Transcript Document 7211586

Why Carry Out Esthetic
Bonded Restorations on
Posterior Teeth?
Prevention과 oral hygiene이
잘 유지되고 있는 35세 환자의
caries free mouth.
Traditional approach using
amalgam : 증례(1)
 recurrent
caries around old composite
restoration on M & PM
 cavity prep & pin placement for
amalgam
 completed amalgam filling
Traditional approach using
amalgam : 증례(2)
 interproximal
caries on #14,15
 intact occlusal surface
 traditional approach
• occlusal extension prep for amalgam
 술후
사진.
More conservative approach
using adhesive technique
 similar
case above
 maximum sound tissue preservative
cavity form
 direct composite restoration
Evolution of decayed tooth
 a)
•
“classical” approach
“natural caries decay”의 진행, 수복물의
변성, mechanical failure 발생 빈법
– (left arrow) unfavorable condition : mesiodistal
fissure로 진행 - premature root canal tx.protective crowning
– (right arrow) onlay만으로 더 이상의 진행
prevention.
 B)
“ adhesive” approach
• mechanical failure 발생 감소.
Fractured tooth :증례 (1)
 sensitivity
to pressure
 intact on radiography
 deep fractured fissure on mesial side
 direct composite restoration으로 sealing
& reinforce : sensitivity 감소
Fractured tooth : 증례(2)
 frail
& wide class 1 amalgam filling.
( No cuspal coverage)
: spontaneous & pressure induced pain
 일차적으로 composite inlay수복으로
symptom완화 시도.
 술후 방사선 사진
: 와동형성을 심부까지 extension하지 않음.
Fractured tooth :증례 (3)
superficial class 2 : not visible defect
but thermal change & pressure에
sensitivity
 deep ,discolaorated fissure ( leakage )
 endodontic therapy
 crown for prevent from further crack
progression

prevention form의
retoration은 많은 양의 치질
삭제를 요한다.
Decmentation of gold inlay
 부적절한
marginal fit으로
severe secondary caries 발생.
rich blend color로 natural
anatomy와 esthetic,
optimal function을 만족시키고
있는 수복형태.
new esthetic material의
만족 할만한 long-term behavior
 after
5-year
 after 9-year
Bonded ceramic inlay
• 구치부 심미 수복 중 most long lasting.
But, 과정이 복잡하고 가격이 비싸다
 after
3-year
 after 5-year
Traditional approach vs
modern approach
HISTORICAL
PERSEPECTIVE
1) esthetic intracoronal
restoration
: not a modern concept
(1) 1856 prefabricated ceramic inlay
sealed with gold foil
(2) 1882 fired ceramic inlay
(Herbest, Germany)
(3) 1888 fired ceramic inlays over
platinum foil (Land)
(4) 1895 ceramic inlay was introduced
well before amalgam
(5) 1905 resinous adhesive + porcelain
etching (Nyman)
Low fusing ceramic inlay (Ducera)에 fatigue
test (mechanical loading & thermocycling)
: porcelain etching과 new adhesive에 의한
adhesion remain
( D:dentin LC:luting composite C:ceramic )
(6) 1871 silicate cement : direct esthetic
m.의 real development begin (Fletcher)
(7) 1937 unfilled resin
(8) 1938 development of epoxy molecule
(Castan Swiss)
(9) 1951 acid conditioning
(Hager, Swiss)
(10) 1952 “hybrid layer” first description
(11) 1955 further development of enamel
etchin (Buonocore)
(12) 1962 Bowen’s Bis-GMA formulation에
의한 composite resin (Bowen)
: moder adhesive dentistry의 beginning
(13) 수년 전까지 posterior esthetic material은
amalgam이나 gold filling과 경쟁이 되지 않았다.
