Preservation, Conservation, and Restoration of Posterior Tooth by xzd16972

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             Preservation, Conservation, and
         Restoration of Posterior Tooth Structure
               With Advanced Biomaterials
               Douglas A. Terry, DDS          Assistant Professor                                              Karl Leinfelder,             mechanical properties and clini-
               Institute of Esthetic and      Department of Restorative Dentistry and                           DDS, MS                     cal success of composite resins.7
                 Restorative Dentistry         Biomaterials                                                    Professor Emeritus
               Houston, Texas                 University of Texas Health Science Center                        Department of Biomaterials
                                                                                                                                            The filler particles are silanated
               Phone: 281.481.3470                                                                             University of Alabama        for satisfactory adhesion to the
               Fax: 281.484.0953              Adjunct Faculty                                                   School of Dentistry         organic matrix. The indirect sys-
               Email:                         UCLA Center for Esthetic Dentistry                               Birmingham, Alabama
                 dterry@dentalinstitute.com   Member of International Oral Design                              Phone: 919.489.4287          tem’s filler composition varies for
                                                                                                               Fax: 919.489.5807            the dentin material and the body
                                                                                                               Email: kcullie@aol.com
                                                                                                                                            and incisal. The dentin material
       he search continues for the            development of adhesive dental                    and the specific material proper-           is a highly filled hybrid (85% by

T      ideal restorative material
       that has properties similar
to tooth structure. Such a system
                                              technology has dramatically
                                              changed the way dentistry is
                                              practiced in the modern dental
                                                                                                ties of this next generation of an
                                                                                                indirect composite resin system
                                                                                                (TESCERA™ ATL™, BISCO, Inc)
                                                                                                                                            weight, 73% by volume) similar
                                                                                                                                            to the proprietary mixture of the
                                                                                                                                            direct restorative AELITE™ LS
should be resistant to masticato-             office. Modern adhesive restora-                  including a detailed review of the          (BISCO, Inc). This increased filler
ry forces and have not only simi-             tive materials and techniques                     laboratory and clinical recon-              loading allows for a volumetric
lar physical and mechanical                   have provided dentists with more                  structive phase with preparation            shrinkage of 1.5% while main-
properties to that of the natural             conservative treatment avenues                    design and fabrication (layering            taining a high flexural strength.8,9
tooth but also a similar appear-              that preserve tooth structure                     technique and fiber reinforce-              The body and the incisal material
ance to natural dentin and enam-              while improving the longevity                     ment). Adhesive surface prepara-            consist of a reinforced microfill
el.1 The longevity of a restoration           and esthetics of the restoration.5                tion and cementation protocol               (70% by weight) similar to the
increases as the mechanical pro-                  Indirect laboratory-processed                 have been presented to demon-               proprietary mixture of the direct
perties more closely approximate              composite resin systems provide                   strate the clinical application of          restorative Micronew™ (BISCO,
those of the enamel and dentin.2              an esthetic alternative for intra-                this system to fabricate inlay              Inc).8 Added to the nanoparticles
An ideal restorative material                 coronal posterior restorations.                   restorations on the maxillary right         is a relatively large reinforcement
should fulfill the three basic                Laboratory-processed inlays/onlays                first molar and second premolar.            particle that averages 1 µm com-
requirements of function, esthet-             fabricated with composite resin                                                               pared to the main filler, which is
ics, and biocompatibility. At pre-            provide esthetic results that may                 SYSTEM COMPONENTS                           0.04 µm. The average particle
sent, no restorative satisfactorily           also reinforce tooth structure.4                      A better understanding of a             size for this composite is approx-
fulfills all these prerequisites.3            Because adhesive procedures                       specific indirect composite resin           imately 50 nm (0.05 µm). The
     Optimizing the adhesion of               strengthen the cusps and provide                  system requires a discussion of             presence of these 1-µm reinforce-
restorative biomaterials to the               additional support for the denti-                 the components of the system:               ment particles contributes to the
mineralized hard tissues of the               tion, a more conservative prepa-                  the resin material and the curing           strength by acting as a “crack stop-
tooth is a decisive factor for en-            ration design can be used. Ad-                    mechanism. The indirect com-                per,” whereas the increased parti-
hancing the mechanical strength,              ditional clinical benefits include                posite resin system used in this            cle concentration of the microfill
marginal adaptation, and sealing              precise marginal integrity, wear                  case, TESCERA™ ATL™, contains               particles provides improved clini-
that appears to improve the reli-             resistance similar to enamel, wear                a combination of three types of             cal performance through an
ability and longevity of the adhe-            compatibility with opposing nat-                  composite material: dentin, body,           increased polishability, durability
sive restoration.4,5 The search for           ural dentition, ideal proximal                    and incisal components. Other               of the polish, wear resistance, and
a tooth restorative interface that            contacts, excellent anatomic mor-                 indirect composite resin systems            fracture resistance.10
mimics the natural tooth condi-               phology, and optimal esthetics.4,5                that could have been used in-                    The matrices for the dentin,
tion has resulted in an effective                 Whereas many articles have                    clude: belleGlass™ NG (Kerr                 body, and incisal material con-
micromechanical bond between                  examined the plethora of uses                     Corporation), Cristobal®+ (Dent-            sist of various combinations of
composite and mineralized tooth               for indirect resin reinforced sys-                sply Prosthetics), and GRADIA™              diluents: Bis-GMA (bisphenol
structure. The principle advan-               tems, this article will focus on                  Light-Cured Micro-Ceramic Com-              A-glycidyl methacrylate), ure-
tages of a bonded restoration                 the inlay restoration employing                   posite (GC America Inc).                    thane dimethacrylate, ethoxy-
include: restoration retention,               an indirect resin reinforced sys-                     In choosing a resin material,           lated bis “a” dimethacrylate
reduction or elimination of mar-              tem that uses three curing mech-                  the particle size determines how            (DIMA), and TEGDMA (trieth-
ginal microleakage, and rein-                 anisms—pressure, light, and heat                  to best use composite materials.6           ylene glycol dimethacrylate).
forcement of remaining tooth                  underwater. This article describes                The filler particle size, distribu-         However, the matrix for the
structures.6 This evolution in the            each of the system’s mechanisms                   tion, and quantity affects the              incisal differs from that of the

