Kelley Brummett, DMD 

Resin-based temporary cements are wonderful due to their translucency and their ease of cleanup after light curing. My favorite is TempoCem from DMG.  

To prevent resin-based temporary cement from bonding to the newly placed composite, some dentists apply Vaseline on the prep before placing the provisional. 

Instead of Vaseline, I use glycerin. We keep glycerin in a little syringe in the room, and we put just a smidge in a little dapping dish so I can coat the top of the prep with it. Since beginning to use glycerin, I have not had difficulty retrieving bonded provisionals. 

If your provisionals come off, just get a new and stronger temporary cement. No! I am just kidding! If the provisional comes loose, it is often because you do not have enough space, so excursive interferences are high. When this happens, I engage with the patient in checking their occlusion, and continue to work out the determinants of their occlusion.  

Figuring these things out while the patient is in a provisional that is retrievable due to the ease of the temporary cement used, helps me continue to make progress on their occlusion before moving forward with the final restoration.  

It is not a failure of cement; it is a growth opportunity for discovery and patient engagement! 

The more complex the dental treatment plan gets, the more challenging the process becomes. Adding in interdisciplinary care with multiple specialists adds another layer of complexity. We need to clearly plan our sections, and clearly communicate the outcomes we hope for from the other providers.

The Challenges

One of the challenges has been communicating to my orthodontist my visual for the results. The other challenge has been how to visualize tooth movement to optimize my restorative. What has helped me tremendously is doing an ortho setup as well as a restorative wax-up.

My Process

This is a process I use when planning complex cases involving orthodontic and restorative that has helped create clear expectations for everyone.

1. I start my aesthetic treatment planning by drawing white shapes and lines on photographs of the teeth to determine the desired tooth proportions and gingival aesthetics. I’ve blogged about this before in these two articles: Tooth Proportion Aesthetic Ratio and Where the Pink Should Be. I also draw lines on photographs to determine the Anterior Segment Aesthetic Ratio.
2. When a complex restorative case involves orthodontics, I want a clear sense from my white lines of where I want the teeth moved so I can optimize my restorative. I will send a set of preoperative models to the laboratory and ask them to do an ortho setup. Multiple copies of the ortho setup allow us to move the teeth and do a restorative wax-up on the moved teeth. Once I examine the wax-up I decide if the teeth look the way I visualized they would. Do they have the right length to width ratios? Do they have all gingival margins in the right positions? If I were to just do a carved restorative wax-up, I wouldn’t understand if the tooth movement is helpful. If you are not familiar with ortho setups, I recommend reading this article from 2012.
3. Once I have the teeth positioned in an ortho model the way I think will be best for my restorative, I send my orthodontist the model to communicate exactly where I want the teeth moved. The orthodontist provides feedback on what will be involved to get those movements. Based on that, I can balance the risks and benefits of alternative treatment plans and discuss with the orthodontist whether restorative treatment should occur at the very end of orthodontics or be done in phases during orthodontic treatment.

There is a practice in Ohio I recently work with, in which the dentist and a young hygienist were having a chat about the idea of restorative partnership. When she first heard the idea, her reply was beautiful. She said, “Oh you want me to learn about treatment planting,” and I thought that was just the coolest thing ever because that is what we get to do when we think about developing patients over time. We are planting ideas…planting seeds that we can grow.

When I was still working as a hygienist, I found I was good at talking with patients about what was going on in their mouths… what I saw… what the possibilities were. And I even enjoyed dreaming with patients about what their mouth could be like if they chose to do dentistry proactively rather than reactively. So, it is interesting to me how many hygienists become nervous about the idea of talking about dentistry with patients.

This nervousness exists because we have been taught in and out of hygiene school that it is illegal for hygienists to diagnose. This one barrier has become an incredible obstacle to having conversations about current conditions and possibilities with patients. It does not need to be this way.

When I think about restorative partnership, now, I think of it as treatment planting! The doctor diagnoses and discusses the potential of treatment with the patient. And during recall appointments, the hygienist has amazing opportunity to plant seeds during encouraging conversations. A restorative partner deeply appreciates the developmental path that dental patients are often on and looks for opportunities to plant seeds of awareness, curiosity, and of course, possibilities.

Wouldn’t it be cool if a patient came in one day and said, “You know, we’ve been talking about this idea of comprehensive care… we’ve been talking about the idea of restoring this quadrant… and I want to go ahead with it.” Wouldn’t it be exciting if suddenly what you have been talking about blooms like a beautiful flower?

If you have been thinking about having a conversation with your team members about restorative partnership, starting the conversation around “planting seeds” would be enormously helpful. Think about looking at cases together…creating learning opportunities in your office, where you can start sharing more of your knowledge about what it takes to work in a patient’s mouth, examining photographs together and talking about what you see, talking about the implications and consequences of not having treatment done, and what the benefits could be of thinking about treatment.

The restorative choice is always in the patient’s hands, and what I find to be most exciting about the restorative partnership is the partnership that we, as dental professionals, get to develop with our patients.

