by Bob F

 By: Bob F    •    S1327        November 2010  Dental Portfolio
 


 

(Details)

Posted by Bob F on 13 November 2010, 7:00 PM

The Preparation

The column below explains how to prepare the tooth.


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Personal Protective Equipment (Details)

Posted by Bob F on 13 November 2010, 6:17 PM

  • Before we do anything, we must make sure to have proper Personal Protective Equipment (PPE) on.
    • Consists of: Mask, Glasses, Gloves.
  • PPE is put on in the order above so as to reduce contamination while donning.
  • Your mask must cover your entire nose and mouth area.  It must be a snug fit for it to be effective.
  • Glasses should be made of a high impact plastic and cover entire eye area including sides of eyes.
  • Before wearing gloves, you must wash your hands to prevent incubation of bacteria under gloves.  This is the last component of your PPE that you put on because it reduces contamination on your gloves.  We don’t want to risk infecting a patient because we didn’t put on our PPE properly. 
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Survey the Teeth (Details)

Posted by Bob F on 13 November 2010, 6:21 PM
  • Today we’re going to be doing a Class II MO 'restoration' on tooth #19.

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Color match Enamel and Dentin (Details)

Posted by Bob F on 13 November 2010, 7:41 PM
  • Done without rubber dam so that you have a better color perspective in the context of the entire mouth.
  • Place a small sample of composite on the un-prepared, un-etched tooth and light cure for 20 seconds.
    • Light curing reveals the true color of the composite and must be done to properly color match.
    • Try to color match using color corrected lighting.  Fluorescent lights do not have a good color rendering index.  For more information on color rendering please visit this site: Color Rendering Index Explained
  • It looks like this tooth is close to an A2 shade.  The tooth is also quite opaque so we will be not be using an enamel shade over the dentin shade.  (Our tooth may look opaque due to aging outside its natural environment.  I also only had these two shades with me at the time)
  • After you're done color matching, just chip off the composite.
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Rubber Dam Placement (Details)

Posted by Bob F on 13 November 2010, 7:43 PM

  • We will be clamping tooth #18 with a molar dam clasp and exposing teeth mesially until tooth #22
  • Because we are working with composite, it is particularly important to have a good seal. 
  • The dam must cover the entire mouth including the maxillary arch.
  • Once the prep has gone through the etching procedure it must be kept isolated from further moisture so as to not compromise the integrity of the bonding area.

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Positioning and Seating (Details)

Posted by Bob F on 13 November 2010, 7:44 PM

  • Seated in the 11:00 position
  • Back straight and minimal spine angle
  • Arms close to body
  • Completely seated
  • Lower back firm against back rest
  • Knees at a right angle
  • Feet planted flat on floor
  • Patient seated partially reclined
  • Work is done through direct vision
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Outline Form (Details)

Posted by Bob F on 13 November 2010, 7:48 PM

  • A 34D bur is used to start the rough outline form that is determined by the extent of decay
  • The outline form is started with the box form which should break contact both facial-lingually (1/2mm separation) and gingivally.
  • The 34D is used to finish the gingival floor.
  • Switching to the 330D to extend and finish the outline form allows the ability to work on the walls of the preparation.  The cutting diamond encrusted end of the 34D is usually not long enough to contact the depth of an entire wall.
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Resistance Form (Details)

Posted by Bob F on 13 November 2010, 7:49 PM
  • Avoid having a cavo surface on occluding areas by using articulating paper. (Not applicable to our restoration)
  • Internal line angles are rounded to prevent focused stress points in the tooth that may lead to tooth structure or restorative material failure.
  • Minimal or no undermined enamel should be created.  Preparation walls should be parallel or slightly convergent.
    • Unlike amalgam, composite doesn't have any anti-cavitative features, and bonds to the tooth instead of being held by mechanical retention.  Many schools of thought teach to create divergent walls so that if the restoration fails, it will completely fall out and the patient will notice and return.  In clinical practice, there is little or no chance of all your restorations walls to fail within a reasonable time period.  Extensive recurrent decay would have to develop in order to produce a "floating restoration" and have it fall out.  
    • For this reason, it makes more sense to produce parallel or convergent composite preparations.  By doing this, you share the disruptive forces against your restoration amongst mechanical AND bonding forces rather than just bonding forces.  In addition, because of the more obtuse angle formed by your restorative material at the cavo surface margin, there is more material strength to resist marginal breakdown.  (NOTE: There is no source for this information other than clinical observation during practice)
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Dave - 09 October 2016, 6:40 PM
         In addition, because of the more obtuse angle formed by your restorative material at the cavo surface margin, there is more material strength to resist marginal breakdown. 

