Posterior Molar 2nd opinion

115 Rating(s).


Posted on By Matthew Gillespie In Composite Resin

As this is my first case posting on this forum I will give a bit more of a detailed approach to my workflow for the group. I will be less detailed in the future but I always use the same techniques when restoring with direct composite.

This patient presented to my office for a second opinion after being tx planned for a root canal with build up and crown at his insurance based dentist. Upon testing this tooth, the pulp was dx'ed as reversible pulpitis and healthy apical tissues. I explained to the patient the possible need for root canal therapy in the future but at this time we would restore this tooth properly and keep an eye on the pulpal status.

I used Biomimetic restorative principles as taught by David Alleman and Simone Deliperi to restore this tooth with a stress-reduced direct composite.

I removed all carious tissues according the publication 'A systematic approach to deep caries removal end-points: the peripheral seal concept in adhesive dentistry' by Alleman, Magne. In order to facilitate caries removal I used Caries Indicator dye which is what you see remaining. This was purposefully left over the pulp horn as this was greater that 5mm in depth from the corresponding occlusal surface.

I used hydro-abrasion to treat the dentin prior to my bonding protocols to increase the bond strength of my adhesive layer. I then followed air abrasion with my immediate dentin sealing (IDS)bonding protocol of using a self-etching DBA (Kuraray SE protect bond). I then completed resin coating (RC) of my IDS using a thin layer of flowable composite.

After resin coating, I then use hydro abrasion once again over the entire tooth surface prior to total acid etching. The hydro abrasion removes any accidental bonding agent that was applied to the enamel layer prior to etching and also increases bondability to my flowable layer.

I then build up the enamel replacement portion of the proximal wall according to protocols in the publication ‘Functional and Aesthetic Guidelines for Stress-Reduced Direct Posterior Composite Restorations’ by Simone Deliperi. I used thin (1mm) horizontal layers for my dentin replacement.


Process

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5 Comments

Matthew; Thanks for the post but please utilize all 6 upload spots to add more information....to your post. Dr. Salama


Reply

Do you mean upload the pictures separately? I am unsure of what exactly you are referring to. If there are recommended pictures or steps this forum likes to see please let me know so I can provide more detailed information.


Thanks


Reply

Matthew, The belief by the majority of dentists that composite is an inferior material is primarily driven by finances rather than clinical experience although Gordon Christiansen confirms that the average posterior resin survives only 7 years. I commend you in your approach to restoring this tooth using this approach. I have restored teeth like this both with and without a Biomimetic approach and the results are similar: 20+ years of clinical survival. I have converted fewer than 10 posterior resins to indirect restorations in 2 decades. Great results and congratulations for having the courage to post your work on DentalXP, the forum for real clinical dentists.


Reply

Gerald,
I completely agree with you. When I was an ‘insurance based’ dentist this is a great service that I was unable to provide to my patients due to those financial considerations you mentioned. That restoration took me about an hour start to finish to complete and if I was still an ‘in-network’ provider I could have only charged $150 for that restoration.

I also agree with you about the perceptions of composite resin. It is funny dentists will dismiss dentinal bonding yet are so quick to remove all the enamel from a tooth so there is only dentin left to bond to….it is just completely backwards.

You will be seeing me post more now that I am actually proud of the work I am doing. Thank you for pushing me in the right direction.


Reply

Hi Matthew; My greatest hope for you is that you LOVE what you do, are proud of your work and are well compensated for what you do for your patients. You are taking the right path. Best regards, Gerald


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Brasseler
Augma Bio