46                                                                                        May 2004                                            CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE
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Special Feature continued
dentin and body in that the              ber and onto the composite sur-
incisal uses a low Bis-GMA con-          face. During the incremental
centration, whereas the dentin           build-up process, each light-cure
and body materials have a higher         cycle requires 2 minutes and sta-
concentration. A study of the            bilizes the restoration. In the
incisal material by Ferracane and        authors’ experiences, this allows
Condon at Oregon Health                  for the placement of subsequent
Sciences University indicates a          increments without deforming
greater abrasion resistance than         the underlying composite layer.         Figure 1—Reinforcement materials of dif-   Figure 2—Preoperative occlusal view of
                                                                                 ferent shapes, sizes, and configurations   defective composite restorations with
other indirect systems tested.10             After the restoration develop-      can be used to improve the flexural        recurrent decay.
The manufacturer suggests that           ment, the final cure is accom-          strength and fracture resistance of the
this improved wear resistance of         plished in a heat cup with the          indirect composite restoration.
the incisal material is a result of      restoration submerged in water.
the change in concentration of           Any residual free oxygen in the         releasing pressure) for 10 to 13           CO, Inc), which consists of pre-
Bis-GMA.11                               water is removed by adding an           minutes depending on the res-              tensile stressed quartz fibers that
     Polymerization for this sys-        oxygen-scavenger agent because          toration size and the initial water        are cured into a resin matrix to
tem combines light and heat              oxygen limits the degree of poly-       temperature. The final curing              provide a rigid, strong reinforcing
underwater. The artificial dentin        merization by competing at the          process with heat under pressure           structure. These materials consist
is initially pressurized (60 pounds      carbon double bond sites. Re-           increases the polymer conversion           of different shapes and configura-
per square inch [psi]) in a light        moving oxygen allows for a more         and eliminates the residual                tions (ie, U-bars, barrels, sleeves,
cup before the light-curing cycle        complete cure because no air-           monomers. The resulting com-               and fiber bundles) that have been
is initiated. The initial pressur-       inhibited layer remains uncured.12      posite material provides increased         surface treated to enhance the
ization eliminates the incorpora-        The removal of oxygen also may          strength and homogeneity, excel-           adhesion to any synthetic restora-
tion of internal voids and bub-          improve the physical and mech-          lent esthetics with enhanced               tive material (Figure 1).
bles during the incremental              anical properties at the surface.       optical properties and fluores-
build-up process. The light cup          The final restorations are cured        cence, low water sorption and              CASE STUDY
contains white reflection beads,         using an initial full cycle of pres-    solubility, color stability, and           Preoperative Considerations
which provide support to the             sure (60 psi) with light and heat       superior resistance to wear and                 A 41-year-old woman pre-
working die while reflecting and         (peak heat of 130°C and decreas-        deformation.4                              sented with defective composite
diffusing light around the cham-         ing to approximately 90°C before                                                   resin restorations in the maxil-
                                                                                 FIBER REINFORCEMENT                        lary right first molar and second
                                                                                     A principal consideration in           premolar. The existing compos-
                                                                                 determining the long-term suc-             ite restorations had open margins
                                                                                 cess of laboratory-fabricated resin        with recurrent decay (Figure 2).
                                                                                 inlays is tooth reinforcement. To          After thorough examination and
                                                                                 reinforce the composite resin,             assessment, the patient expressed
                                                                                 additional fibers (TESCERA™                interest in replacing the existing
                                                                                 reinforcement material, BISCO,             restorations with the most con-
                                                                                 Inc) are integrated into the resin         servative, durable, and esthetic
                                                                                 matrix13,14 during fabrication and         restorations available. The pre-
                                                                                 before the curing process. Other           operative considerations included:
                                                                                 fibers that could have been used           preoperative models, custom
                                                                                 in this case are: Contruct (Kerr           shade selection, a hand-drawn
                                                                                 Corporation) and Ribbond®                  occlusal and shade diagram, and
                                                                                 (Ribbond® Inc). These fibers               caries assessment using quantita-
                                                                                 have been surface treated to en-           tive light-induced fluorescence.
                                                                                 hance the adhesion to any syn-                  Before establishing the cavo-
                                                                                 thetic restorative material. Al-           surface boundaries of the prepa-
                                                                                 though no long-term clinical               ration design, it was necessary to
                                                                                 trials are available to determine          evaluate the lingual fissure with
                                                                                 the clinical success of these mate-        light-induced fluorescence (DIA-
                                                                                 rials, a recent short-term study           GNOdent, KaVo America Corp-
                                                                                 on 60 single-crown restorations            oration). This system relies on
                                                                                 demonstrated no breakage after             fluorescent diagnosis of caries,
                                                                                 1 year.15,16 The authors believe it        in which the fluorescent proper-
                                                                                 is prudent to incorporate the              ties of enamel and dentin are
                                                                                 composite reinforced fibers be-            altered by mineral loss. This
                                                                                 cause the flexural strength and            device aids in monitoring or
                                                                                 fracture resistance of the restora-        assessing caries and is a useful
                                                                                 tion is increased.15,17                    adjunct to diagnosing fissure
                                                                                     Another reinforcing structure          caries. The DIAGNOdent scale
                                                                                 for these indirect composite               reading of 11 indicated no caries
                                                                                 resin systems is the TESCERA™              present but the region was to be
                                                                                 structural fibrous material (BIS-          monitored in the future.
                       Circle 39 on Reader Service Card

