RESTORATIVE DENTISTRY

Evolving Conservative Dentistry

George Freedman, DDS, FAACD, FACD

mere 20 years ago, fourth gen- The intervening years have tween infected and affected den- eration adhesives revolution- seen the development of improved tin and how much tooth structure Aized restorative dentistry by fifth and seventh generation ad- must be removed to assure long- offering a predictable technique hesives,3,4 microhybrid and nano- term operative success?)11,12,13 for bonding to both enamel and hybrid composites, LED curing 2. The disinfection of the pre- dentin.1 Less than five years later, lights, soft tissue lasers,5,6,7 and a pared dentinal tissue (how to advances in ionomer and resin host of other adjunct technologies eliminate the remaining bacteria technologies provided clinically that make dental treatment bet- to prevent redecay?),14,15 and successful dentin and enamel re- ter, easier, faster,8 and more pre- 3. The facilitation and simplification placement. In 2003, the first selec- dictable.9,10 These innovations of the restorative protocol (how to tive preparation burs that could have been evolutionary, rather differentiate healthy and un- than revolutionary, building upon healthy dentin were introduced.2 the existing science by gradual These were all revolutionary in- improvement and facilitation. novations that significantly al- tered the practice of dentistry. The three major clinical con- Within a decade, adhesive-resin cerns encountered by practitioners and composites had displaced in recent years have included: amalgam as the mainstream re- 1. The end-point of cavity prepa- storative materials. ration (how to differentiate be- Figure 1

Figure 2 Figure 3 Figure 4 Figure 5 20|oralhealth December 2010 www.oralhealthjournal.com RESTORATIVE DENTISTRY

Figure 6 Figure 7

Figure 8 Figure 9 Figure 10

Figure 11 Figure 13

Figure 12

reduce the numerous steps and tech- alized)16 but the conservation of II, on the other hand, is degraded nique sensitivities that arise in the affected dentin (infected tooth by healthy dentin and ceases to restoration of function and form?) structure that can be healed and cut (Figs. 4, 5). Smartburs II are remineralized). (Fig. 1) The slow used after the initial caries access Recent technological advances speed Smartbur II relies on tooth preparation has exposed the deep, have done much to allay these structure hardness, and not tis- underlying caries. In cases where concerns and to move dental prac- sue staining, to scientifically de- the caries is exposed (Fig. 6), tice towards ever greater clinical termine the endpoint. Its specifi- these instruments can typically predictability. cally designed Knoop hardness be utilized without the need for (harder than diseased dentin but local anesthetics because they do Preparation End-Point softer than healthy dentin) allows not traumatize or open healthy Second generation Smartburs II the bur to selectively remove soft dentinal tubules (Fig. 7). (SSWhite, Lakewood, NJ) are carious dentin while not cutting self-limiting polymer burs that the harder healthy dentin. Cavity Disinfection have been developed to address It is well established that some bac- the clinical problem of prepara- A carbide or diamond bur can teria remain in the prepared tooth tion endpoint: the removal of in- inadvertently penetrate through structures, no matter how thorough fected dentin (softened tooth the thin remaining dentin into the preparation process, and despite structure that cannot be reminer- the pulp (Figs. 2, 3) the Smartbur a tactile firmness and non-stained 22|oralhealth December 2010 www.oralhealthjournal.com RESTORATIVE DENTISTRY