-I'm just thinking about this, not sure why there's more material strength with an obtuse angle.  One possible advantage might be that convergent rather than divergent prep would keep restorative material further away from contact point.

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Retention Form (Details)

Posted by Bob F on 13 November 2010, 7:49 PM

  • When preparing a tooth, we must mind the restoration materials we are using.  Composite has a much stronger bond to enamel then dentin. We want to take advantage of this by placing bevels in enamel to maximize the bonding area and ensure a proper marginal seal and robust restoration.
  • One half to one millimeter wide bevels are placed in the proximal margins at a 45 degree angle.  The gingival floor should be kept in the enamel.  If possible, the gingival floor should have a bevel within the enamel.  A gingival floor that is in dentin should have a butt margin and should be at least 1mm deep axially.  Tooth number 19 is a somewhat short tooth and may not always have room for a gingival bevel.  We will not be applying a gingival bevel in our restoration for that reason.
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Convenience Form (Details)

Posted by Bob F on 13 November 2010, 7:49 PM
  • Proximal bevels also allow for easier access to finishing the restoration.
  • The lingual bevel can be made larger because there is less of an aesthetic requirement.
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Removing Remaining Carious Dentin (Details)

Posted by Bob F on 13 November 2010, 7:49 PM
  • When removing caries in dentin, the largest spoon or largest round bur should be used on the low speed hand piece.  Large spoons and burs reduced applying a focused strain on the tooth and give the operator better feedback and control when distinguishing decay from healthy dentin.
    • We obviously don’t have anything remaining to remove from our tooth…
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Refinement of Resistance and Retention Form (Details)

Posted by Bob F on 13 November 2010, 7:50 PM
  • Removing of the remaining decay in dentin may have changed the shape of the preparation or caused undermined enamel.  This step is used to refine the resistance and retention features of the preparation.
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Finishing Enamel Walls and Margin (Details)

Posted by Bob F on 13 November 2010, 7:50 PM
  • When performing a restoration, we want to create the best marginal seal possible to prevent any leakage that may lead to failure.  During this step, we check the entire preparation (particularly our margins) to make sure everything is clean and smooth.
  • All cavo surface angles and bevels have been tailored to maximize bonding the enamel rods and all line angles are curved.
  • The 330D and 34D are used to finish the walls and floors and the 132F is used to finish any bevels.
Please view "Post Procedure Analysis" for a review of this preparation.
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(Details)

Posted by Bob F on 13 November 2010, 7:30 PM

Placing the Restoration

Explained within this column is the restoration phase.


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Placing a Sectional Matrix (Details)

Posted by Bob F on 13 November 2010, 7:51 PM

  • First place the matrix and wedge into place to seal the cervical margin.  The appropriate sized wedge should be placed on the side of the matrix opposite from the prepared tooth and inserted from the lingual side.
    • Note that we are using a plastic wedge because they don’t soften like wooden wedges.  This allows us to maintain placement of the wedge without having to further adjust if our environment becomes moist.
  • The matrix ring is place between the wedge and the adjacent unprepared tooth.
    • I personally find that placing the C-ring ‘outside’ the wedge/matrix complex produces a better gingival margin adaptation for me.
  • Burnish the metal band with a plastic instrument to create the proper contact area.
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Prepare the Tooth for Bonding (Details)

Posted by Bob F on 13 November 2010, 7:52 PM

  • We are using a 37% phosphoric acid etchant to remove the smear layer and etch the preparation.
  • The etchant is first applied to the enamel, and then the dentin such that the total etch time is 20 seconds for the enamel and 10 seconds in the dentin.
    • A longer etching time is unnecessary as it does not result in a thicker hybrid layer.6

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Rinse Well (Details)

Posted by Bob F on 13 November 2010, 7:52 PM
  • Do not desiccate the tooth.  Desiccation causes the collagen cross bridges in the dentin to collapse resulting in a weaker bond.
  • The tooth should be dried until moist.
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Pulp Protection (Details)

