Category Archives: Restorative Techniques

Full Arch Rubber Dam for Restorative Procedures

By Dr. Christopher C.K. Ho

The application of rubber dam is recommended to achieve adequate isolation for many dental procedures, helping to provide a clean, dry environment and minimises contamination from saliva and blood.

It also plays a crucial role in preventing ingestion or aspiration of instruments, tooth debris, dental materials, medicaments, irrigants or other foreign bodies. As well as the provision of isolation and moisture control, there is the added benefit of retraction of lips, cheeks and tongue. This allows improved access, visualisation and protection of soft tissues from rotary instrumentation.  The use of coloured rubber dam helps to achieve better visualisation of the teeth with a contrasting colour of the rubber dam material.

It is often commented that placement of the rubber dam is a difficult procedure and that the time it takes to apply the dam is excessive. The other concern for dentists is that it can uncomfortable for the patient while the dam is being placed due to the stretching required to seat the dam.

The author utilises a technique that has been very useful in his practice in isolating a full arch very quickly, and comfortably for the patient. This is particularly useful when working on multiple teeth with direct procedures like the removal of amalgam and caries, and placement of restorations. It can also be effectively used in the preparation and cementation of indirect restorations, e.g. porcelain veneers/onlays/crowns.

This technique is a useful one to have in your armamentarium for utilisation within clinical practice.

Upper Arch

Figure 1: Upper arch

Rubber Dam

Figure 2: Rubber Dam: use of Flexidam (Roeko) This rubber dam is non-latex and consists of a very flexible material that is able to withstand stretching and has high tear resistance. Holes are punched in the 12 and 22 positions.

slit technique

Figure 3: A slit technique is used to join the holes punched so that they are joined.

Rubber Dam Clamps

Figure 4: Rubber dam clamps are placed on the molars and depending on the isolation required, clamps can be placed anywhere from 2nd premolar to the 2nd molar.

Rubber dam

Figure 5: Rubber dam is stretched over the clamps and then the front part of the dam is carefully directed under the labial sulcus, which effectively isolates the teeth.

 

Rubber dam

Figure 6: Rubber dam in place

putty bite

Figure 7: A quick setting putty/bite registration material is then used to seal the palate.

 

Rubber dam

Figure 8: Rubber dam in place (occlusal view)

Rubber dam

Figure 9: Rubber dam in place (frontal view)

 

Ceramic restorations on Discoloured stumps around the gingival tissues

A tooth can discolour for a lot of reasons. If you ask a Sydney dentist about this, you will be advised that teeth could discolour due to age, food, beverage, medications, trauma, dental caries or exposure to highly staining compounds.

A tooth fitted with a porcelain fused to metal crown may stain after prolonged exposure to the metal. This results in an unsightly discoloured stump that often reflects and affects the gum tissue. Teeth with discoloured stumps are very unattractive. It gives the patient a smile that looks dirty, old and diseased, especially since the stained appearance reflects on the soft tissue or gums too.

It is a frustrating problem because even if you place the margins at a subgingival level, the problem still remains. When we encounter a problem like this in the clinic, we suggest a few things to the patient:

1. Internal bleaching. An initial remedy for the discoloured stump that has spread to the gingival tissues is to perform an internal bleaching procedure. This is most appropriate for root canal treated teeth, with effectiveness that is quite unreliable.

2. Opaque restoration. A more definite solution that we provide involves masking or covering the discoloured stump with an opaque restorative material or composite resin. Using Kolor +- Kerr Dental we overlay the darkened area to mask the unappealing area so that it does not reflect on the crowns and on the gum tissues.

This kind of remedy is applicable for root canal treated teeth, teeth receiving dental crowns, bridges and veneers. It may be performed on porcelain-fused-to-metal crowns, all-porcelain crowns or even zirconium crowns. The result you receive is a natural-looking teeth restoration, the appears good as new. The teeth will appear beautiful, healthy and clean.

Discoloured stumpsDiscoloured stumpsCeramic restorationsCeramic restorations

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What is Biomimetic Dentistry?

The days of invasive dentistry that involves having to remove vital parts of teeth or cut down teeth for crowns are drawing to a close with the latest in Biomimetic technology. Biomimetic Dentistry allows a Sydney dentist to conserve teeth by treating weakened teeth that may be fractured or decayed and protecting them from bacterial invasion by sealing them with an adhesive restoration.

