anterior cases

I made this veneer  on #9 with emax LT block and E4D, stained and glazed it.
I normally send out all anterior cases, this one I gave it a try because #8 was a full porcelain crown made by previous dentist, and it seems pretty easy to match.

This second one is a replacement of PFM crown.

The last photo was taken of a try-in with glycerin, lab fabricated this empress crown. gingiva was still red due to lack of good oral hygiene.

somehow on this day my flash on left did not work, sorry about the shadow on the left.



The next one is 2 veneers and 2 crowns

Onlays as alternative to crown

I believe that we, dentist, cut too much sound tooth structure away on daily basis. "Large filling, no problem, we will put a crown on it." "Filling keeps coming off or breaking? let's put a crown on it."
"Broken tooth or filling? let's crown it"
Teeth are not like hair or nails, it does not grow back after cut.

I made this onlay (lava ultimate) with E4D, cemented in the same appointment.

Tooth #30 had a deep O composite, fracture lines on D and mid-lingual.

Occlusal composite removed, crack line at the base of DL cusp.

Caries detector used, and the finished restoration only covering DL cusp, and D marginal ridge.

Buccal cusps and ML cusp are all kept as untouched. Did not extend margins beyond old composite.

newly erupted molars

Once in a while we get a permanent molars that takes long time to completely erupt. The gingiva will be covering half of the tooth for long time and we keep waiting, waiting, waiting...

Now I used a cotton pellet ( as big as needed) as gingival retraction, to push away the gingiva and to control fluid. Laser gingivectomy can also be done, but most of time, I find the cotton pellet is sufficient.

I use it from the beginning, if burs are needed to remove caries, it will keep it away from getting touched by the bur. Sometimes the sandblasting is enough to remove decalcified enamel.  

pre-op view with decay on occlusal, DB cusp covered

cotton pellet on distal, caries removal started.

composite placed and cured

 Waiting for the gingiva to recede can take a long time and the caries only gets worse. These teeth are not in occlusion, and it is difficult to clean for the little ones (7 or 8 years-old). Most of time I find heavy plaque and food debris, especially under the gingiva. Sealant on one of these as early as possible will prevent the decay.

distal decay on 2nd molars.

I hate distal caries on 2nd molars caused by impacted 3rd molars: difficult access, close to pulp, post-op sensitivity, periodontal problems, etc. Just few problems that I know it will be hard to deal with.

I followed Pascal Magne's advice on this one, and it turned out really nice and easy. Check out the sequence:

pre-op taken 11/2011

decay exposed after #32 extracted

matrix band placed, caries detector used

pulp capping and primer

immediately after band removal, prior to finishing or polishing

pot-op x-ray, no finishing or polishing on distal

The martrix band can be purchased at www.greatercurve.com

Cut a second piece and slide into the first band to even go deeper and to protect gingiva during caries removal. Discard it prior to placing composite. Voila!

If an indirect restoration (onlay) is needed on 2nd molar with distal decay, this technique can be used for margin elevation.  check out the next case:

#18 MO composite DO amalgam with open margin on distal

amalgam removed, found base

base removed, found decay

different angle to show the DL wall

MO composite removed

still removing more decay

I was really dreading seeing pulp, did not want to end up in RCT

fortuanately, no pulpal exposure! I placed a composite to elevate the margin, IDS done

CAD/CAM onlay cemented with composite as cement

immediately after cementation

In this case I did not use greater curve matrix, did not know about this technique. It was hard to place rubber dam and have a good seal on distal, I thought removing it and replacing for tofflemire band will be even worse for fluid control. I cemented the onlay with resin cement, the little "puff" on distal is the cement, indicating where the junction between composite for margin elevation and the onlay. I removed it later with finishing strips. I wish I had used the greater curve bands for margin elevation and cementation, it would have made my day so much easier.


Next case the decay was smaller, 3rd molar was extracted, crown lengthening done, and I used distal access instead of occlusal access. it was deeper than it looked. 

pre-op bite-wing

after extraction of #32

clinical view after crown lengthening, I thought it will be small...

Wrong, it was almost to pulp

1

1

 Fortunately, the tooth is till "alive" and asymptomatic today, I am glad we did not need RCT.

IDS ( immediate dentin sealing) protocol


-prep tooth according to biomimetic principles

-etch exposed dentin for no longer than 15 seconds.

-gently dry leaving moist dentin

-apply primer  (optibond FL) with microbrush for 15 seconds, evaporate solvent. if needed, apply second coat.