Posted by Bob F on 13 November 2010, 7:51 PM
  • Today we are not using a liner but if the preparation allows, a liner such as a glass ionomer (GI) should be used on the pulpal floor.
    • Glass ionomer bonds readily to dentin and provides limited fluoride protection in the dentin.
  • A liner is used to strengthen the floor of the preparation and increase the resistance of the restoration.
  • To apply a GI liner, the dentin must be etched for 10 seconds to remove the smear layer then dried moist.  The liner is then applied to the pulpal floor and spread thin.  Light cure for 20 seconds.
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Ed Dergosits D.D.S. - 05 April 2015, 12:08 AM

Did they teach this in the didactic curriculum at UCSF or was it the belief of one of the clinical instructors? GI does not strengthen the floor.  I do not understand what you mean by "increasing the resistence of the restoration" but placing a GI base does not increase anything except the time it takes to restore the tooth. I know this portfolio is more than 4 years old.  You are probably in your OMFS residency by now.

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No Untreated Lights (Details)

Posted by Bob F on 13 November 2010, 7:53 PM

  • Any material that is designed to light cure can cure with ambient or direct white light.  For this reason, we cannot use any untreated lights from here until we are done curing our final composite layer.
  • If using a loupe light or any other light with an orange filter, use on the lowest necessary brightness.  Even filter treated lights can reduce your working time by causing polymerization.  No filter can be 100% effective. 
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Apply Bonding Agent (CRITICAL!) (Details)

Posted by Bob F on 13 November 2010, 7:58 PM

  • We’re using OptiBond Solo Plus which is a two in one primer and bonding agent.
    • This bonding agent produces the critical hybrid layer consisting of primer entrapped collagen fibrils in the dentin.  Desiccation of the tooth causes the collagen bridges to collapse and reduces the ability of the primer/bond to penetrate the collagen and create a healthy hybrid layer.
  • The bonding agent is RUBBED on for 15 seconds over all areas of the tooth to be bonded.
  • Then the bonding agent GENTLY blown with the air syringe and made to be as thin as possible.
  • RUB BONDING AGENT ON AGAIN FOR 15 SECONDS and GENTLY blown thin.
  • Light cure for 20 seconds after applying two layers of bonding agent.
    • Rubbing the bonding agent improves its penetration and produces a thicker hybrid layer.3
    • A second layer of bonding agent significantly increases bonding agent coverage and strength.3
    • For more on bonding and bonding technique, visit: DentistryToday.com
  • The prep should and does look ‘wet’ and even.  The surface of the bonding agent produces an oxygen inhibited layer to which the composite will bond to.

Seal Box Form Margins (Details)

Posted by Bob F on 13 November 2010, 7:58 PM

  • Flowable composite is used on the box form margins ONLY.  An explorer is used to gently brush the composite into place to seal the margins.  This gives us a better ability to achieve a complete seal in the box form where it is tight and difficult to work.  Flowable is only used in the box form because it has a reduced compressive strength compared to regular micro-hybrid composites.
  • Light cure for 20 seconds.
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Placing the Composite Restoration (Details)

Posted by Bob F on 13 November 2010, 7:58 PM

  • Starting with the box form, the preparation is filled in roughly 1-1.5mm increments while making sure to light cure for 20 seconds between each layer.
  • Filling in layers reduces potential polymerization shrinkage that can either cause microleakage or tension on the cusps.  Thinner layers also allows for more complete penetration of the curing light.
  • The Mini 1 and W-3 NiAlN coated hand instruments are used to vibrate each layer into place.
    • Make sure to have gauze nearby to wipe your instruments clean regularly while placing the composite.  The non-stick coating is only non-stick when it’s clean.
  • Movement with the instrument should always be in a wiping motion towards the cavo surface to reduce bubbles and defects in the surface.
  • Our previously selected enamel shade will be the top layer of composite and roughly the same thickness of the existing enamel.  This layer will be sculpted to match the existing tooth anatomy before curing.
  • All margins are checked for a proper seal.
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Pre-finishing (Details)

Posted by Bob F on 13 November 2010, 7:59 PM

  • After removing the matrix, the 135, 379 and 247 burs will be used to further sculpt the composite.  A fine variation of each bur will be followed by an extra-fine version to achieve a ~15 micron finish.
  • A 14L DeMeo Carver is used to finish the gingival margins.
  • Occlusion is checked and adjusted during this step.
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(Details)

Posted by Bob F on 13 November 2010, 7:33 PM

Polish and Finish

This column contains steps for polishing and finishing.