Biological & physiochemical short comings
2-2 a.b amalgam restoration의
satisfactory long-term behavior
- amalgam over 20 year
- free of recurrent decay
2-3 a.b gold inlay의 excellent long
term behavior
- 24 year old gold inlay
(14) limitation of esthetic material의 durabillity
a. marginal degradation
b. wear
c. mechanical failure
<clinical finding>
a. Recurrent decay
b. pulpal injury
c. loss of function
RESTORATIVE MATERIALS
Bonded posterior restoration에
이용되는
material의 기능에 의한 분류
 Liner
 Base
 Adhesive
 Luting
composite
 Restorative material
Direct composite filling
: enamel, dentin 각각에 대한
adaptation비교
 Enamel
: perfect adaptation
 Dentin : separation
Dentin etching
(phosporic acid, 10 sec)
 exposure
collagen fiber network
 porius structure
 <주의> No over etching!
• Collagen fiber denaturation & weakening
으로 dentinal tubule collapse
Hybrid layer or
interdiffusion zone
 intertubular
dentin과 peritubular dentin
사이로 resin tag형성.
Ceramic bonded inlay : 1.5year
loading
(thermal & functional)
 resist
Hybrid layer에 의한 dentin
bonding failure example
 원인
• Maybe spontaneous collagen collapse or
compression during etching & dehydration
Liner application
under Direct composite
part에 pulp protection 위해
calcium hydroxide cement을 partial lining.
 deepest
Base,liner application이
marginal seal에 미치는 영향
 Base,liner
: fluorecent resin leakage
 bonding agent : full surface adhesion
Prep for adhesive restoraion
 PM
: direct filling
 M: compomer base로 resin inlay위한
형태 형성.
• Resin restoration volume감소.
Conventional glass ionomer
cements : structure
 developed
by Wilson & Kent by 1972
 polycarboxylate cement liquid
(polyacrylic acid)
 + silicatecement liquid
(aluminisilicate glass)
 final
state : 2 phase
• Matrix : gelation of polyacid by metal ions
from the glass during the initial acid attack
• Filler
– large particle : intact glass core sheathed by
siliceous hydrogel
– small particle : completely degraded in siliceous
hydogel
Compomer 1
: Dyrect의 structure
유사한 matrix에 GI filler
(aluminosilicate glass)첨가
 Resin과
 Advantage
• Ease of manipulation due to long working
time and rapid set ( light activation)
• Resistance to early contamination by
water and to dehydration
• Higher early strength and superior
mechanical properties
• Fluoride release
Compomer 2
: temporary restoration & base
 Delay
the final steps of the restorative
procedure
Base,liner : rationale for using
& selecting
Ceramics 1
“heterogeneous conventional dental porcelain”
2
phase : glassy matrix & crystalline
inclusion
 after firing
 after HF acid etching : imprints of leucite
crystal
• Reinforced heterogeneous porcelain :
higher proportion of alumina & leucite
Ceramics 2
“glass ceramic(Dicor)”
 glassy
matrix + crystalline inclusion
 1st step : casting of glass (amorphous
glass)
 after “thermal ceramization” :
development of crystalline structure
Ceramics 3
“slip casting (In Ceram)
 crystalline
matrix + infiltrated glass
 1st processing : sintering spinell crystals
 infiltrated by a glass
Ceramics 4
“low fusing ceramic (LFC,Ducera)
 homogeneous
porcelain
 firing phase : melting glass particle
 final stage : homogeneous glass react
superficially with water & produce a
reinforced hydroxylated layer.
