DTUS1110

Crown or same-day onlay? By Lorin Berland, FAACD “The trend in dentistry today is clearly toward more esthetic and less invasive. Indirect resin and ceramic inlays and onlays are not only com- patible with this trend, but fulfill very nicely the restorative void between fillings and crowns,” wrote Ronald D. Jackson, DDS, FAGD, FAACD (Cosmetic Tribune, Dec. 2008). Regarding durability, esthetic inlays and onlays are not new anymore. They have a track record and it is good. With today’s materials, longevity is mainly a matter of diagnosis, cor- rect treatment planning and proper execution of technique. The problem with replacing old amalgams with tooth-colored composites is they are dif- ficult, inconsistent and unpredictable. Yet, the warranty on these 30-, 40-, 50-year- old silver fillings is running out. We have to remember that amalgam technology is more than 150 years old. At that time, people lost their teeth a lot ear- lier and died a lot earlier, too. Now, however, we have a large segment of the population that is more older than 50 and growing — and they want to keep their teeth feeling good and look- ing good. Let’s think like our patients. Our patients want to replace these old amalgams, but they want to do it conservatively, consistently, effi- ciently, predictably and economically — and they want to do it in one visit. So, what are the advantages of indirect labo- ratory-processed composite resin posterior res- torations? Restorations fabricated in this manner look better, undergo less shrinkage, help restore the strength of the tooth, have minimal porosity and excellent marginal integrity, and they have smoother surfaces that are kinder to the gums and result in less plaque accumulation. They are very durable and can be done in one visit. Patients appreciate avoiding the inconve- nient, uncomfortable and expensive second appointment. No second appointment means no temporaries, no emergency visits, and best of all, healthy tooth structure is preserved. By contrast, replacing amalgam restorations with direct posterior composites, especially ones involving an interproximal surface, are difficult for the patient as well as the dentist. For many reasons, these direct composite replacements frequently prove to be inadequate, especially over time. The inherent problems of isolation, the large bulk of composite required and the lay- ered curing of the composite, as well as the effects of shrink- age, all affect con- tacts, occlusion, mar- gins and postoperative tooth sensitivity. Gold will always be an excellent res- toration for poste- rior teeth, but due to appearance, mass and an increasing price, it is becoming more unacceptable in today’s image-con- scious society. The prep This patient came in with a dental emer- gency. The filling had fallen out of his bro- ken, lower right molar the day before he was going overseas for three weeks on busi- ness. He wanted a “quick and permanent solution” (Fig. 1). The tooth was anesthetized. Next, a FenderWedge (Direc- ta Dental) was used to further isolate the involved tooth, protect the adjacent inter- proximal surface and pre-wedge the teeth for optimal contacts (Fig. 2). The Isolite (Isolite Systems) was placed to obtain a dry and illuminated field. We used caries detector to ensure complete decay removal (Fig. 3). The tooth was then micro- etched, etched and desensitized with HemaSeal and Cide (Advantage Dental Products, Inc.). Two layers of self-etching bonding agent (OptiBond All-In-One Unidose, Kerr Dental) were applied to provide reduced postoperative sensitivity and high dentin bond strength. This was then air-thinned and light-cured. Flowable composite (Premise Flowable, Kerr Dental) was added to the internal walls and Clinical DENTAL TRIBUNE | April 201010A AD Fig. 1: #30 pre-op. Fig. 2: FenderWedge in place. Take a look at the advantages of indirect laboratory-processed composite resin posterior restorations