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Polishing (Details)

Posted by Bob F on 13 November 2010, 8:01 PM

  • Polishing diamond impregnated rubber points and cups are used on the low speed handpiece in the following order to polish the composite; green, yellow, white.  These polishers are used slow, wet and lightly.
  • Soflex disks are useful for inter proximal areas.  These are used in order on the lowspeed from a dark (medium-fine) to the lightest color (superfine).  The superfine disk is used dry while the rest are used moist.
  • Polishing will be followed up with the jiffy brush (silicon carbide brush) on the low speed handpiece.  This brush is used dry, spun as fast as possible and brushed over the composite surfaces in a gentle sweeping motion.  When used properly, a high shine finish should result.
    • Previously I had been taught to use this brush hard fast and dry.  This only resulted in a worn brush for me.  I find that a soft onset and offset combined with mild pressure produces a better shine.
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Glazing the Composite (Details)

Posted by Bob F on 13 November 2010, 8:01 PM

  • This step is optional.
  • When done properly, Glazing should fill in micro fractures and defects in the composite surface to create a more complete restoration.
  • Glazing is NOT a substitute for polishing.
  • To use OptiGuard (a composite glaze), the entire surface of the composite must be etched for 20 seconds.  The etchant is then washed off and the surface dried completely without desiccating the tooth.  The glaze is applied with a brush and blown very thin.  Light cure for 20 seconds.
    • Occlusion should be checked again and contacts should be flossed to remove any residue.
  • We did not glaze our composite.
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Admire the Restoration (Details)

Posted by Bob F on 13 November 2010, 8:05 PM

  • Remove the rubber dam.
  • Use carbon paper and ask the patient to ‘tap their teeth together gently’ to check occlusion.
  • Admire your fine work and smile.
    • Smiling is an important sign to the patient that conveys that the restoration went well and was completed to or above the standard of care.
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(Details)

Posted by Bob F on 22 November 2010, 4:34 PM

 

 

 

Post Procedure Analysis

 

 


Critical Requirements (Details)

Posted by Bob F on 22 November 2010, 4:05 PM
  • Conserve tooth structure.
    • This is inherent in any composite restoration because composites have few requirements none of which involve size/depth of the preparation.
    • I realize now that I was over conservative with my preparation.
  • Occlusally and facially esthetically pleasing.
    • We are using custom composite colors to match enamel/dentin.  Even though my colors were in short supply, the match is decent.
  • Proper retention and resistance.
    • The appropriate features (bevels, wall angles, and rounded internal line angles) were added to the preparation to optimize retention and resistance.3
    • The micro hybrid fill composites we are using posses good wear resistance and compressive strength while providing good polish-ability and aesthetics.

My restoration meets these critical requirements, but it does have some problems.  The most significant problem is that my preparation is too conservative.  I was being naive at the time, but my box form should have been about half a millimeter deeper gingivally, I should have applied a gingival bevel, and my entire occlusal preparation was too narrow and un-extended.  I automatically assumed because tooth number 19 is a short tooth, I couldn’t go too deep or place a gingival bevel.  Also, there is no minimum depth that is required when using composites, but I believe the axial depth of my box form should have been about half a millimeter deeper as well. If the decay reaches the DEJ, it’s usually well past it.  This is the first class II I’ve done on a natural tooth as well as the first one I’ve done in a while, so I attribute my errors to that.

Comments (0) Add comment

New Skills Learned (Details)

Posted by Bob F on 22 November 2010, 4:06 PM
  • Color matching
  • Refinement of polishing composites

Before performing this restoration, I took a look at some colors to get a good idea and also experimented with polishing some of my old work.  Unfortunately, natural teeth change color/transparency over time when removed from the mouth.  During my polishing experimentation, I learned that the best polish is a good pre-finish.  If the restoration has been properly contoured and smoothed, a medium rubber point and a jiffy brush provide a good shine and finish.

