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The opinions within this web page are not ours. Authors have been credited
for the individual posts and photographs where they are. - www.rxroots.com

Going to the limits of rubber dam

From: "Winfried Zeppenfeld" To: "ROOTS" Sent: Saturday, January 14, 2006 3:09 AM Subject: [roots] Going to the limits of rubber dam This was really a tough one. Patient is a colleague, and he knew exactly what he wanted: He wanted to save his tooth, he wanted no puffs and he wanted the tooth restored with an adhesive ceramic inlay instead of a crown to save tooth structure and of course he wanted to have the inlay placed with rubber dam on......... The first time ever I had to flap the gingiva to be able to place a rubber dam. - Winfried bite wing brought by patient

external resorption/initial access

removal of soft tissue,bonding

space with gutta,buildup with access cavity

cleaned and shaped, wire film

obturation,apical furcation

prep finished, impression

ceramic inlays,seating inlays

rubber dam placed, cementing inlays Winfried, Looks really nice, flap and dam is very inventive. Question, did you place fibre posts in these teeth? I can see an outline that looks like a fibre post, and I can't think what else it may be. It shows on your last photo mainly, but a little on the photo with the flap as well - Bill Hi Bill, I think Carlos posted a case like that earlier. Yup, There is a DT Light post in there. I thought it might come in handy in case I needed a crown. - Winfried Winnie, Very nice restorations. - mhenley Hi Mac 1. Ceramic inlay: etch with hydroflouric acid (Ultradent ceramic etchant), silanate with Monobond S, blow dry, coat with the thinnest layer of Heliobond possible without light curing 2. Tooth (built up with composite or Fuji II LC improved to avoid undercuts), acid etch with phosphoric acid, place Syntac primer and adhesive, then Heliobond, blow as thin as possible, light cure, place Variolink II in cavity, seat inlay, cure in easily accessible spot with 2 mm light rod, remove excess material,. let the rest autocure, cover with glycerol gel, light cure. WInnfried, For me this is the most difficult restoration to seat . Can you describe how you remove the resin without concern for creating a " gap ". I get pretty anal about that potential . - Thanks, Mac Hi Mac, After lightcuring a small, easily accessible area with a 2mm light rod, I let the rest autocure. When the Variolink autocures, it goes through jellylike a stage where you can easily pick it off with an explorer. First I go through the intrproximal contact with dental floss, which I pull out sideways, but not on the level of the margin. When most of the excess Variolink has been removed, I take an explorer and try to move it perpendicular to the gap in contact with the tooth and the restauration. This will push resin into the gap rather than pulling it out just like a snow plough. When alle the excessive material has been removed, I light cure the whole thing for a few seconds, put glycerol on to get rid of the inhibition layer and light cure completely for 1 minute from each side (check the temperature your light creates, you may want to make a little pause in between) When I'm done I take remainders of the cured resin off with a white stone and with a scalpel blade #12 in the interproximal areas - there shouldn't be much left. Finally, I check the interproximal space with dental floss. If it rips or blocks, I seperate the teeth a little bit with an Ivory seperator and clean the contact area with Proflex (perforated steel tape) which I hold with 2 hemostats at each end. I've been doing this procedure without any changes for 15 years and it works very fine for me. Hope this helps.- Winfried Winfried, Many thanks. I've been using a metal matrix and doing a complete cure with a plasma light. Good consistant marginal cure , but a "bear " to finish!! I like your technique an will give it a try nexy week! - Mike You are a winner Winfried! why didn't post the post treatment picture. I mean after the inlays cemented, why the rads alone? - Vipin. Hi Vipin, to be honest, I forgot to take a post op pic. But I wouldn't have liked it anyway because there is one thing I screwed up: I flapped it with a papilla preservation flap and did not think about the fact that the col was too narrow. So there was no way I could reposition the papilla microsurgically and expect it not to become partially necrotic. Since the hard tissue is underneath, it will take a little while. Sorry, I can't take a pic for you now because the colleague lives 2 hours away. - Winfried Hi Winfried, Difficult case! I see there could be invasion of biologic width issue distal of #12. What do you think about osseous crown lengthening after endo & build up, prior to the final restorations? - Tony Hi Tony, I discussed that with the pt/colleague. He said nobody ever died from lack of biologic width and his bone would do the job itself in the long run, if necessary. I did create a groove on the distal side of 24 (#12US) with the ZI15 instrument, just enough to stuff the cord in. So that was kind of mini crown lengthening.