Figure 14 Figure 15 Figure 16

Figure 17 Figure 18 Figure 19

Figure 20 Figure 21 Figure 22

appearance. It is now possible to that releases oxygen ions. (Fig. high concentration of ozone is very greatly decrease the likelihood of 9) These ions break open the li- effective in bacterial wall disrup- viable bacteria beneath the restora- posomes, rupturing the cell tion and destroys them within 20- tion by chemo-therapeutic methods walls, and killing the bacteria. 40 seconds.21,22,23,24 (Fig. 13) that can penetrate as far as 2-3mm into the remaining enamel or den- • Ozonix (Biozonix, Munchen, Simplification of the tin. These techniques effectively de- Germany) Localized Ozone Restorative Protocol stroy bacterial viability and permit Generator. (Fig. 10) The ozone ions Most restorative protocols require the subsequent remineralization of are generated in situ, and break numerous materials, each selected compromised tooth structures. down to oxygen molecules and oxy- for particular beneficial properties, gen ions. (Fig. 11) The ions are im- numerous steps, and a cumula- • The technologies that have mediately, and selectively, toxic to tively complex description of the been shown to be effective surface bacteria. A very low level of ozone specific sequence that must be fol- bactericidals are: concentration is required for a com- lowed exactly. For example, micro- Aseptim Plus (SciCan, Toronto, prehensive bactericidal hybrid composites have excellent ON) Photo-Activated Disinfection effect.18,19,20 compressive strength for occlusal System.17 (Fig. 8) surfaces BUT they may not flow This compact unit utilizes tolo- • Healozone (CurOzone USA, and adapt to margins and undercut nium chloride to specifically Aurora, ON). (Fig. 12) The ozone areas of the preparation and can be stain liposomes in bacterial cell ions are generated remotely and difficult to sculpt. Flowable com- walls. The stain is subsequently introduced to the tip-sealed tooth posites can adapt readily to the targeted by a red diode light surface through a handpiece. The micro-anatomy of the tooth surface www.oralhealthjournal.com December 2010 oralhealth|23 RESTORATIVE DENTISTRY

Figure 23 Figure 24 Figure 25

Figure 26 Figure 27 Figure 28

Figure 29 Figure 30 Figure 31 and are very polishable BUT can- teriors, and it is suitable for the anatomy of the restoration and to not withstand the masticatory occlusal surfaces of posterior teeth. seal the marginal areas. forces of direct occlusal contact. Two viscosities are available, a Used individually, or preferably Beautifil Flow Plus (Shofu, San sculptable non-flow (F 00) (Fig. 15) together, these innovative tech- Marcos, CA) introduces a new cate- and a low-flow (F 03) (Fig. 16), niques and materials provide gory of restorative material: the “in- which are used together in the practical clinical solutions to the jectable” flowable composite resin. Resin Cone Technique. Both are concerns listed above. The follow- (Fig. 14) Based on Giomer chemistry, suitable for the occlusal surfaces of ing demonstration indicates an it is neither a conventional composite posterior teeth. The highly elastic effective step-by-step protocol nor a flowable resin; Flow Plus is a Beautifil Flow F 10 is placed after that incorporates the latest ad- unique blend of these materials with the adhesive for interface stress vances in restorative dentistry. the benefits of both. Its high strength relief. Then, the non-flow is in- resin matrix is densely packed by jected to form cusps and marginal Clinical Protocol fillers optimized to 67%. ridges. It injects smoothly from the The rubber dam is punched and syringe, holds its shape, and does lubricated with water soluble Wink Beautifil Flow Plus F O3 has a not develop a dispensing “horn”. (Pulpdent, Watertown, MA) (Fig. higher yield point than other flow- Beautifil Flow Plus is not subject 17) to facilitate its insertion through ables; thus, it is not deformed by to technique sensitivity, and the interproximal contacts without the strong occlusal forces placed Cone Injection Technique offers an tearing. The Vita Easyshade on the posterior teeth. Due to its important time advantage when Compact (Vident, Brea, CA) deter- excellent physical properties, compared to the layering tech- mines the shade of the restorative Beautifil Flow Plus is indicated for nique. Beautifil Flow Plus 03 is material at the beginning of the restoring both anteriors and pos- placed last to finalize the occlusal procedure, either before the rubber 24|oralhealth December 2010 www.oralhealthjournal.com RESTORATIVE DENTISTRY