Composite resins : structure
Composite resin
: surface roughness
Composite resin
: polymerization
 light
activated
• pore-free structure
• homogeneity of activation
• possibility of multilayer application
 chemically
cured
• numerous void from hand mixing
Composite resin 1
: monomodal heterogeneous
microfilled composite
 Prepolymerized
complex with higher
filler density
 Filler : pyrolytic silica
Composite resin 2
: monomodal spheroidal
composite

milled rounded , various size particle
Composite resin 3
: hybrid composite
Composite resin 4
: small hybrid composite
composite kit including
different opacities
 dentin
 enamel
 translucent
Ceramic inlay : fracture
CLASSIFICATION OF
TECHNIQUES AND
RESTORATIVE STRATEGIES
Esthetic restorative technique
for post.teeth
; 3 group
 Direct
technique
 Semidirect technique
 indirect technique
Basic requirement for
successful bonding
 Perfectly
healthy soft tissue
 Margins preferably placed supra or juxta
gingivally
 Clean & dry operating field ysing rubber
dam
– “ wet bonding” = on dentin humid substrate ,
no saliva or blood bonding
Indications for adhesive
restoration
 excellent
oral hygiene
 low caries susceptibility
 true esthetic demend
Direct technique
 small
& medium size intraoral cavity
Semidirect technique
teeth (within different quadrant) 의
wide class II,III or occlusal coverage
 1-3
Indirect technique
 full
arch or quadrant rehabillitation
Fractured buccal wall due to
resin polymerization stress in
largr cavity
Modification of the
conventional prep. for a luted
restoration
 Direct
technique
• if thickness of the remaining wall is
enough,more prefarable
 Luted
restoration
• significant tissue loss
Marginal seal
 Direct
filling
• minimal enamel thickness at the gingival
margin (1mm at least) & bevel :
satisfactory marginal seal
• butt margin : leakage
 Luted
restiration
• perfect marginal seal regardless of
finishing design or enamel thickness
• dentin margin : modern adhesive
technique으로 best adaptation & seal
Technique selection by gingival
enamel thickness
 Direct
technique
• small restorations with thick margin
 Luted
technique
• large prep. with thin enamel margin (less
than 1mm thickness & height)
Hybrid restoration
 amalgam
base : sealing dentin margin
 composite surface : esthetic
Functional strain distribution
 last
molar : maximum
 decrease progressively toward the
anterior teeth
Anatomic factor influencing the
strength of the restored tooth
 cuspal
inclination
 enamel thickness
 extension of the pulp horn
 cusp form & demension
 cervical concavity & other defect
(erosion,abrsion lesion)
Relationship with Crown
inclination and restored tooth
strength
 amalgam
filled mandibular post.teeth의
lingual inclination으로 인하여 functional
stress하에서 non-supporting cusp fracture
 candidate for adheive restoration
Relation to cervical concavity
 conventional
amalgam filling : risk of
mesiodistal fracture
 candidate for adhesive restoration
Conservative treatment
:fissured or partially fractured
tooth
Combined technique
 Complete
rehabilitation after completion
of the orthodontic phase
 Fractured worn restoration removal
 New direct composite filling
 Ceramic overlay was placed on the
premolar to restore the vertical
dimension & proper function
Full upper arch restoration
using composite inlay & PFM
crown
Prosthetic indications
 The
ultimate goal of adhesive dentistry
is to reduce and postpone the prosthetic
solution
 The extent of delay or existing
restoration may contraindicate an
adhesive option
Tooth Preparation
Tissue characteristics related to
preparations for adhesive
Technique 1
 Thick
enamel margin bevel
 transitional line between the bottom of
the cavity & bevel
 exposed prism on bevel
• perpendicular to their long axes
Tissue characteristics related to
preparations for adhesive
technique 2.
 Thin
gingival enamel margin
 SEM view of cavity border
 enamel prism
• less structural arrangement
• minimally to adhesion
Tissue characteristics related to
preparations for adhesive
technique 3.
 Preparation
extending into cervical dentin
 enamel is missing on the gingival margin
 SEM view of outer dentin
• few number of dentinal tubule
• mostly cross sectioned
Tissue characteristics related to
preparations for adhesive
technique 4.
 Changes
in prism orientation along the
entire DEJ
Tissue characteristics related to
preparations for adhesive technique
5. : Section of the cervical region
 changes
in the orientation and organization of
rod in the last millimeters of enamel
• apical inclination
• approximately 30% of teeth
• obstacle for bonding because the margins present
unsupported prisms
Tissue characteristics related to
preparations for adhesive technique 6 :
Different orientation of the tubule on the
various surface of class II cavity
 bevel
provides sections of tubule that
are more perpendicular to their long
axes than with a butt preparation
General principles 1
“Principle of maximum preservation”
conventional approach
• extension for prevention
 modern rule
• selective removal of decayed tissue
 proximal ridge,enamel bridge,sound occlusal
surface have to be preserved (even where
the enamel is not fully supported by dentin)

General preinciples 2
: Technique selection
 by
remaining sound tissue amount &
morphology
 cavity prep for direct filling vs for
semidirect inlay
General principles 3
: direct technique 증례
 small
lesion in the buccodistal groove
necessitated the coverage the fragile
distal cusp.
 extreamly frail wall은 composite
shrinkage로 발생되는 stress로부터
protection 해주어야 한다.