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Problems and Experience Gained (Details)

Posted by Bob F on 22 November 2010, 4:07 PM
  • Messy marginal ridge when placing the composite restoration.
    • While placing the composite, I didn’t mind the marginal ridge.  This resulted in having more pre-finishing work.  I believe I may have been too busy managing the camera during this time to realize.
  • Wiping my composite tools instead of lifting off.
    • This is a habit I’m trying to break.  I’ve gotten better about it, but when reviewing my videos again, it seems I’m not as good about it as I would like to be.
  • Use the HVE instead of the saliva ejector when using a rubber dam.
    • The saliva ejector was just closer to me when I went to grab a vacuum.  The reason I bring this up is because I was using a weak suction when cleaning up the etchant.  You don’t want the etchant to get on any skin around or in the mouth as it will cause chemical burns.  The HVE should ALWAYS be used when cleaning etchant.
  • Inserting the matrix wedge difficulty.
    • The wedge moves the matrix when it’s being placed.  A little lubricant solved that problem and allowed it to slip into place without altering the matrix placement.
  • Our light cure gun timer is only for 10 seconds.  NOT 20 SECONDS!!
    • I only learned of this through watching my videos.  I don’t know why they would make a 10 second timer with a 5 second beep.  It takes 20 seconds or more to properly cure any light cured material.
  • Proper UV light curing and OptiGard
    • I’ve learned that our light cure guns do not produce the optimal range of UV light in a sufficient intensity to cure some materials.  OptiGuard is amongst the materials that cannot be cured with our light cure guns.
    • There is evidence that a ‘full’ light source (halogen bulb) can produce a greater degree of polymerization than an LED curing gun.1  Any curing device should be carefully looked at and be confirmed to produce the proper wavelengths of light in the necessary intensity to ensure complete polymerization of light cured materials.
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Reflections (Details)

Posted by Bob F on 22 November 2010, 4:07 PM

After spending so much time and effort on the first portfolio, I was dreading this project.  But many things changed since then that made this project almost a joy to do.  First of all Mahara simplifies everything.  Having one standard entity to present your work is absolutely key in the up and coming portfolio world.  Mahara does this well in that it further standardizes the look of all portfolios and makes it much less work then using all the gizmo’s of power point.  Also, I experimented with filming my restoration during the last project.  This time around, I was much better at it.  I find that video documentation is far superior to pictures because it captures things you don’t notice until later, and you don’t have to stop every minute to take a dozen pictures.  Images can be taken of the video after the procedure is completed.

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Future Impact (Details)

Posted by Bob F on 22 November 2010, 4:10 PM

With each portfolio, my work is refined and I gain a useful understanding of each step/tool/material.  This project is no different.  Spending the time to document, then review a procedure really allows the procedure to root itself in your mind.  My work here is a solid step towards improving upon my training.

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References (Details)

Posted by Bob F on 25 November 2010, 11:24 AM
  1. Beun, S., Glorieux, T., Devaux, J., Vreven, J., & Leloup, G. (2005). Characterization of nanofilled compared to universal and microfilled composites. Dental Materials , 23, 51-59.
  2. CRI Explained. (n.d.). Retrieved from full spectrum solutions: http://www.fullspectrumsolutions.com/cri_explained.htm
  3. Freedman, G., & Goldstep, F. (1997). Fifth generation bonding systems: state of the art in adhesive dentistry. Journal of the Canadian Dental Association , 63 (6), 439-43.
  4. Leinfelder, K., & Freedman, G. (n.d.). Essentials of Dentin Bonding: Clinical Technique for Long-term Success. Retrieved from Dentistry Today: http://www.dentistrytoday.com/restorative/1772
  5. Opdam, N. J., Roeters, J. J., Kuijs, R., & Burgersdijk, R. C. (1998). Necessity of bevels for box only Class II composite restorations. The Journal of Prosthetic Dentistry , 80 (3), 274-279.
  6. Sundfeld, R. H., Valentino, T. A., de Alexandre, R. S., Briso, A. L., & Sundefeld, M. L. (2005). Hybrid layer thickness and resin tag length of a self-etching adhesive bonded to sound dentin. Journal of Dentistry , 33 (8), 675-681.
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Diastemas.net, the best thing since skinned Kiwis? (Details)

Posted by Bob F on 24 February 2011, 11:41 AM

Portfolio based dental education and competency examination is the future we will soon come to embrace.  Diastemas.net is a peer based community of student dentists from around the world.  From this web portal, we share, review, and indulge in each others work.  I have posted this portfolio and spent some time interacting with the community.  Below is a short review article I have written about my experience with this new age of dentistry.