Figure 32 Figure 33 Figure 34

Figure 35 Figure 36 Figure 37

Figure 38 Figure 39 Figure 40

dam is placed, or immediately af- termine the preparation end- takes one minute or less of chair- terwards. (Fig. 18) It is important point; any further rotation of the time, and offers a greatly improved to record the shade while the tooth bur in the cavity simply abrades restorative predictability. is still moist; once it is desiccated, the bur, not the dentin. This Beautibond seventh generation sin- the tooth will appear unnaturally leaves the harder, remineraliz- gle-component, single-step adhe- chalky and opaque. The tooth is able (affected) dentin, covering sive (Shofu, San Marcos, CA) is air-dried and the CarieScan PRO the pulp chamber, intact. (Fig. 24) scrubbed onto all prepared dentin caries indicator (CarieScan, and enamel surfaces. (Fig. 30) It is Dundee, United Kingdom) (Fig. 19) The restorative process begins left undisturbed for 10 seconds, and is utilized to confirm the location with an optional etching step; sev- is then completely dried with an oil- and the extent of the decay.25,26,27,28 enth generation adhesives do not free air syringe. (Fig. 31) The (Fig. 20) require a separate etching step. A Beautibond is polymerized with a brief etch, 15 seconds or less, is un- Fusion high power LED curing- Access through the enamel is likely to harm the bonding strength light (DentLight, Richardson, TX). developed with a Great White of the dental surfaces. Etch-Rite (Fig. 32) Gold #2 carbide29 (Fig. 21) or a (Pulpdent, Watertown, MA) is ap- TDA #849 diamond (Fig. 22) high plied to the enamel first and then Next, the cavity is filled utilizing speed bur (both from SSWhite, the dentin (Fig. 25) and rinsed off the innovative resin Cone Lakewood NJ).30 Once the deep with copious water less than 15 Technique (as opposed to the more decay is exposed, The Smartbur seconds later. (Fig. 26) Then, the laborious and time consuming lay- II selectively removes the soft prepared tooth surfaces are disin- ering technique). Sculptable carious (infected) dentin. (Fig. 23) fected with the Aseptim Plus, (Fig. Beautifil Flow Plus F 00 is injected The structure of the Smartbur II 27) Ozonics, (Fig. 28) or Healozone. onto the bonded surface of the is designed to automatically de- (Fig. 29) Each of these treatments preparation; (Fig. 33) the composite www.oralhealthjournal.com December 2010 oralhealth|27 RESTORATIVE DENTISTRY