Better than traditional methods, Biomimetic Dentistry does not require a dentist to destroy healthy tooth structure in order to build a new restoration. Using the latest in technology, we can bond and adhere teeth together and build missing components of teeth without destroying vital tissue. Modern Dentistry believes in conservativeness of treatments and so nowadays we seek to undertake as little prep or even no prep when it comes to applying veneers or offer onlay, partial crown Biomimetic solutions in preference to a traditional crown thus conserving teeth. This means that restorative treatments are achieved without compromising health.


Indirect Restorations


The advances in adhesives and bonding materials have improved dramatically over the last 40 years, in so much that dentists can restore many cases that would have required crowns with minimally invasive conservative restorations. Although relatively successful and producing increased likelihood for success, understand that carrying out conventional crowns can lead to non-vitality of teeth due to the aggressive preparation required. By utilising the philosophy behind Biomimetics, the preparation needed is often reduced, thus minimising the biological impact to the tooth. Additionally, when this route is opted, many times the preparations can be kept at a supragingival level, leading to the preservation of healthier tissues that allow easier impressions and simpler adhesion procedures.

The Biomimetic technology involves the use of innovative materials. These new materials mimic tooth dentin so well that it even fuses to the existing tooth, offering reliable stabilisation and strength to the restoration. Biomimetic means to copy or mimic nature. For any restorative or cosmetic job done, a patient should appreciate any effort to get their smiles back in the healthiest and most aesthetically appealing manner.

Bio MimeticImage Courtesy of  https://biomimeticdentistryce.com/what-is-biomimetic-dentistry/

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PORCELAIN VENEER PROVISIONALISATION

As a Sydney dentist, when I teach veneer provisional fabrication I teach a few different methods.

  • Direct buildup – a very small dot of etch is placed on the tooth in the mid-labial section and then bond is applied generously over the remaining preparation including the etched area and non- etched areas. This will allow sealing of the dentine so there is no sensitivity. Composite is then directly placed and sculpted into position to simulate the anatomy. This is best for a single or minimal amount of veneers. Please remember after removal of the provisional, a bur must be run over the etched area to remove any remaining composite that may be still bonded in the spot.
  • Bis-acryl provisionalisation conventional method. Using a putty key the temporary material is placed into the putty and placed over the prepared teeth. This is then removed and trimmed and cemented into position with temporary cement. This can be difficult due to the fact that these temporaries are thin and can break upon removal. It is recommended that a clear temporary resin cement like TempBond NE is used, as using an opaque cement can lead to very opaque looking veneer causing concern for the patient.

TempBond NE - sydney dentist

  • Shrink Wrap: Firstly the preparations are cleaned with chlorhexidine, and then a generous amount of desensitizer is used over the teeth, as this protocol does not involve cementation of the temporary veners. Using a putty key the temporary bis-acryl resin material (e.g. Protemp – 3M Espe, Luxatemp – DMG, Integrity- Denstply) is placed into the putty and placed over the prepared teeth, and as this polymerises the material undertoes shrinkage which “Shrink wraps” the temporary veneers onto the prepared teeth. Any excess is carefully removed best with multi-fluted carbide burs.

Shrink Wrap - sydney dentist

  • Spot Etch and Shrink Wrap: This is exactly the same technique as the shrink wrap but we add the spot- etch technique where avery small dot of etch is placed on the tooth in the mid-labial section and then bond is applied generously over the remaining preparation including the etched area and non- etched areas. The shrink-wrap technique then allows for the temporary material to bond to the etched area and the rest of the temporary is wrapped onto the teeth.

 spot-etch temporisation - sydney dentist

Each technique has advantages and disadvantages, however my favoured technique is the spot etch and shrink wrap technique as this ensures that the patient does not lose their temporary. Just remember that it can be more difficult to remove due to this being etched onto one specific area, so warn the patient, and also remember to go over the etched area with a bur upon removal of the temporaries to ensure that there is no remaining composite or adhesives stuck to the tooth. Once I have done this I like to use the Prepstart(air abrasion 27 micron Aluminium Oxide at 40 psi) to clean the tooth and prepare for adhesive processes.

prep start - Veneer - Sydney Dentist