sensitivity to light • Voco Xtra Great placement with metal tips •Beautifil Bulk Flowable •Self-leveling •Venus Bulk Fill •A1, A2, A3 Universal shades

Roggendorf MJ1, Krämer N, Appelt A, Naumann M, Frankenberger R. Marginal quality of flowable 4-mm base vs. conventionally layered resin composite. J Dent. 2011;39:643-647.

24 Polymerization Shrinkage Stress Polymerization Shrinkage Stress Bulk Fill Posterior Composites (MPa) Low Shrinkage Stress

• Voco Xtra Fill •Beautifil Bulk Flow •Aura Bulk Fill •Tetric Evo-Ceram Bulk Fill •Sonic Fill

Sonic Energy Assisted Light ADVANTAGES Polymerization Sonic Energy Assisted Light Polymerization

 Improved flowability of composites

 Improved marginal adaptation

 5mm depth of cure

 Increased sculptability and ease in shaping anatomy

 Composite designed specifically for use Sonic Fill

Sonic Energy Assisted Light Sonic Energy Assisted Light Polymerization Polymerization

Sonic Fill Sonic Fill

25 Composite Direct Placement Interproximal Contacts Challenges Original Attempted Solutions Interproximal Contacts

Microband Focu-tip Trimax Christensen JJ. Duplicating the form and function of posterior teeth with Class II resin-based composite. Gen Dent. 2012;60:104-108.

Interproximal Contacts Interproximal Contact Sectional Matrix Challenges Solution

 Not enough pressure to separate teeth  Fly off  Wedge in the way Contact Perfect

Tofflemire vs. Sectional Interproximal Contact Tofflemire vs. Sectional Matrices Solution Tofflemire System Sectional Matrices  Thin contact at the Broad contacts at the marginal ridge proper height of contour Non‐anatomical Anatomically shaped  Food trap below contact contacts  Increased likelihood of: Tight Contacts fracture, recurrent caries and periodontal disease. Proper contacts that floss properly and promote gingival health Contact Perfect

26 Interproximal Contact Retainers

Universal V3 Ring Narrow V3 Ring

TrioDent/Palodent

Interproximal Contact Interproximal Contact Also Available as: Bands

Holes allow grip with Bendable tab Pin-Tweezers

Marginal Ridge Contour Side holes for easy removal Universal Ring Narrow Ring

Pin Tweezers Palodent Plus TrioDent/Palodent Plus

Interproximal Contact Interproximal Contact Bands Anatomical Wedges

Bicuspid

Molar Wave Wedges

Sub-gingival Molar Pin Tweezers TrioDent/Palodent Plus TrioDent/Palodent Plus

27 Place contoured band, wedge & V-Ring

Selective etching Prepare Challenge: enamel Wash thoroughly Adjacentmargins Class II Composite Restorations Apply bonding agent

Re-contour diamond/finishing carbides Finishing strips Sonicfill

Fill box 2/3’s full Compress w 1P Remove wedge Cure peel band back Finish buildup Place V-Ring on Cure IP adjacent tooth Cure Remove band & Burnish desired cure contact area ContacEZ

Selective etching

Place Composite as before Peel back Light Cure Place Universal band bonding agent Cure from Light Cure both sides at gingiva

28 V4 Clear‐Metal Matrix System Adjust occlusion •Transparent ring tines, wedge and matrix band to allow cure –through – great with bulk fill and deep cavities

•Very versatile – can be used on missing cusps, large boxes and where little tooth Finish and structure remains polish •Superior grip, even on severely compromised teeth

V4 Ring ClearMetal Matrix

Non‐stick •Transparent, Versatile non‐stick coating Can be used: •Leaves no Easier to clean and •where little tooth structure marks on remains restoration more durable tines Resin filled Micro‐Windows for •on large boxes optimum curing •misaligned/malpositioned •Hundreds of cure‐through teeth micro‐windows New tine shape •missing cusps •Similar curing to plastic Increased grip and •more compatible with Highly anatomical matrices stability circumferential bands •SuperCurve Matrix Clear tines •Malleable Light passes through the tines • Burnishale

