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Case Study
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Clinical Protocols for Adhesive Inlay and Onlay Restorations on Teeth #18 and #19

Case Presentation 

A 28-year-old male patient presented with failing amalgam restorations and interproximal decay on teeth #18 through #21 and pain elicited with direct pressure to the mesiobuccal cusp of tooth #19. Based on the abfractional wear patterns on the cuspal tips of tooth #19, it was evident that the patient had a history of nocturnal bruxism and resultant occlusal wear (Figure 1). The undermined mesiobuccal cusp of tooth #19, the failing restoration, and the decay of teeth #18, #20 and #21 required treatment with a restorative material that was durable, yet kind to the opposing dentition. Two direct ceramic optimized polymer restorations were to be performed for teeth #20 and #21, and a fiber-reinforced polymer onlay restoration and a polymer inlay were selected for teeth #19 and #18, respectively. The patient consented to the treatment plan and the procedure was initiated.

 

Preparation

Using the shade guide, the base shade was recorded from the buccolingual one-third. The enamel shade comprised the occlusal one half and margins of the restoration, establishing a natural transition from enamel to ceramic optimized polymer. Detailed shade mapping or clinical photography was required in order to achieve detailed characterization. Shade selection occurred prior to actual preparation and possible dentinal dehydration, which could have altered the selection. In order to facilitate provisional fabrication, an index was also taken of the preparation site with fast-setting bite registration material. This information was forwarded to the laboratory to be developed in the definitive restorations.

Caries indicator was used to facilitate removal of all infected tooth structures. The preparation requirements were facilitated with the use of diamond burs (Figure 2). Due to its dimensional stability, the impression was subsequently taken with a polyvinylsiloxane material. An internal or "stump" shade was taken of the preparation to ensure proper shade blend with the existing dentition. In order to support occlusal load, provisional restorations were fabricated with the aid of a bisacrylic material, and cemented with a noneugenol provisional cement (Figure 3).

 

Cementation

Upon receipt of the laboratory-fabricated restorations, the patient was prepared for intraoral try-in. A rubber dam was placed in order to facilitate isolation of the site.1 Upon removal of the provisional restorations, the preparations were cleaned and disinfected with an antimicrobial rinse mixed with a pumice slurry (Figure 4). The restorations were evaluated for material integrity and marginal adaptation on the models to ensure that no voids were present (Figure 5). The restorations were placed in the preparations for final evaluation of marginal integrity and adaptation, appropriate contact, and color match (Figure 6). Proper shade match was evaluated with the aid of try-in paste. In order to avoid postoperative sensitivity, the preparations were not permitted to become desiccated during the try-in and subsequent bonding steps.2

Once properly fitted, the restorations required surface conditioning. When internal surfaces were altered, the internal aspects of the restoration were cleaned and/or microetched prior to surface conditioning. The internal surface was washed and acidified with 37% phosphoric acid and thoroughly rinsed, dried, and coated with silane for 60 seconds. A warm-air dryer was used to evaporate the excess liquid.

The tooth preparations were acid-etched with 37% phosphoric acid for 10 to 15 seconds using the total-etch technique to facilitate proper bond strengths.3 In the total-etch technique, the enamel was initially trimmed with acid and etched for 5 seconds (Figure 7). This was immediately followed by filling the rest of the preparation with acid etch and allowing it to stand an additional 10 seconds (Figure 8). Once the dentin and enamel were etched for 10 and 15 seconds, respectively, an antibacterial solution was applied to act as a rewetting agent. Excess liquid was blotted dry, leaving a moist preparation.

The dentin primer was placed (Figure 9) and allowed to penetrate for 30 seconds. A warm-air dryer was used for 15 seconds to evaporate any acetone or alcohol residue. Dual-cured bonding resin was subsequently applied to all internal surfaces of the preparations as well as the bonding surfaces of the surface-conditioned restorations (Figure 10). A mixture of the dual-curing, radiopaque, and fluoride-releasing luting cement was carefully placed into the preparations, and the restorations were seated.

Excess material was removed with a rubber-tipped instrument (Figure 11). Care was taken to remove all excess cement from the restoration. The restorations were tacked in place with a 1-mm argon laser-curing tip for 1 second on the facial margin. The curing light was not applied to the interproximal areas (Figure 12) to avoid accidental curing of the uncleaned areas. Meticulous care was exercised to remove all excess cement prior to final cure. A dry brush or rubber-tipped instrument and explorer were used for interproximal flossing to facilitate finishing of interproximal areas (Figure 13). Glycerin gel was applied in order to prevent the formation of an oxygen-inhibition layer at all margins, which enhanced the composite cure at the cavosurface.4 Final curing was accomplished with an argon laser for 10 seconds per surface for each restoration (Figure 14).

 

Finishing

Excess cured cement at the margins was removed with a curette, carbide finishing bur, and a diamond bur (Figures 15 and 16). Retraction cords were removed prior to any finishing, which facilitated the removal of any remaining excess composite material at the gingival margins. Any cement in the interproximal areas was removed with an interproximal scaler, #12 scalpel blade, and an interproximal metal strip.

Final polishing (Figures 17 and 18) was accomplished using polishing cups and polishing paste. The rubber dam was removed and the occlusion was evaluated and adjusted (Figure 19). Centric and lateral excursions were verified. The restorations were then etched and resealed with a surface sealer in order to ensure prolonged longevity (Figures 20 and 21). The definitive restoration exhibited aesthetics, color, and contour that were indistinguishable from the natural dentition (Figure 22). The restorations replaced the weakened cuspal tissues of tooth #19, restored the teeth to consummate anatomical form, and eliminated discomfort upon occlusal function.

 

References:

  1. Barghi N, Knight GT, Berry TG. Comparing two methods of moisture control in bonding to enamel: A clinical study. Oper Dent 1991;16(4):130-135.
  2. Bertolotti R. Total etch—the rational dentin bonding protocol. J Esthet Dent 1991;3(1):1-6.
  3. Kanca J III. Improving bond strength through acid etching of dentin and bonding to wet dentin surfaces. J Esthet Dent 1992. 123(9):35-43.
  4. Bergman P, Noack MJ, Roulet JF. Marginal adaptation with glass ceramic inlays adhesively luted with glycerin gel. Quint Int 1991;22(9):739-744.
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