Amal­gam subs­ti­tu­te in pos­te­rior re­gion with an or­mo­cer com­bi­na­tion – a cli­ni­cal ca­se study

El Dentista Moderno - - Estética Y Cons Ervadora -

Di­rect com­po­si­te res­to­ra­tions for the pos­te­rior re­gion ha­ve be­co­me a standard part of mo­dern con­ser­va­ti­ve/ res­to­ra­ti­ve den­tistry. This ty­pe of res­to­ra­tion is very po­pu­lar with pa­tients and den­tists ali­ke, and its per­for­man­ce in the mas­ti­ca­tory load-bea­ring pos­te­rior teeth has now been de­mons­tra­ted in nu­me­rous cli­ni­cal stu­dies. In ad­di­tion to com­po­si­tes ba­sed on con­ven­tio­nal met­hacry­la­te che­mistry, or­mo­cer com­po­si­tes can al­so be used for this ran­ge of in­di­ca­tions.


The ran­ge of pro­ducts avai­la­ble in the field of di­rect com­po­si­tes has ex­pan­ded greatly in re­cent years[ 1- 3]. In ad­di­tion to the con­ven­tio­nal uni­ver­sal com­po­si­tes, the enor­mous ri­se in pa­tients’ aest­he­tic ex­pec­ta­tions has re­sul­ted in the launch of a lar­ge num­ber of so-ca­lled “aest­he­tic com­po­si­tes” on the mar­ket. The­se of­fer com­po­si­te ma­te­rials in dif­fe­rent opa­ci­ties and trans­lu­cen­cies, each in a suf­fi­cient num­ber of dif­fe­rent sha­des[ 4]. Opa­que den­ti­ne sha­des and trans­lu­cent enamel sha­des ma­ke it pos­si­ble to achie­ve highly aest­he­tic di­rect res­to­ra­tions using the mul­ti-sha­de (poly­chro­ma­tic) la­ye­ring tech­ni­que. They are prac­ti­cally in­dis­tin­guis­ha­ble from the den­tal hard tis­sue and, in in­di­vi­dual ca­ses, they even ri­val the aest­he­tics of all-ce­ra­mic res­to­ra­tions[ 5, 6]. So­me of the­se com­po­si­te sys­tems com­pri­se mo­re than 30 dif­fe­rent com­po­si­te ma­te­rials of dif­fe­rent sha­des and de­grees of trans­lu­cency. It is, ho­we­ver, es­sen­tial to ha­ve ap­pro­pria­te ex­pe­rien­ce in the hand­ling of

the­se ma­te­rials, which are pri­ma­rily used in the an­te­rior re­gion[ 4, 7]. On the ot­her hand, anot­her trend ob­ser­ved in com­po­si­te de­ve­lop­ment in re­cent years con­sists in ma­king the use of the­se ma­te­rials in the pos­te­rior re­gion sim­pler and mo­re re­lia­ble at the same ti­me[8-14]. The introduction of bulk-fill com­po­si­tes ma­de it pos­si­ble to achie­ve this goal whi­le al­so im­pro­ving cost-ef­fi­ciency in use by in­crea­sing the la­yer thick­nes­ses that can be light-cu­red – from 2 mm pre­viously to 4-5 mm – and si­mul­ta­neo­usly shor­te­ning the cu­ring ti­mes[ 15- 19]. Most com­po­si­tes con­tain or­ga­nic mo­no­mer ma­tri­ces ba­sed on con­ven­tio­nal met­hacry­la­te che­mistry[ 20]. Si­lo­ra­ne tech­no­logy[ 21-26] and or­mo­cer che­mistry[ 27-34] pre­sent al­ter­na­ti­ve ap­proa­ches. Or­mo­cers (“or­ga­ni­cally mo­di­fied ce­ra­mics”) are or­ga­ni­cally mo­di­fied, non-me­ta­llic, inor­ga­nic com­po­si­tes[ 35]. Or­mo­cers can be clas­si­fied bet­ween inor­ga­nic and or­ga­nic poly­mers and pos­sess both an inor­ga­nic and an or­ga­nic net­work[ 32, 36- 38]. This group of ma­te­rials was de­ve­lo­ped by the Fraun­ho­fer Ins­ti­tu­te for Si­li­ca­te Re­search (ISC) in Würz­burg and mar­ke­ted for the first ti­me as a den­tal res­to­ra­ti­ve ma­te­rial in 1998 in co­lla­bo­ra­tion with part­ners in the den­tal in­dustry[ 29, 30]. Sin­ce then the­re has been con­si­de­ra­ble furt­her de­ve­lop­ment of the or­mo­cer-ba­sed com­po­si­tes for this ran­ge of ap­pli­ca­tions. In the den­tal or­mo­cers to da­te, ad­di­tio­nal met­hacry­la­tes we­re ad­ded to the pu­re or­mo­cer che­mistry (in ad­di­tion to initia­tors, sta­bi­li­sers, pig­ments and inor­ga­nic fi­llers) in or­der to im­pro­ve wor­ka­bi­lity and ad­just the vis­co­sity of the ma­trix[ 39]. The­re­fo­re, it is bet­ter to speak of or­mo­cer-ba­sed com­po­si­tes he­re. The na­nohy­brid or­mo­cer res­to­ra­ti­ve ma­te­rial Ad­mi­ra Fu­sion (VO­CO, Cux­ha­ven) does not con­tain any con­ven­tio­nal mo­no­mers along­si­de the or­mo­cers in its ma­trix. It features a na­nohy­brid fi­ller tech­no­logy with an inor­ga­nic fi­ller con­tent of 84% by weight. The ma­te­rial dis­plays a poly­me­ri­za­tion sh­rin­ka­ge of 1.25% by vo­lu­me with a si­mul­ta­neo­usly low sh­rin­ka­ge stress (3.87 MPa). Thanks to its ma­te­rial com­po­si­tion, Ad­mi­ra