48                                                                         May 2004                                           CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE
GC AMRERICA PASTE PAK
NEED NEW SCAN




            Circle 40 on Reader Service Card
Special Feature continued
Clinical Preparation                  tion is valuable in preparation         ment to prevent improper color       or restorative recipe can be used
   Before administering anes-         design when considering place-          selection as a result of dehydra-    to diagram the existing colors of
thesia and rubber dam isolation,      ment of centric stops beyond or         tion and elevated values.19 When     the tooth to be prepared and will
the preoperative occlusal stops       within the restoration and in           teeth dehydrate, air replaces        indicate anatomic morphologic
and excursive guiding planes          minimizing finishing proce-             water between the enamel rods,       details such as developmental
were recorded with articulation       dures.18 A preoperative selection       changing the refractive index that   grooves, shape of embrasures,
paper and transferred to a hand       of composite resins, tints, and         makes the enamel appear opaque       prominences, convexities, facets,
drawn occlusal diagram, record-       modifiers with their shade and          and white.20 The use of a color-     angles, plane areas, or any other
ed on an intraoral camera or          orientation is recorded. Shade          corrected daylight source of         characteristics that can provide
indicated and reviewed on a           selection should be accom-              5,000ºK is necessary for proper      helpful information when recon-
stone model. This initial registra-   plished before rubber dam place-        color registration.14 A shade map    structing the tooth surfaces.19
                                                                                                                       The following protocol requires
                                                                                                                   two appointments. At the first
                                                                                                                   appointment, when anesthesia is
                                                                                                                   administered, the treatment site
                                                                                                                   was isolated with a rubber dam.
                                                                                                                   An elongated hole was created to
                                                                                                                   allow placement of the rubber
                                                                                                                   dam over the retainers to achieve
                                                                                                                   ease of placement and removal,
                                                                                                                   to provide an adequate field con-
                                                                                                                   trol, and to protect against con-
                                                                                                                   tamination.20,21 After removal of
                                                                                                                   the composite restorations and
                                                                                                                   recurrent caries, the dam was
                                                                                                                   removed and a second photo-
                                                                                                                   graphic comparison to the under-
                                                                                                                   lying dentin color was performed
                                                                                                                   before completion of the prepara-
                                                                                                                   tion to reduce the influences of
                                                                                                                   tooth dehydration (Figure 3).
                                                                                                                   The rubber dam was replaced, a
                                                                                                                   final caries assessment was per-
                                                                                                                   formed with light-induced fluo-
                                                                                                                   rescence (DIAGNOdent) (Figure
                                                                                                                   4), and the preparations were
                                                                                                                   refined. The cavity design fol-
                                                                                                                   lowed the preparation guidelines
                                                                                                                   for indirect inlay restorations,
                                                                                                                   which includes: all enamel sup-
                                                                                                                   ported by sound dentin, all inter-
                                                                                                                   nal angles and edges rounded,
                                                                                                                   isthmus width at least 2 mm with
                                                                                                                   a depth of at least 1.5 mm, all
                                                                                                                   proximal walls flared or diverged
                                                                                                                   5° to 15° with no undercuts,
                                                                                                                   sharp cavosurface margins, and
                                                                                                                   the gingival margins prepared to
                                                                                                                   a 90° cavosurface line angle (butt
                                                                                                                   joint) with no feather-edge
                                                                                                                   preparation.4,13,15,22,23 As a general
                                                                                                                   guide, when the isthmus pre-
                                                                                                                   paration exceeds one half of the
                                                                                                                   distance from the central fossa to
                                                                                                                   the cusp tip, cuspal coverage
                                                                                                                   should be considered. In areas of
                                                                          Circle 41 on Reader Service Card
                                                                                                                   low stress and where there is min-
                                                                                                                   imal potential of tooth flexure,
                                                                                                                   thinner areas of tooth structure
                                                                                                                   may be judiciously inlayed. For
                                                                                                                   large restorations or weak teeth
                                                                                                                   with minimal enamel, fibers
                                                                                                                   should be included as a base on
                                                                                                                   which to veneer the composite.14

50                                                                   May 2004                                        CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE
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     Before taking the impression,    been used include: Concepsis®         Inc) was applied onto the primed
it is important to seal the dentin    (Ultradent Products, Inc) and         surface with an applicator tip in 2
tubules with a hybrid layer.5,24,25   Pumice Preppies™ (Whip Mix            separate coats, air-dried for 10
This protects the pulp from           Corporation). A self-priming          seconds, and light-cured for 10
microorganisms and reduces            etchant (TYRIAN™ SPE, BISCO,          seconds per surface (Figure 5).
sensitivity during the provisional    Inc) was applied to the entire        An accurate polyvinylsiloxane
stage. The preparation was cleaned    cavity surface with an applicator     impression (TAKE 1®, Kerr Corp-
with a 2% chlorhexidine diglu-        tip in 2 separate coats, slightly     oration) was taken defining all
conate disinfectant (Cavity Clean-    agitated for 10 seconds, and blot-    cavosurface margins. Other im-        Figure 3—Photographic custom shade
                                                                                                                  comparison to the natural tooth structure.
ser™, BISCO, Inc) and lightly air-    ted dry with a foam pellet. A thin    pression materials that could
dried for 5 seconds. Other            layer of single component adhe-       have been used include: Aquasil™
disinfectants that could have         sive (ONE-STEP® PLUS, BISCO,          (Dentsply Caulk), Imprint™ II or




                                                                                                                  Figure 4—Caries detection was per-
                                                                                                                  formed with light-induced fluorescence.