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Attached files Attachments 1

Diastemas Reflections by Bob Forooghi.pdf (103.2K) - Download

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The Author

Bob F's profile picture

Thank you for viewing this portfolio.  Any comments will be greatly appreciated.  To view my profile, click here. 

Creative Commons License

Creative Commons license

Class II Composite Restoration by Bob F is licensed under a Creative Commons Attribution-Share Alike 3.0 Unported license.

Permissions beyond the scope of this license may be available from Bob F.

(Details)

class II 2 restoration e-portfolio portfolio eportfolio e portfolio composite natural color match restorative two dental dentistry dent enamel dentin gum gingiva  dental eportfolio dentist portfolio dental e-portfolio dentist e-portfolio dental portfolio dentist portfolio composite restoration portfolio

Update - Sept 2013 (Details)

Posted by Bob F on 22 September 2013, 3:18 PM

I produced this portfolio in my second year of dental school.  I have since received regular emails and have been in almost constant discussion about the techniques I present here.  Of course since producing this my knowledge and skills have also improved significantly.  The following is a quick "what would I change now" if I were to re-write this portfolio.  This was a reply to a recent email I received:

 


At this point I would consider everything from the rubber dam to the final polish and finish as inadequate in my portfolio.
 
  • - My initial rubber dam is very messy with folds all over.
  • - I almost never use the 34D bur anymore.  It's too small.  Most common burs are the 330 Carbide (because it's cheaper than diamonds) and a crown and bridge bur for the (too common) deep class II walls.
  • - The concept of an outline form is almost deleted from my mind.  When beginning a tooth, I strictly aim for the caries and remove healthy tooth structure if more visualization is needed.
  • - I'll then remove any undercuts and place proxima/gingival bevels with respect to the enamel rod orientation.  If the prep is small, I'll break the contact with my bevels with a thin flame bur to keep it conservative.  Either way, the contact must be broken.  If it's not, you're just wasting time, making things difficult, and you'll most likely end up with a poor and soon to fail restoration.  In the long run, that would be much less conservitive so do the job right, don't be scared to make it bigger if you need to.
  • - Those standard G-rings are good, but the new G-rings are AWESOME: http://www.garrisondental.com/store/matrix-systems/composi-tight-3d-slick-band-matrices/composi-tight-3d-system-slick-bands-matric  Use whatever jelly bean shaped matrix band you wish, that ring produces the perfect separation and the rubber pads adapt to give excellent contour.  I recommend skipping the pricier V3 ring system.
  • - In the real world, sensitivity is a HUGE issue.  You don't want to talk about it with the patient, you don't want them calling, you just don't want to mess with it and give your patient a bad experience.  Fifth gen bonding agents are good, but 7th gen all-in-one's are getting pretty good too.  The best option is to use a desensitizer such as gluma after your etch, but before the bond.  There is reserach that shows an improvement in bond strength too.  I believe Gluma is mixed into OptiBond Solo Plus.  Take care not to use something that interferes with your bond.  Currently I often use flowable or a GI liner.  The GI liner for deeper preparations because the etch is less harsh and sensitivity inducing.  These liners provide two benefits...more on that later.
  • - If you're doing a full etch, take EXTRA care not to etch the dentin for more than 10sec.  This leads to significantly more sensitivity in my experience.
  • - After your etch, suction the etchant, then wash it really well.  You suction first to avoid any of the acid etch flowing elsewhere.  DO NOT COMPLETELY DRY THE TOOTH.  In fact, just a quick blow with the air syringe is enough.  Studies show that having a damp surface actually provides a stronger bond because of the acetone in the bonding agent.  Acetone is hydrophilic so it gets sucked down into the wet tubules better.  Minimal water does not interfere with the bond, saliva destroys the bond.  Keep it saliva free.  Dry moderately to evaporate the acetone/water before curing.  No need to apply multiple layers of bond but you can scrub it in, dry a bit then scrub some more before curing.
  • - Place your liner or flowable.  I almost always use flowable on the floor of my preparation.  Not only to get really good adaption, seal the tubules and reduce sensitivity, but also to reduce your C-factor.  As you may know, all resins shrink on curing.  The fewer tooth walls you place an incrament of composite against, the less of a chance it has to pull away from one of the walls and weaken/break the bond.  Placing something on the floor first instantly eliminates that surface and reduces your C-factor.  Now there are other minute details such as the thickness of said layer being cured as well.  Take care NOT to place the liner on the cavo surface or higher up on the walls.
  • - If you got some liner/base on your cavo surface or made your walls untidy, you'll need to re-prep to clean the walls.  You get better at keeping things neat in time.  Etch+bond again if you do re-prep.
  • - Place your composite, jiggle it into place as best you can.  Place ~2mm layers and make sure your curing light is producing enough intensity in the correct wavelength of light (they have measuring tools or just don't skimp on your curing light).
  • - Finish your restoration anyway you like but make sure you don't have an overhang and the contact flosses smoothly without fraying floss.
 