Fu­sion al­so has high bio­com­pa­ti­bi­lity and co­lour sta­bi­lity. Ad­mi­ra Fu­sion is avai­la­ble in a wi­de spec­trum of sha­des in th­ree le­vels of trans­lu­cency/ opa­city (10 uni­ver­sal Vi­ta sha­des, 4 opa­que den­ti­ne sha­des, 4 spe­cial sha­des) and can thus be used in aest­he­ti­cally de­man­ding si­tua­tions in both the sim­pli­fied sin­gle-sha­de tech­ni­que, for exam­ple in the pos­te­rior re­gion, and a poly­chro­ma­tic mul­ti­ple-la­yer tech­ni­que, ac­cor­ding to re­qui­re­ment. This res­to­ra­ti­ve ma­te­rial is com­ple­men­ted by the low-vis­co­sity, flo­wa­ble Ad­mi­ra Fu­sion Flow (VO­CO, Cux­ha­ven), which is avai­la­ble in 12 sha­des and dis­plays outs­tan­ding flow pro­per­ties even in the na­rro­west of ca­vity re­gions thanks to its ex­ce­llent wet­ting pro­per­ties. For a flo­wa­ble ma­te­rial, Ad­mi­ra Fu­sion Flow dis­plays a low poly­me­ri­za­tion sh­rin­ka­ge of 2.75% by vo­lu­me with a si­mul­ta­neo­usly low sh­rin­ka­ge stress (7.27 MPa).