- Winfried An inspiring application getting an onlay in in a very difficult case. I think most bicuspids with a large proximal box should be onlayed rather than crowned. Whether you agree or not, enjoyed this masterful display of skill.- Agriestic Winfried, Wow what a great result........I couldnt have done this myself without the scope. What an awesome result. CLAP CLAP CLAP - Glenn Great case Win, I love your attention for details !! This colleague was very lucky to have you as his dentist. I am curious why this colleague didn't want a puff? Regarding the resorption defect, did you consider the use TCA in order to remove or inactivate the resorptive tissue within the tooth? - Marga Thanks Marga, he's a pulp lover! But, looking at Fred, there is hope ;-) ! Actually, I would have preferred the obturation in the buccal root of the 24 to be a liitle longer, but I gave in to the patient. No TCA, to be honest, I don't have any in my practice. Where do you get it? - Winfried Great and wonderful case Winfried !!!! COngratulations and thank you for sharing that case and.... ...and thank you also for sharing your protocol of working. Here is something I would like to add: - if we are doing restorative dentistry we know how bad effect have the oxygen and oxygen radicals on the polymerization of the composite resins (you just wrote that you used the glicerol gel to protect the outer surface of the Variolink)....we also know the existence of oxygen inhibited layer when we are doing composite fillings or build ups...also we know from hundreds of articles about internbal bleaching that we have to be careful when we place resins in those teeth because the bonds are very low due to oxygen radicals left in the dentinal tubules...BUT.... from time to time we read in endodontics about hydrogen peroxide irrigation or its use as a good chemical treatment in order to BOND posts in the root canals (see an article in Jan issue of IEJ) For me it has remained a paradox...why oxygen radicals are bad for polymerization process of the resins in restorative dentistry, but have no effect or a good effect when we want to talk about the adhesion of the sealers in the radicular dentin or adhesion of the resins used to lute fiber posts in the root canals And another one : the prosthodontsts or restorative dentists are using FREE- EUGENOL provisory cements for their temporaries so that the tooth structure not to be contaminated with eugenol and so the adhesive luting of the crown/onlay should not be endangered, but on the other hand we see in endodontics root canal obturations with ZOE sealers than immediately adhesive pulp chamber sealings. ....simple as that .. bonding over eugenol directly ! Thank you again for showing your case and again reminding about the issue with oxygen radicals and effects on polymerization - Roberto Congratulations...you exceeded my imagination limits. Thanks for sharing. Did you electrosurge for eliminate soft tissue and pretreatment BU? I think you use some translucent fiber post in each premolar, what and bonding protocol? Did you consider crown lenghtening for perio or biologycal space requests? Did you consider overlay for cuspal coverage requests? - Nuria Hi Nuria, I used electrosurgery as described. There are DT Light Posts in the teeth. They don't hurt and the pt. gets money fropm the insurance company for the post.......I use Optibond FL when I feel I get enough light down the canal or AdheSE with the catalyst when I cement those posts. I actually did some crown lengthening by cutting that groove with the ZI15 Scaler (Deppeler, Switzerland). My choice would have been a normal crown because of the deep subgingival resorption, but the patient demanded an adhesive inlay - treating colleagues is always something special. - Winfried Hi Winfried!! That's excellent work! and a wonderful presentation - enjoyed it very much Thanks for sharing. Do you routinely do the endo and the restoration also for all your cases? - Rajiv Patel Hi Rajiv, I'm a GP, so it's quite natural that I do the restauration too. - Winfried

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