                                                                                                                  Figure 5—Hybridization of the inlay
                                                                                                                  preparations before impression taking.

                                                                                                                  Position™ Penta™ Quick (3M
                                                                                                                  ESPE), and Splash!® (Discus Den-
                                                                                                                  tal®, Inc). A direct provisional
                                                                                                                  restoration was placed with a
                                                                                                                  matrix band (AutoMatrix®, Dent-
                                                                                                                  sply Caulk) using a light-cured,
                                                                                                                  semi-flexible material (Fermit/
                                                                                                                  Fermit N, Ivoclar Vivadent®, Inc)
                                                                                                                  and the occlusion was inspected.
                                                                                                                  The laboratory narrative includ-
                                                                                                                  ed a comprehensive description
                                                                                                                  of the patient and her expecta-
                                                                                                                  tions with the preoperative mod-
                                                                                                                  els, a hand drawn shade and
                                                                                                                  occlusal mapping diagram, a
                                                                                                                  model of the opposing dentition,
                                                                                                                  an interarch occlusal bite regis-
                                                                                                                  tration, preoperative photographs,
                                                                                                                  photographs of the preparations
                                                                                                                  with the corresponding custom
                                                                                                                  shade tab for comparison, and an
                                                                                                                  accurate final impression of the
                                                                                                                  preparations.

                                                                                                                  Laboratory Fabrication
                                                                     Circle 43 on Reader Service Card                 The technician needs more
                                                                                                                  than the stone model to fabricate
                                                                                                                  an esthetic restoration that rep-
                                                                                                                  licates the colors, texture, shape,
                                                                                                                  contour, and anatomic mor-
                                                                                                                  phology of the existing tooth. A
                                                                                                                  shade diagram describing the
                                                                                                                  transition of color from fossa to