A 42-year-old pa­tient pre­sen­ted in our prac­ti­ce re­ques­ting the re­pla­ce­ment of an amal­gam res­to­ra­tion in tooth 46 (lo­wer right first mo­lar) with a tooth-co­lou­red res­to­ra­tion (Fig. 1). The tooth res­pon­ded sen­si­ti­vely to the cold test wit­hout de­lay and the per­cus­sion test was al­so nor­mal. Hav- ing been in­for­med of the pos­si­ble treat­ment al­ter­na­ti­ves and their costs, the pa­tient elec­ted to ha­ve a com­po­si­te res­to­ra­tion with the na­nohy­brid or­mo­cer Ad­mi­ra Fu­sion (VO­CO Gm­bH, Cux­ha­ven) in the sin­gle-sha­de tech­ni­que. Treat­ment star­ted with tho­rough clea­ning of the tooth with a fluo­ri­de-free prophy­la­xis pas­te and a rub­ber cup to re­mo­ve ex­ter­nal de­po­sits. The ap­pro­pria­te com­po­si­te sha­de was then de­ter­mi­ned on the still wet tooth using the sha­de guide sup­plied with the sys­tem. Fo­llo­wing ad­mi­nis­tra­tion of lo­cal anaest­he­tic, the amal­gam was ca­re­fully ex­trac­ted from the tooth (Fig. 2). Af­ter ex­ca­va­tion, the pre­pa­ra­tion was fi­nis­hed with a fi­ne­grit dia­mond bur (Fig. 3) and the treat­ment area then iso­la­ted using a rub­ber dam (Fig. 4). The rub­ber dam se­pa­ra­tes the ope­ra­ting si­te from the oral ca­vity, fa­ci­li­ta­tes clean and ef­fec­ti­ve wor­king, and gua­ran­tees that the wor­king area re­mains free of con­ta­mi­na­ting subs­tan­ces such as blood, cre­vi­cu­lar fluid and sa­li­va. Con­ta­mi­na­tion of the enamel and den­ti­ne would re­sult in con­si­de­rably poo­rer ad­he­sion of the com­po­si­te to the den­tal hard tis­sue and would en­dan­ger the long-term suc­cess of a res­to­ra­tion with op­ti­mal mar­gi­nal in­te­grity. Ad­di­tio­nally, the rub­ber

dam pro­tects the pa­tient from irri­ta­ting subs­tan­ces such as the ad­he­si­ve sys­tem. The rub­ber dam is thus an es­sen­tial aid in en­su­ring qua­lity and fa­ci­li­ta­ting work in the ad­he­si­ve tech­ni­que. The mi­ni­mal ef­fort re­qui­red in applying the rub­ber dam is al­so off­set by avoi­ding the chan­ging of cot­ton rolls and the pa­tient’s re­quests for rin­sing. The ca­vity was then de­mar­ca­ted with a sec­tio­nal ma­trix ma­de of me­tal, which was adap­ted to the cer­vi­cal shoul­der with the help of a plas­tic wed­ge (Fig. 5). The ma­trix sys­tem’s clam­ping ring gua­ran­tees suf­fi­cient se­pa­ra­tion of the tooth from the me­sial ad­ja­cent tooth and en­su­res tight ap­pro­xi­mal con­tact of the new res­to­ra­tion. The uni­ver­sal ad­he­si­ve Fu­tu­ra­bond M+ (VO­CO Gm­bH, Cux­ha­ven) was cho­sen for the ad­he­si­ve pre-treat­ment of the den­tal hard tis­sue. Fu­tu­ra­bond M+ is a mo­dern one-bottle ad­he­si­ve which is com­pa­ti­ble with all con­di­tio­ning tech­ni­ques: the self-etch tech­ni­que and both phosp­ho­ric acid-ba­sed con­di­tio­ning tech­ni­ques (se­lec­ti­ve enamel et­ching or com- ple­te etch and rin­se pre-treat­ment of enamel and den­ti­ne). In this ca­se, the to­tal etch pre-treat­ment of enamel and den­ti­ne with phosp­ho­ric acid was em­plo­yed. Firstly, 35% phosp­ho­ric acid (Vo­co­cid, VO­CO Gm­bH, Cux­ha­ven) was ap­plied in a cir­cle along the enamel mar­gins and allo­wed to work for 15 se­conds. Sub­se­quently, all the den­ti­ne in the ca­vity was ad­di­tio­nally co­ve­red with et­ching gel (to­tal etch) (Fig. 6). Af­ter a furt­her 15 se­conds, the acid, along with the pro­ducts dis­sol­ved from the den­tal hard tis­sue, was rin­sed off for 20 se­conds with the com­pres­sed air and wa­ter spray, and ex­cess wa­ter then ca­re­fully re­mo­ved from the ca­vity with com­pres­sed air (Fig. 7). Fi­gu­re 8 shows the ap­pli­ca­tion of a ge­ne­rous amount of the uni­ver­sal bon­ding agent Fu­tu­ra­bond M+ to the enamel and den­ti­ne with a mi­cro­brush. The ad­he­si­ve was tho­roughly rub­bed in­to the den­tal hard tis­sue with the ap­pli­ca­tor for 20 se­conds. The sol­vent was then ca­re­fully dried off with dry, oil-free com­pres­sed air (Fig. 9) and the bon­ding agent light-cu­red for 10 se­conds (Fig. 10). The re­sult was a

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