SpeedCEM Plus is a dual-cure self-adhesive resin cement from Ivoclar that has been designed to be used with restorations that have inherent mechanical retention. It can be used for most materials – all-metal restorations, zirconia oxide ceramics, or something in the lithium disilicate category. The material will fully pull MRIs on its own, but it can also be light-cured. It has great esthetics, low technique sensitivity from the standpoint of using the material, and great bond strength. It is easily cleaned up. 

Prepping the Internal Surface of the Restoration 

Oxide-based ceramic restorations are etched with air abrasion. Your laboratory can do this, or you can use between 30 and 50-micron aluminum oxide to air abrade the intaglio of the restoration. Confirm with your lab if they are going to be doing this. 

The internal surface of lithium disilicate based restorations is etched using chemistry. You can use hydrochloric acid at 5% for no more than 20 seconds, or you can use an Ivoclar Vivadent product called Monobond Etch & Prime for 60 seconds.  

If you try in the restoration after it has been etched, as I like to do, then the restoration will need to be cleaned again before it is bonded. For this cleaning purpose, I use Ivoclar Vivadent’s Ivoclean. It’s a phosphate-free restorative cleaning material that can be used on metal, oxide-based ceramic materials, and on lithium disilicate materials. I simply vigorously shake the bottle and apply Ivoclean for 20 to 30 seconds, rinse the restoration and dry it. I recommend using a clean air source for drying such as an Adec airline on your unit. 

If you are going to use metal ceramics or lithium disilicate, you now need to condition the inside of the restorative material. I use the product Monobond Plus, which is appropriate for all kinds of materials.  

If you are working with zirconia or an oxide-based ceramic, one of the advantages of SpeedCEM Plus is you do not have to do anything to the inside of the restoration other than the air abrasion and cleaning because the chemistry in the SpeedCEM Plus will prime or condition the inside of the zirconia restoration.  

Prepping the Prepared Tooth 

With SpeedCEM Plus, we do not need to do anything to the tooth prior to cementation other than cleaning the tooth. I like to clean the prepared tooth with light air abrasion and apply a 2% chlorhexidine solution to the prep and clean the tooth with a bristle brush in a slow-speed handpiece. 

SpeedCEM Plus Application & Cure 

After cleaning the prep, you can load the restoration with SpeedCEM Plus and seat the restoration. SpeedCEM Plus comes with a mixing tip through which you express the adhesive.  

You now have two choices. You can hold the restoration in place with firm pressure and allow it to go to its self-cure mode which intraorally takes approximately 3 minutes. Alternatively, you can use your curing light to speed up the process.  

After I seat the restoration, I like to check the margins with an explore to make sure I have not had a mis-seat and then I pick up my curing light and, at a distance of 1 to 10 mm, I cure for one second at each line angle. We call this the quarter technique… mesial buccal one second, distal buccal one second, mesial lingual one second and distal lingual one second. I can now quickly go in and clean up all excess cement, making sure I get excess cement out of the interproximals. It’s important to cure on the line angles, not just buccal and lingual, or you will leave a lot of material that doesn’t reach the gel phase interproximally.     

Once all the excess material is cleaned off, I cover all of the margins with an oxygen barrier, and I do a 20-second cure on each of the four line angles using the quarter technique. The patient is good to go once you check the occlusion. 

Notes 

• SpeedCEM Plus comes in three shades 
• It is designed to be capped in the refrigerator. Never remove the used mixing tip and put a new empty tip on as this would leave the base and catalyst at the ends of the barrel exposed to air. You can either replace the used mixing tip with the original manufacturer’s cap or leave the used mixing tip on and disinfect it just like you wipe your light-curing unit. I recommend you do the latter, as it decreases the risk of contaminating the resin and initiating the self-cure process in the barrel. 
• Because the material is so versatile, you also can use it for placing your posts. 

I believe that some wear is normal. I base this on the fact that I have very few if any patients who are in their seventies or eighties and still have mamelons on their incisors. Wear is a concern when the amount of tooth structure being lost is out pacing the patient’s age.

In Part 1 of this series, I wrote about determining when wear leaves the physiologic category and becomes something we need to discuss with patients. Both attrition and erosion can cause severe tooth wear, but they pose different long-term risks. Once we have a sense of the cause of tooth wear, we can partner with the patient to treat the damage and manage the progression.

These are the guidelines for discerning attrition from erosion.

Attrition is the loss of tooth structure caused when the patient rubs two tooth surfaces together. You will observe:

· Matching facets on upper and lower teeth

· Facets on tooth surfaces that occlude

· Enamel and dentin worn evenly

Erosion is caused by the presence of acid from issues like GERD and eating disorders. You will observe:

· Facets that may or may not match on upper and lower teeth

· Facets on tooth surfaces that are not in occlusion

· Dentin cupped out and wearing faster than enamel

· Tooth structure wearing around restorations that remain unchanged

Note that attrition can be seen in addition to erosion, often giving us a false sense of how much the patient truly parafunctions, as the etched tooth structure wears away more easily.