52                                                                    May 2004                                      CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE
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Special Feature continued
                                                                                                                                       significantly increases the flexur-
                                                                                                                                       al strength and fracture resis-
                                                                                                                                       tance of the restoration.15,17 A B-
                                                                                                                                       2 shaded body composite is
                                                                                                                                       developed in increments to cre-
                                                                                                                                       ate an internal dentin core with
                                                                                                                                       each subsequent layer cured in
                                                                                                                                       the light cup for 2 minutes
Figure 6—Development of the inner core      Figure 7—A small amount of red/brown          Figure 8—A final occlusal layer (incisal     (Figure 6). An incisal clear shad-
of the restoration with a body B-2 shaded   tint was applied to specific areas on the     clear) was applied at the cavosurface mar-
                                            occlusal to give the illusion of fissure      gin and smoothed into the existing           ed composite is applied over the
composite resin.
                                            stains.                                       anatomic morphology.                         occlusal surface to create a har-
                                                                                                                                       monious integration of the tooth
cavosurface margin, marginal                limited by its ability to match all           impression is poured for a master            enamel with the restorative
ridge translucency, occlusal wear           natural teeth.25 Variations in the            cast and a working cast. The                 material. While the material is
facets, and occlusal-groove stain-          color of enamel are related to                casts are mounted on an articula-            still soft, the internal characteris-
ing becomes the technician’s                such factors as opalescent level,             tor for the duplication of oc-               tics (creation of pits and fissures,
restorative recipe. To convey the           value, translucency, and opacity.             clusal movements. The working                staining of grooves, or creation
color of the enamel and the                 While the selection of the dentin             model is mounted on dies to                  of internal color) were applied
dentin, a 35-mm photograph of               color is relatively simple, the               facilitate the layering process.             using an endodontic file. A mix-
the shade tab next to the preex-            matching of the enamel where                  After blocking out any undercuts             ture of orange tint with a small
isting tooth and the internal cav-          there is integration of tooth                 in the preparation, a thin layer of          amount of red/brown tint was
ity preparation provides valuable           structure with restorative materi-            die hardener is applied to the               applied in a previously formed
information to the technician.              al requires a comprehensive un-               cavity and air-dried; then a sepa-           invagination, according to the
Digital photography provides                derstanding of restorative mate-              rator is applied and air-dried.              preoperative photographs and
another method for instant trans-           rials, internal shade modifications,              As an initial step in the build-         shade diagram. The serrations of
mission of information from the             tooth morphology, occlusion,                  up procedure, 1 mm to 2 mm of                a clean endodontic file are used
dentist to the laboratory via the           and color. The following labora-              dentin B-3 shaded composite is               to enfold and compress the lay-
Internet. However, the authors              tory procedure describes how                  placed on the pulpal floor of the            ers together causing a narrowing
find that the variances in shade            this interpretation can be used               die as the initial artificial dentin         of the invagination. This allows
tabs within the same system                 with laboratory-processed com-                layer. The preparation’s dimen-              the stain to migrate to the
necessitate the inclusion of spe-           posite resins to integrate the                sion is measured in a mesio-dis-             occlusal, creating a fine line of
cific shade tabs for the techni-            existing color of the natural                 tal direction for the placement of           stain from the base of the invagi-
cian so that an exact visual refer-         tooth with the optical properties             reinforcement fibers. These fi-              nation to the occlusal surface.
ence can be used during the                 of the restorative material.                  bers are internally adapted to the           The surface is then cured in the
fabrication of the restoration.14                On review of the laboratory              initial layer. Each composite                light cup for 2 minutes. This
Although the shade tab is a piv-            narrative, a die stone is mixed               layer is pressurized (60 psi) in a           allows for intraoral occlusal
otal reference point between the            with the correct powder to liquid             light cup and light-cured for 2              adjustment without losing inter-
dentist and the technician, it is           ratio under vacuum and the                    minutes. This addition of fibers             nal characterization. To create
                                                                                                                                       the illusion of occlusal fissure, a
