Clinical dentistry by Michael C. DiTolla, DDS, FAGD
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IntroductionThis case study demonstrates the clinical procedure for removing old, less esthetic amalgam inlays with all-ceramic inlays such as Premise Indirect.Figure #1The inadequate restorations on the second premolar and first molar will be replaced by all-ceramic Premise Indirect inlays. -
Figure #2First, the old amalgam restorations and any caries are removed. -
Figure #3Next, the shade of the restoration is determined. -
Figure #4Sharp angles between the preparation floor and walls are avoided by using a tapered diamond. -
Figure #5The preparation walls are almost parallel. Depending on the variation of the cusp, they may vary between 6 degrees and 9 degrees. -
Figure #6Deep dentin should be lined. -
Figure #7Vivaglass, a light-cured glass ionomer (Ivoclar Vivadent), is used in this case. -
Figure #8Finally, the enamel margins are finished. -
Figure #9The preparation margins must show up clearly on the impression in order for the dental technician to fabricate an accurately fitting restoration. -
Figure #10Light curing cement is particularly suited for temporary restorations. -
Figure #11For this case, temporary eugenol cements that inhibit polymerization are unnecessary. -
Figure #12A small temporary grip is attached to the Premise Indirect inlays to facilitate manipulation during try-ins. -
Figure #13The glycerine in the preparation should fill out the cementation space. -
Figure #14The shade might already be determined at this point. -
Figure #15Light refracts in almost the same was as it will in the luting composite at a later stage. -
Figure #16Subsequently, accuracy of fit and contact points are checked. -
Figure #17The occlusion is not checked at this point. -
Figure #18The first step in preparing for cementation is the removal of the inlay from the preparation. -
Figure #19At this stage, at the latest, the fields should be isolated by a rubber dam or quick dam. -
Figure #20After the restoration has been tried in, it is rinsed and dried. -
Figure #21The restoration is then cleaned with a commercial cleanser and dried thoroughly. -
Figure #22The areas are air dried to improve the bond between the ceramic material and the luting cement, as well as between the luting cement and the tooth structure. -
Figure #23First, the ceramic is etched with a hydrofluoric acid for 60 seconds. Then the enamel is etched with phosphoric acid for 30 to 45 seconds. -
Figure #24The acid is rinsed off and the surface dried. -
Figure #25Syntac primer (Ivoclar Vivadent) is applied to the preparation for at least 15 seconds. Syntac adhesive is then applied to the cavity preparation for 10 seconds. -
Figure #26Next the ceramic is silanized with Monobond S (Ivoclar Vivadent). This is done by brushing the silane onto the inner surface of the ceramic for 60 seconds. -
Figure #27Heliobond™ (Ivoclar Vivadent) is applied to the inlays, as well as to the tooth, to increase wetting. -
Figure #28All materials are then dried with a stream of air. Heliobond is not fully cured at this point. -
Figure #29Have your assistant mix the luting composite. For this case, I use the time-test dual cement Variolink® (Ivoclar Vivadent). -
Figure #30Then the mixed composite is applied to the preparation. -
Figure #31The inlay is placed in the preparation. Under slight pressure, excess composite is forced out through the cementation space. -
Figure #32The excess cement is then removed with a spatula. -
Figure #33While my assistant holds the inlay in the preparation, you may carefully remove proximal excess with dental floss. -
Figure #34The luting composite in the cementation space is liberally covered with glycerine to ensure complete polymerization. Liquid Strip is used to protect the composite from contact with oxygen. -
Figure #35The occlusal surface is light cured first. Adequate time, at least 40 to 60 seconds, should be allowed for this step. Polymerization by proximal regions is facilitated by light wedges. Although the majority of Variolink cement has been polymerized, it is still necessary to take great care. Adequate time, at least one minute, should be taken for polymerization. -
Figure #36Then, the grips are broken off. -
Figure #37The rest of the glycerine is removed by rinsing thoroughly with water. -
Figure #38Occlusal excess is carefully removed with a tungsten carbide or a diamond finisher. -
Figure #39Particular care must be taken in the proximal region. Excess is located with dental floss and removed with a suitable instrument. -
Figure #40The Quick Dam is removed before the final occlusal check. -
Figure #41Initial contacts are removed with a diamond. -
Figure #42Silicone polishers are suitable for smoothing ceramic surfaces. -
Figure #43The areas adjacent to the inlay are fluoridated last. In this case, Fluor Protector Gel is used. -
Figure #44As you can see, the Premise Indirect composite inlays are difficult to distinguish from natural tooth structure. They blend nearly seamlessly with surrounding dentition.