ClearMetal Matrix ClearMetal Matrix

Non‐stick •Transparent, non‐stick coating •Leaves no marks on restoration Resin filled Micro‐Windows for optimum curing •Hundreds of cure‐through micro‐windows •Similar curing to plastic Highly anatomical matrices •SuperCurve Matrix •Malleable • Burnishale Small tip light output Small tip light output through band

29 V4 Wedge US Population is Aging

•Notches split the Population 60+ by Age: 1900-2050 wedge into 3 Source: U.S. Bureau of the Census sections

120,000,000 92 M •Sections compress 100,000,000 and expand independently 80,000,000 57 M allowing for more 60,000,000 42 M interproximal 40,000,000 28 M Number of Persons 60+ Persons of Number anatomical •Great sealing on variations the gingival margin 20,000,000 whatever the 0 interproximal 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 Age Age Age Age anatomy 60-64 65-74 75-84 85+

•Transparent, to allow cure‐through Number of people aged 60+

US Population is Aging US Population is Aging

Percentage 60+ by Age: 1900-2050 Source: U.S. Bureau of the Census • Xerostomia 30 0 25%

25 0 18% • Difficulty maintaining oral hygiene 17% 20 0 14% • Root exposures 15 0 Percentage 60+ 10 0 • Some unable to tolerate long appointments 5 0 • Difficulty coming to office 0 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Age Age Age Age • Fixed Income 60-64 65-74 75-84 85+

Percentage of people aged 60+

US Population is Aging Oral Environment Challenges- Xerostomia

 Don’t miss appointments  Appreciative  Pay bill  Often need more treatment  Refer new patients  Say Thank You!

60+ Patients are Wonderful Multiple Medications

30 Oral Environment Challenges- Oral Environment Challenges- Xerostomia Xerostomia

“40% of all prescription drugs In a published study of 131 different have dry mouth listed in the prescribed medications the most PDR as a possible side effect” common side effect cited was xerostomia.

Chalmers J. Personal Communication. 2006. Smith RG, Burtner AP. Oral side-effects of the most frequently prescribed drugs. Spec Care Dent. 1994;14:96-102.

Oral Environment Challenges- Oral Environment Challenges- Xerostomia Carbohydrates

Nutrition Facts:16 fl oz; calories 140; Nutrition Facts: Serving Size: total fat 0g; 8.3 fl. oz Calories: • Incidence increases with # of drugs taken sodium 220mg; potassium 60mg; 140 Total Fat: 0g Sodium: • 50% of patients taking 4 or more medications total carbs 28g; sugars 28g 200mg Protein: 0g Total Carbohydrates: 28g had Dry Mouth Sugars: 28g

Oral Environment Challenges- Oral Environment Challenges- Antacids Bottled Water

Ingredients:Calcium carbonate, adipic acid, corn starch, Fluoride-less water Fluoridated water crospovidone, dextrose, flavors, malodextrin, sucrose, talc, colors.

31 Oral Environment Challenges- Need Therapeutic Illegal Drugs Restorations

 Xerostomia patients  High carbohydrate users  Non-fluoridated water users  Drug abusers “Meth mouth” or chronic marijuana use

Look, we all know that Glass Composite Glass Ionomers are weak! Challenges Ionomer •Which wears more resin modified glass •Post-operative sensitivity  Low post-op sensitivity ionomers or pure glass ionomers? •Recurrent decay  Fluoride Release •According to research what is the average •Achieving proper moisture  Moisture variability 10 year survival rate of posterior single surface glass ionomers? •Polymerization shrinkage  No shrinkage •Increased time-layering  Bulk placement •Technique sensitivity  Simple-more forgiving

Look, we all know that Glass Glass Ionomer Ionomers are weak! Base/Restorative

•Which form(s) of glass ionomer can be used as an RUC under bonded crowns? Under conventionally cemented crowns? •Will placement of large glass ionomers always result in less total tooth and restored surface than placement of composites? Fuji IX Self Cure SDI Self Cure Glass Ionomer Glass Ionomer

32 Glass Ionomer Glass Ionomer Uses Characteristics •Multiple cervical carious lesions •Pediatric Patients •More highly filled-reduced wear •Sealants •Self-curing in 2.5-5 minutes •Class V restorations •No polymerization (setting) shrinkage stress •Sandwich Technique •Expansion/contraction similar to tooth •Crown buildups •High fluoride release •Long term interim restorations •Bioactive •Cements