                                                                                                                                       small amount of red/brown tint
                                                                                                                                       was applied according to the pre-
                                                                                                                                       operative photographs and shade
                                                                                                                                       diagram and cured in the light
                                                                                                                                       cup for 2 minutes (Figure 7). A
                                                                                                                                       final enamel of incisal clear com-
                                                                                                                                       posite was applied at the cavo-
                                                                                                                                       surface margin and smoothed
                                                                                                                                       into the existing anatomic mor-
                                                                                                                                       phology (Figure 8).
                                                                                                                                            After the final light-cure cycle,
                                                                                                                                       the restorations were removed
                                                                                                                                       from the dies, placed in a tray, and
                                                                                                                                       submerged in water in the heat
                                                                                                                                       cup for the final cure. The inlays
                                                                                                                                       were removed from the curing
                                                                                                                                       unit, returned to the master
                                                                                                                                       model, and finished according to
                                                                                                                                       conventional laboratory proce-
                                                                                                                                       dures. The completed laboratory
                                                                                                                                       result reveals the enhanced optical
                                                                                                                                       characteristics and the anatomic
                                                           Circle 45 on Reader Service Card                                            morphologic detail that can be
                                                                                                                                       achieved with these advanced
                                                                                                                                       indirect resin biomaterials.

54                                                                                  May 2004                                              CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE
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Special Feature continued
Adhesive Protocol and                preparations were rinsed thor-                 necessary equilibrations were
Cementation                          oughly to eliminate all the abra-              made. The teeth were isolated
    When anesthesia had been         sive particles. A throat pack of               with a rubber dam to protect
administered to the patient on       gauze was placed before remov-                 against contamination and to
the next visit, the provisional      ing the provisional and during                 achieve adequate field control.21,26
restorations were removed using      the try-in of the composite inlay              A self-priming etchant (TYRIAN™
a spoon excavator because the        to protect the patient from aspi-              SPE) was applied to the entire
material flexes. The cavity prepa-   rating the restoration.23 The                  cavity surface with a foam pellet
rations were cleaned using hand      restorations were tried in for the             in 2 separate coats, slightly agi-     Figure 9—A self-priming etchant was ap-
                                                                                                                           plied to the entire cavity surface with a
and sonic instruments and a 2%       evaluation of color and marginal               tated for 10 seconds, and blotted      foam pellet in two separate coats.
chlorhexidine digluconate (Cavity    adaptation. The interproximal                  dry with a new foam pellet (Fig-
Cleanser™) disinfectant. The         contacts were inspected and the                ure 9). A thin layer of single




                                                                                                                           Figure 10—A thin layer of single compo-
                                                                                                                           nent adhesive was applied onto the primed
                                                                                                                           surface with an applicator tip in 2 sepa-
                                                                                                                           rate coats, air-dried for 10 seconds, and
                                                                                                                           light-cured for 10 seconds per surface.

