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Dr. Raymond Bertolotti
Some Illustrations of Adhesion Dentistry
and Important Clinical Information on Bonding of Posterior
Composites
The simultaneous bonding of Herculite to both gold and
dentin surfaces is in figures 1a and b. An elderly patient
presented with fracture of tooth with a gold 3/4 crown.
The key steps for adhesion of the Herculite to the gold
were intraoral tin plating of the gold and etching of the
dentin. A suitable adhesive (in this case, Clearfil Liner
Bond) allowed simultaneous bonding to these two surfaces
and completion of this case in less than 15 minutes!
photo 1a
photo 1b
Another example (figures 2 a and b) is the use of an adhesive (in this case Panavia 21) to bond gold to a tooth. The patient presented with cracked tooth syndrome. Unlike the previous case, this procedure required two appointments due to the laboratory work. The prepared tooth (figure 2a) needed only a uniform reduction of about 1.5 mm on the occlusal surface without any conventional retention form or breaking of contacts. The second appointment did not require anesthesia since the self etching primer (ED Primer) used to bond to dentin and enamel does not require anesthesia for its application.
photo 2a
photo 2b
A third illustration is bonding of an Artglass veneer to mask existing metal and off-color porcelain on the mesial abutment of an upper bridge (figures 3a and b). The key procedures here are intraoral tin plating of the gold and selection of a suitable adhesive (Clearfil Porcelain Bond) for simultaneous bonding of porcelain, metal, dentin, and enamel.
photo 3a
photo 3b
Important Clinical Information on Bonding of Posterior Composites
We wish to provide all interested clinicians with information on one of the most popular topics in the seminar: how to achieve perfect posterior composite contacts. We are constantly amazed that this topic is such a well kept secret. Dr. Bertolotti has been teaching it for more than ten years now. It is one of the keys to phasing out the amalgam and implementing posterior composites as the treatment of choice.
How To Get Perfect Contacts:
The Palodent® sectional matrix and Bitine® ring has historically been the surest method of establishing a tight and anatomically correct contact in either composite or amalgam. It is now challenged by two other systems which work similarly, Danville Contact Matrix and Garrison (GDS) Compositite. The method continues to be one of the best kept secrets in restorative dentistry.
The matrix is placed in the obvious interproximal position. Two may be used simultaneously for MOD restorations. Alternatively one interproximal surface may be done at a time. It is often necessary to adapt the matrix at the gingival margin with a wedge or perhaps with a paper point or even gutta percha (the paper works well with a rubber dam). If the matrix adapts without a wedge, the wedge is not necessary when a flowable composite is used for the first increment. (Unlike "packable" composite, the flowable composite exerts very little force on the matrix.) The following figure illustrates a typical placement:
Fig. 1
Fig. 2
The ring is placed by spreading it with an "Ivory type" rubber dam forcep, gripping with the sides of the forcep, not the points. The ring adapts the matrix to the tooth and provides separation (since it is a spring pushing from both sides). Note that the ring (especially the non-retentive Palodent®) should preferably be placed along side the wedge, not vertically above it (to get better ring retention and to push the ring away from the prep, preventing collapse of the matrix into a wide prep).
Palodent® Bitine® and Danville Contact rings have flat tines. The "flats" of the ring are intended to touch the matrix. If the "end" touches the matrix, it tends to collapse into wide preps. Danville rings are made in two models to optimize the adaption of the matrix and prevent collapse of the ring into the prep. One model arcs away from the tooth being restored (as illustrated above) and the other arcs over the tooth being restored. The Palodent® ring is intended to arc away from the tooth being restored, as in figure 1. A pair of normal Danville rings is illustrated in figure 2 while a normal and "reverse" Danville ring are illustrated in figure 3.
Fig. 3
Fig. 4
The GDS ring does not have flats so it is omnidirectional but unfortunately it tends to collapse into wide preps as shown in figure 4. The Danville and Palodent® have flats which are designed to prevent this collapse by pushing the matrix against the tooth with the aid of the flats (see figure 5).
Fig. 5
Fig. 6
The Danville ring also has the advantages of 15 degree offset angle on the occlusal (to allow multiple ring stacking) as illustrated in figure 6.
Another feature of the Danville rings is a converging taper of the tines, resulting in a self-retentive nature lacking in the Palodent®. The GDS likewise has a good self-retentive design but unfortunately, in my opinion and according to numerous clinicians, lacks sufficient separating force for good contacts. Both the Palodent® and Danville have better separating force.
For those interested in how separation results without wedges, the following diagram, figure 7, will explain the physics. Equal and opposite spring force is exerted from each side to separate the teeth. The longer the ring is in place, the more separation. In the clinic, about 5 minutes seems ideal for most restorations.
Fig. 7
More About Dr. Bertolotti & Contact Info, (click here).
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