-apply bonding agent (optibond FL) to exposed dentin. DO NOT BLOW THIN, I was doing so as I usually do with composite restorations, and when I use sandblaster during cementation, some of the bonding agent was removed and it caused post-op sensitivity

-light cure

-air block with glycerin

-light cure again.

--scrub sealed dentinal area with fine pumice on cotton pellet to remove remaining oxygen inhibiting layer. rinse off pumice

-remove bonding agent on enamel or margins by oscillating tips, or finishing burs. pack cords to protect gingiva prior to finishing if necessary.  Pack wax to block out undercut where the impression material can get locked and tear upon removal, it usually happens at gingival embrasures with margins away from gingiva

-impression.

it may look complicated, but it does not take much longer. the bonding strength is greatly increased in comparison to delayed bonding at cementation, there are actually a lot of benefits. The main one for me is: no post-op sensitivity! 

today I am attending a seminar in IDEA facility, with Pascal Magne and Michael Magne. Love it! Eye opener. If you ever have a chance, take it!

http://www.ideausa.net/

What is it all about? if you have not heard about Pascal Magne, it is all about Biomimetic principles, copying the nature, saving every bit of tissue as possible. Some of concepts are contradicting to what I learned in school ( not that I am that old), and to what majority of dentist believe in.

Just to illustrate:
-immediate dentin sealing after prep, prior to impression taking. 

- margin elevation technique. if there is a subgingival margin, elevate it with composite and then place margin of indirect restoration on the equi or supra-gingival area.

-preservation of pulp (vital, normal response)at all cost. Do not kill the pulp, it starts what he calls the "circle of death" for tooth: RCT tooth, crown, crown with post, fracture or failed tooth, extraction. Even with deep caries removal, create a absolute healthy tooth structure periphery, and at the pink deepest part, leave it undisturbed.

-bilaminar approach to treat teeth when there is need for facial and lingual restoration, e.g. erosion and wear cases: ultraconservative veneer on facial, composite on palatal to restore wear facet. Do not make a full crown prep.

-never cut for full crown, even with a pre-existing crown replacement, sometimes we can get away from full crown. Onlays, inlays, veneers, whatever it takes to not remove more than needed. we don't need full crowns for tooth after RCT, we don't need full crowns after a big amalgam to "wrap and protect" the tooth.

-CAD/CAM composite onlays: very conservative, it can be 1mm thin on occlusal. use it to restore posterior may be better than emax or zirconia. harder is not always better. how much do we have to cut for porcelain, emax or zirconia? much deeper than 1mm, they are not kind to opposing dentition, bonding is harder ( talk about bonding to zirconia!).

-there is a on going research for CAD/CAM composite abutment for implants, and results are very promising. bonds well, can be prepped at chairside ( veneer prep), it absorbs and flex like dentin.

I wish I can spread, intrigue and convert as many dentist so we can all think being minimally invasive... to conserve and appreciate what nature gave us, and not to be " serial tooth killer".

occlusal caries

I have heard unexpected responses from patients when I inform them of caries:
" but I don't feel anything..."
" really? where? how come I can't see or feel it?"

These pictures can really illustrate how a caries can fool all of us, even dentists.

deceiving caries

This tooth was diagnosed for occlusal composite over a year ago. Pt did not set appointment when I reminded him again that there is a large decay. He used demand force review system to question if the diagnosis was correct, because he had never had any symptoms, nor had been advised of so many filling before I took over previous owner's practice. BTW, demand force review system is a great way to get feedback from patients, there are a lot of information that they may feel uncomfortable sharing with you face to face. There is clearly a large radiolucency under the thick layer of occlusal enamel.  The pre-op intra-oral photo does not show large decay, only deep grooves with a shadow coming through enamel.

I replied to him and promised that I can show him photos of the tooth while we are working on it, step-by-step. He came in for filling on #18. Here is a sequence of photos taken with caries detector:

I am pretty sure that it will very soon end up in a RCT if we have waited a little longer. it was huge as I kept removing decay.

I often hear people complaning how dentist drilled too much of their good tooth away, that a tiny hole can become a huge one. I think I/O pictures are the best tool to help them understand why we do what we do. It is also great documentation in case RCT was needed. Fortunately I did not have any pulpal exposure, but it was darn close! I was very glad that he came in, because there was no other way to prove to him how big the decay was, he took a leap of faith for allowing me to drill the tooth.

There are also interproximal caries on other teeth shown on bite-wing, I hope he will trust me after this one.