                                                                                                                                                            Figure 11—
                                                                                                                                                            A thin layer
                                                                                                                                                            of single
                                                                                                                                                            component
                                                                                                                                                            adhesive is
                                                                                                                                                            applied to
                                                                                                                                                            the internal
                                                                                                                                                            surface of the
                                                                                                                                                            inlay, air-
                                                                                                                                                            dried, and
                                                                                                                                                            light-cured
                                                                                                                                                            for 10
                                                                                                                                                            seconds.




                                                                                                                           Figure 12—A sable brush was used to
                                                                                                                           remove the excess resin cement leaving
                                                                                                                           only a small increment at the margin to
                                                                                                                           counteract any polymerization shrinkage
                                                                                                                           of the cement.

                                                                                                                           component adhesive (ONE-STEP™
                                                                                                                           PLUS) was applied onto the
                                                                                                                           primed surface with an applica-
                                           Circle 47 on Reader Service Card
                                                                                                                           tor tip in 2 separate coats, (Fig-
                                                                                                                           ure 10) air-dried for 10 seconds,
                                                                                                                           and light-cured for 10 seconds
                                                                                                                           per surface. The clear shaded
                                                                                                                           dual-cure composite resin (Illus-
                                                                                                                           ion™, BISCO, Inc) was used as a
                                                                                                                           cementation material. This adhe-
                                                                                                                           sive protocol and cementation
                                                                                                                           procedure was performed sepa-
                                                                                                                           rately for one preparation and
                                                                                                                           restoration before beginning the
                                                                                                                           other. The inner surfaces of the

56                                                                            May 2004                                        CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE
Special Feature continued
                                                                Figure 13A—The
                                                                occlusal anatomy and
                                                                cavosurface margins were
                                                                refined with a 30-fluted,
                                                                egg-shaped finishing bur.

                                                                Figure 13B—A short
                                                                tapered, needle-shaped
                                                                finishing bur was used to
                                                                redefine the occlusal
                                                                grooves.                        Figure 14A—The cavosurface was etched         Figure 14B—A composite surface sealant
                                                                                                with a 32% phosphoric acid, rinsed, and       was applied and cured to seal any cracks
                                                                                                air-dried.                                    or microscopic porosities.
 A                                  B