At the end of the day, your restoration is only as good as the care it receives over time.  Decent dentistry is designed to last 7-12yrs.  The best indication of future caries is a tooth that already has a restoration.  The trick is preventative home care.  I myself have quite the regiment and I strongly consult and advise my patients on how to care for their teeth.  The methodology is called Caries Management By Risk Assessment (CAMBRA) which basically means you custom tailor care instructions for each patient.
 
Also, you can only do so much by hand.  If you're lazy or tired, you're going to do poor work.  For that reason I feel CAD/CAM inlays/onlays are an excellent option.  You can focus on just perfecting your prepping skills and let the machine spit out whatever.  It's got decent margins, but it comes out with excellent contours and is being cemented with a restorative resin, so all the margins get bonded anyways.  If you think about it, who burnishes/polishes their cast metal margins any more?  You'll still need to place a liner before your scan though.  This method gives you a much more solid restoration that I feel has a better chance of success (purely my thought process and not research based).
 
I would add to this that since graduating dental school, I feel a bit of a void from not constantly learning.  I find myself getting lost on Google Scholar reading about various topics I think about during work.  Without evidence, it's all just here-say.
 
Dentistry is easy enough, but you're doing everyone a disservice if you just do it this way because 'that's how I've always done it.'
 
 
 
More about what I'm doing:
 
With the advent of modern 3D technologies, dentistry will hit an evolution spurt sometime soon.  Since dental school, I have built a couple 3D printers and attempted to fabricate simple temporaries or in-term restorations with some success.  3D printers have huge value for a dental practice in my opinion.  If not for their accuracy and speed, the sheer cost of producing a temp from a sub $1000 printer is literally less than a penny (yes, it's very accurate).  Compare that to your ~$4/temp bis-acrylic.  Not to mention if you're all digital with CAD/CAM, you can forego the $20 PVS impression you would normally take.  There is a lot more to this so feel free to contact me.
 
I'm currently at the University of Pittsburgh AEGD and getting started working on a potential tech curriculum for the predoc students as well as other educational development projects.  I also can't seem to budge my interest in Oral Surgery so I'll be heading in that direction.  Otherwise, I have preemptive plans to produce dental management and professional networking software for the modern age.  I feel that the existing software is moderate to poor with very limited functionality with a huge interface handicap.
 
BForooghi@gmail.com
anonymous profile picture
Ed Dergosits D.D.S. - 05 April 2015, 12:30 AM

If one chooses to use Gluma it clearly should not be mixed with the bonding agent of choice. I am surprised you do not understand why this is not how it should be used.  Gluma is an antibacterial wetting agent that can be used with a variety of bonding agents.  I personally have used Zepheran for more than 25 years for this purpose. Acetone acts by displacing water in dentinal tubules while carrying water insoluabe resin bonding agent that is soluable in the acetone.  A well placed composite restoration can service for 20 years or more depending on the occlusion.  A failure at 7 year survival would be considered a technical failure in my observation. It is not good for the patient's tooth to remove healthy tooth structure to eliminate undercuts when placing direct resin or amalgam restorations. This is one reason why direct restorations are often preferred over indirect restorations.

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