is formed into cones at the bases of the buccal cusps (Fig. 34) as it adapts intimately to the prepara- tion. Since Flow Plus 00 is a non- flow resin, it stays where it is placed until curing. The Beautifil Flow Plus 00 is then injected to form the cones at the bases of the lingual cusps, (Fig. 35) from cavity Figure 41 Figure 42 floor to the occlusal, until all four cusp bases are restored (Fig. 36). Dentistry and a Diplomate of the 14. Lynch E, Baysan A, Ellwood R et al, Effectiveness of The injected cones are then polym- two fluoride dentifrices to arrest root carious lesions, American Board of Aesthetic Am J Dent, 2000, 13:218-220 erized with the Fusion curing light. Dentistry. Dr. Freedman sits on 15. Nyvad B, Fejerskov O, Scanning electron microsco- (Fig. 37) Once the cone build-up is the Oral Health Editorial Board py of early microbial colonization of human enamel and complete, Beautifil Flow Plus F 03 root surfaces in vivo, Scan J Dent Res, 1987, 95: 287-296 (Dental Materials and Technology) 16. Freedman G, Minimally Invasive Dentistry - The is injected to seal the marginal ar- is a Team Member of REALITY Management of Caries (Contributor)-Polymer Cutting eas (Fig. 38) and the valleys be- and lectures internationally on Instruments section Quintessence Publishing Co. Ltd Surrey United Kingdom 2007 p 109-110 tween the cones. (Fig. 39) The BFF dental esthetics and dental tech- 17. Freedman G, Lynch E, Photo-Activated Disinfection, F 03 is a low-flow material that can nology. A graduate of McGill Oral Health Magazine, December 2009, 19-25 18. Baysan A, Management of Primary Root Caries readily be shaped by the Duckhead University in Montreal, Dr. Freedman maintains a private using Ozone Therapies, PhD Thesis, University of instrument (Hu-Friedy, Chicago, London, 2002 practice limited to Esthetic IL) (Fig. 40) prior to final light- 19. Bocci V, Luzzi E, Corradeschi F, et al, Studies on the Dentistry in Markham, Canada. biological effects of ozone:4 Cytokine production and curing. (Fig. 41) The Duckhead glutathione levels in human erythrocytes, J Biol Regul Homeost Agents, 1993: 7: 133-138 composite instrument minimizes Oral Health welcomes this 20. Ericson D, Zimmerman M, Raber H, Gotrick B, (and in many cases, eliminates) the original article. Bornstein R, Clinical evaluation of efficacy and safety of need for occlusal adjustment and a new method for chemo-mechanical removal of car- ies, Caries Res 1999: 33: 171-177 References polishing, further improving the 1. Nahabayaski N, Bonding mechanisms of resins 21. Baysan A, Lynch E, Grootveld M, The use of ozone efficiency of the restorative proto- and the tooth (in Japanese), Kokubyo Gakkai Zashi, J for the management of primary root carious lesions, Stomat Society, Japan 1982 49:410 In: Albrektsson (ed): Tissue Preservation and Caries col. The completed restoration (Fig. 2. Freedman G, Polymer Preparation Instruments, Treatment, Quintesssence 2001:3:49-67 42) demonstrates the clinical result Dentistry Today, APRIL 2003 22:5 58-62 22. Baysan A, Whiley R, Lynch E, Anti-microbial effects 3. Freedman G, Fifth Generation Bonding Systems: of a novel ozone generation device on micro-organisms of the technique and material en- State of the Art in Adhesive Dentistry, J Canadian Dental associated with primary root carious lesions in vitro, hancements that are available to Assoc June 1997 63:6 347-350 Caries Res 2000, 34: 498-501 4. Freeman, G Seventh-Generation Adhesive Systems, 23. Bocci V, Biological and clinical effects of ozone, Has the practitioner today. Dentistry Today NOVEMBER 2002 21:11 106-111 ozone therapy a future in medicine? Br J Biomed Sci 5. Goldstep, F, Diode Lasers For Periodontal Treatment: 1999, 56: 270-279 The Story So Far, Oral Health December 2009 44-46 24. Bocci V, Ozone as a bioregulator, Pharmacology and Conclusion 6. Goldstep F, Soft Tissue Diode Laser : Where Have toxicology of ozonetherapy today, J Biol Regul Homeost Innovations in end-point determi- You Been All MY Life?, Oral Health July 2009 34-38 Agents 1996: 10:31-53 nation, cavity surface disinfec- 7. Goldstep F. Diode Lasers For Periodontal Treatment: 25. Pitts N, How Electrical Caries Detection and The Story Continues, Dental Town June 2010 11:6 66-69 Monitoring with CarieScan Can Help Deliver Modern tion, and the simplification of re- 8. Freedman G, Goldstep F, Seif, T, Watch and wait is not Caries Management, Oral Health Magazine, July 2010 acceptable treatment - Ultraconservative resin restora- storative techniques have again 34-43 tions, J Can Dent Assoc 1999, 65: 579-581 26. Pitts NB and Stamm J, ICW-CCT Statements, 9. Freedman G, Leinfelder K, Seventh Generation revolutionized dental practice. Journal of Dental Research 2004 83: Special Issue C Adhesive Systems, Dentistry today 2002, 21:106-111 125-128 Mainstream clinical procedures 10. Fusayama T, A simple pain-free adhesive restorative 27. Detection, Assessment, Diagnosis and Monitoring are better, faster, and easier, and system by minimal reduction and tooth etcing, Tokyo Ishiyaku Euro America Inc, 1993 of Caries - Editor NB Pitts, Karger Monographs in Oral much more predictable in the 11. Fusayama T, Okuse K, Hosada H, Relationship Science, Vol 21 ISBN 978-3-8055-9184-3, S Karger AG Basel (Switzerland) 2009 long-term. OH between hardness, discoloration and microbial invasion in carious dentin, J Dent Res, 1966: 45: 1033-1046 28. Pitts NB, Are we ready to move from operative to 12. Hosoya Y, Marshall SJ, Watanabe LG, Marshell GW, non operative/preventive treatment of dental caries in Dr. George Freedman is a Microhardness of carious deciduous dentin, Oper Dent clinical practice? Caries Research 2004: 38:294-304 founder and past president of the 2000: 25: 81-89 29. Kimmel K, Optimal selection and use of rotary American Academy of Cosmetic 13. Kutsch VK, Everett M, Process for the removal of instruments for cavity and crown preparations. Dent soft tooth decay using a unique abrasive fluid stream, Echo 1993: 63 (2) 63-69 Dentistry, a co-founder of the United States Patent 5,601,430, United States Patent 30. Siegel SC, von Fraunhofer JA, Cutting efficiency of Canadian Academy for Esthetic and Trademark Office, February 11, 1997 three diamond bur grit sizes JADA 2000 131, 1706-1710

oralhealthjournal is a ‘coach’s manual’ for dentists. Published since 1911, Oral Health Journal targets all 18,000 practicing dentists across Canada, covers all areas of specialty and is read by 3rd and 4th year dental students and all Canadian dental labs. Independent, Oral Health is not an association publication. Clinical articles are written by dentists, for dentists. 28|oralhealth December 2010 www.oralhealthjournal.com