                                                                                                                                              asked to first perform closure
                                                                                                                                              without force and then centric,
                                                                                                                                              protrusive, and lateral excur-
                                                                                                                                              sions. Any necessary equilibra-
                                                                                                                                              tion was accomplished with a 30-
                                                                                                                                              fluted, egg-shaped finishing bur
                                                                                                                                              (RAPTOR®) and the final polish-
                                                                                                                                              ing was repeated. The contact
Figure 15—Silicon carbide impregnated                                                                                                         was tested with unwaxed floss
brushes were used to polish the occlusal                                                                                                      and the margins inspected. The
concavities, grooves, and fossae that are dif-                                    B                             C
ficult to access with other polishing devices.    A                                                                                           postoperative result demonstrat-
                                                 Figures 16A through 16C—The final polishing was completed with silicone rubber               ed the true integration of form
                                                 points, pre-polish (A), high-shine (B), and a foam cup (C) with composite polishing paste.   and color with composite resin to
                                                                                                                                              create the beauty of natural
inlays were microetched with a                   facial, occlusal, lingual, and                 adjacent tooth (Figures 13A and               esthetics (Figures 17A and 17B).
silicate ceramic sand (CoJet™                    proximal surfaces each for 60                  13B). The interproximal finish-
Sand, 3M ESPE) for 1 to 2 sec-                   seconds. After the resin cement                ing was initiated with a 30-flut-             CONCLUSION
onds and air-dried. A composite                  was polymerized, any excess at                 ed, needle-shaped finishing bur                   Although not a panacea to all
primer was applied to the inter-                 the margin was removed with a                  (ET® 3) and completed with alu-               restorative challenges, these
nal surface of the inlays with a                 scalpel blade (No. 12 Bard                     minum oxide finishing strips                  contemporary indirect resin sys-
brush in 2 separate coats and air-               Parker, Becton, Dickinson, and                 (BISCO, Inc). These were used                 tems provide the patient, techni-
dried. A thin layer of single com-               Company). After completion of                  sequentially from coarse to                   cian, and dentist with an alterna-
ponent adhesive was applied to                   the first restoration, the subse-              extrafine. After the initial finish-          tive approach to various clinical
the internal surface of the inlays,              quent restoration was placed                   ing procedure, the margins and                situations. Progress in adhesive
air-dried, and light-cured for 10                using the same protocol.                       surface defects were sealed. All              technology and composite resin
seconds (Figure 11). After the                                                                  accessible margins were etched                materials allows for not only the
surface treatment, each restora-                 Finishing and Polishing                        with a 32% phosphoric acid                    creation of an esthetic restora-
tion was cemented with a dual-                       The final restorative phase                (UNI-ETCH®, BISCO, Inc),                      tion but also the preservation
cure composite cement (Illus-                    was finishing and polishing,                   rinsed, and air-dried. A compos-              and reinforcement of tooth
ion™). The cement was mixed                      which is critical to the esthetics             ite surface sealant (FORTIFY                  structure. This article has at-
and loaded into a needle tube                    and longevity of the restored                  PLUS™, BISCO, Inc) was applied                tempted to describe the infra-
syringe tip (Centrix, Inc) and                   teeth.27,28 A thorough preopera-               and cured to seal any cracks or               structure of an indirect compos-
injected into the entire prepara-                tive occlusal analysis, which is               microscopic porosities that may               ite resin system (TESCERA™)
tion. A blunt tip instrument was                 communicated to the laboratory                 have formed during finishing                  and the specific components of
used to seat and hold the restora-               technician through preoperative                procedures (Figures 14A and                   this system while providing a
tion firmly in place. The residual               diagnostic models, an occlusal                 14B). Silicon carbide impreg-                 detailed description of the pre-
cement was removed with a sable                  diagram, photographs, and bite                 nated brushes were used to final              paration, fabrication, cementa-
brush (Figure 12), leaving only a                registrations, facilitates the es-             polish the occlusal concavities,              tion, and finishing for an inlay
small increment at the margin to                 tablishment of anatomic mor-                   grooves, and fossae that are diffi-           restoration. While the long-term
counteract any polymerization                    phology and thus minimizes the                 cult to access with other polish-             benefits of this next generation
shrinkage of the cement. Initial                 finishing protocol.18 To refine the            ing devices (Figure 15). The                  formula remains to be deter-
polymerization is for 4 to 7 sec-                occlusal anatomy and margins, a                restoration is finally polished               mined in future clinical trials,
onds for each margin while the                   30-fluted, egg-shaped finishing                with silicone rubber points                   this article has demonstrated
restoration is held in place with                bur (RAPTOR®, BISCO, Inc) and                  (Diacomp, Brasseler USA®), foam               that when proper laboratory and
the blunt tip instrument. A thin                 a 30-fluted, tapered needle-                   cups (Enhance® foam cup, Dent-                clinical techniques are combined
application of glycerin was ap-                  shaped finishing bur (ET3,                     sply Caulk), and composite pol-               with the physical, mechanical,
plied to all the margins to pre-                 Brasseler USA®) were used dry                  ishing paste (Prisma®-Gloss™/                 and optical properties of these
vent the formation of an oxygen                  with light pressure to prevent                 Prisma® Gloss™ Extra Fine,                    new biomaterials, the restorative
inhibition layer on the resin                    heat build-up. This dry finishing              Dentsply Caulk) (Figures 16A                  result can provide preservation
cement.4 The restoration was                     allows the dentist to visualize the            through 16C). The rubber dam                  and conservation of tooth struc-
polymerized from all aspects:                    margins and contours with the                  was removed and the patient was               ture, tooth reinforcement, and

58                                                                                        May 2004                                              CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE
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Special Feature continued
                                                                                              esthetics. Whereas the evening         REFERENCES
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