Tooth preparation for direct
fillings 1
: different design
 most
conservative approach for
superficial carious lesion
 “adhesive preparation” for more deeply
invasive preparation
• ovoid cavity design with some area of
unsupported enamel
cavity” ,”tunnel cavity”,
“buccolingual cavity for conservative
treatment of proximal lesion
 “micro
 “bevelled
conventional” preparation for
replacement of existing metallic
restoration
Tooth preparaion for
direct fillings 2
: two different design 증례
Tooth preparation for
luted restoraions 1
: different design
 unrestored
severe carious lesion
• selective removal of decayed tooth
• internal tapered design obtained by liner and base
 replacement
of large existing restoration
• modification with base
Tooth preparation for
luted restorations 2
: Preparation for indirect
ceramic overlays
 no
sharp angle (esp. internal line angle)
Margin design of
luted restorations 1
: butt margin
 prism
on occlusal margin
• parallel to long axes
 prism
on gingival enamel margin
• same
Margin design of
luted restortions 2
: hollow-ground chamfer ( concave bevel)
 prism
on occlusal margin
• more or less transversly sectioned
 prism
on base of the chamfer
• almost perpendicular to long axes
• more appropriate for eching
Margin design of
luted restorations 3
: 증례(1)
 fracture
of hollow- ground chamfer
occlusal margin
Margin design of
luted restorations 4
: 증례(2)
 concave
bevel design for buccal
finishing line only
• other concave beveled margin will enlarge
the occlusal surface
Cavity configuration and
Geometry of luted retorations 1
 semidirect
intraoral technique
• require more taper than 15 degree
• to faciliate removal
 indirect
technique & semidirect extraoral
technique
• small internal undercuts are tolerated
• by die spacer (indirect) or grinding locally
after removal from the elastic model
(semidirect extraoral)
Cavity configuration and
Geometry of luted restorations 2
: parameters of general preparation design
 Restoration
margins should not coincide
with occlusal contacts(esp.ceramic)
 Minimal
thickness & width of occlusal
isthmus, occlusal coverage
 Optimal
overhang of the restorative
material necessary to obtain a
satisfactory proximal contact
 Extension
into critical esthetic zones
must be considered with caution
DIRECT TECHNIQUES
General indications for direct
technique
Direct filling method 1
: bulk technique
 only
for minimal cavity volume
Direct filling method 1
: 증례(1)
 initial
occlusal groove caries
Direct filling method 1
: 증례(2)
 superficial
proximal caries
Direct filling method 2
: multilayer technique
 In
narrow but deeper cavity
 composite resin shrinkage
compensation
Direct filling method 2
: 증례
 Replacement
of failed restoration
Direct filling method 2 :
procedure(1) “conventional horizontal layering”
 Decayed
1st upper molar
 Proximal extension of the prep
 Failure to place a clear plastic matrix band
 Metallic band & wooden wedge
• for class II cavity,conventional metallic matrix
improves polymerization by light reflex
Direct filling method 2
: procedure(2)
 Base
of light curing GI
 Additional horizontal increment were
made to complete the proximal wall
 Remaining cavity volume was filled with
three last increments
 Internal characterization
Direct filling method 2
: final
Tunnel approach
 Very
superficial proximal lesion
 Only when decayed tissue can be
completely removed without excessive
weakning of the occlusal ridge
Three-sited light cure technique
: rationale
 provide
optimal proximal adaptation & seal
• traditional GI base to reduce resin bulk
• placement of translucent matrix & reflecting
wedge
• placement 1st resin increment on the bottom
of proximal prep
• indirectly cured through the wedge
• 2nd ,third increment
• cured through the cusp
Three-sited light cure technique
: 증례
 Replacement
of the amalgam filling due to
recurrent caries
 Clear matrix & translucent reflecting wedge
 1st composite layer on the gingival floor &
cured through the wedge
 2nd increment was placed buccaly to fill the
main volume & cured through the cusp
Three-sited light cure technique :
증례
3rd increment filled the remaining
proximal space
 in the occlusal part

• oblique layer & cured through the
remaining wall
 last
increment & shaping
Three-sited light cure technique
: final
CONTA PRO
 special
clear,plastic instrument to
improve quality of contact point
 used to force the matrix against the
neighboring teeth to abtain tight
proximal contact
 <사용방법>
• The tapered channel at the top of the
instrument is first filled with composite
• place in the cavity box
• wedged & moved to push the matrix
• removal 후 small band of resin remain in
the cavity
• restorative step
Polymerization shrinkage
control 1
: polymerization tip
 composite
condensation &
polymerization at the same time
Polymerization shrinkage
control 2
: ceramic ingot or prefabricated
ceramic inlay
Oblique incremental technique
 medium
class I cavity
 horizontal layering에서 발생되는
opposing wall에대한 tension발생을 막고
marginal quality improvwmwnt
Oblique technique : 증례
 Replacement
of an occlusal amalgam
filling
 buccolingual extension of the cavity
 colored liquid resin
Oblique technique :증례
 additional
small incremental resin
 shaping with spatula & brush
 final
Anatomic layering of direct
composite restoration
 dentin
layer
 enamel layer
 translucent layer
Instrument : simple set
 sharp
point
 spatula
 round condenser
SEMIDIRECT TECHNIQUES
Semidirect
technique의 indication
1) accessible large lesion extended to CEJ
2) restoration replacement of limited
number of tooth (at the same time)
Transitional
restoration of
young patient
: low cost로 luted restoration 제작
가능하므로 성인기에 이를 때 까지
prosthetic solution을 delay시킬 수 있는
바람직한 수복재 역할
Young
pt에서의 적용례 2
: reduced coronal height, pulp less single
tooth의 conservative & economic
therapeutic option
Direct
filling methods의
common problem in class II lesion
: adequate proximal contour & contact 형성이
어렵다
<solution>
luted restoration semidirect tech은 one
appointment로 chairside에서 제작
Intraoral
semidirect
composite inlay제작 과정
a. 술 전
b. prep & GZ base (약간의 undercut허용)
c. insulating medium
d. incremental resin build
e. shaping
f. 분리 후 post curing
g. cementation
h. complete
Cavity
design for intraoral
semidirect tech
: even. One or two surface prep require
to prevent locking
Semidirect
intramural
technique을 이용한 수복예
a. initial view
b. extended cavity에 separator 바르고
matrix place
c. composite filling & shaping
d. locking으로 인해 rotary instrument로
removal
Microretention
by coarse diamond bur
Semidirect
extraoral technique
a. failed amalgam & provisional filling
b. frail fissured cervical enamel & substantial
cavity width & volume
c. working model < fast setting silicon
material
d. separated die상에 three layer composite
filling (chairside)
e. enamel. Incisal layer & characterized
color resin
f. completion
g. try in
I. Cementation
Special
silicone die를 이용한
resin restoration 제작 과정
a. Color, viscosity, setting time이 적절한
special silicone die
b. shaping
c. surface characterization is easy
Very
natural appearance.
within short working time
simple
post-curing method
: boning water for five minute
<단점> more superficial staining
Post-curing
occlusion check
(photothermal treatment) after a
few minute내
- continuing polymerization으로 인한
internal marginal
-stress 저하
- hardness & wear. Resistance 증가
Advantage
of post curing
1) maximal conversion rate
2) definitive dimensional stability in a few
minute
3) improve margin quality
Try
in
if necessary, some composite and
he added on non-postcured material
Prosthetic
rehabilitation
root canal treated tooth를 포함한.