Zirconia Ceramics, Part 2: Posterior Ceramic Onlay Preparation - Margin Elevation
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- Опубликовано: 21 июл 2024
- In this video, Dr. Richard Stevenson demonstrates about Posterior Ceramic Onlay Preparation - Margin Elevation using a truly biomimetic approach.
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Posterior Ceramic Onlay Preparation - Margin Elevation | Part 2
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Thanks for watching! 
Кино
Beautiful work as always Dr.Stevenson! Hope you are staying safe during these chaotic times.
Staying safe - making videos at home - thank you Doctor!
Your videos teach what textbooks never could. Thankyou and keep up the amazing work
Thank you so much!
I had such a great time watching this video.Amazing work Dr. Stevenson
So glad you liked it!
*As always we are waiting for your Amazing work Dr. Stevenson..*
🌹
I'll keep the videos coming! Thank you.
Another great video Dr Stevenson. Hope you are staying safe during this crazy time.
Thank you - yes, and you too.
Fantastic video, Dr. Stevenson! Thanks thanks thanks forever!
Thank you - stay safe!
I always learn so much from all of your videos. I have a request for one more video. Would you makes one video that includes the types of margins different materials (eg. Zirconia, PFM, emax etc) and preparations (crown, onlays, inlays etc) need? Thank you for the education you provide.
Great idea - It just so happens that I will include that in my very next video!
More webinars please, Doc! I bought all the other ones already
Ok - will do!
Very great job as usual
Wish you all the best
Waiting for your amazing work 👍🏻🌹
Thank you Doctor.
Hey Dr stevenson , always thankful for what you are sharing with us. I have a question, why did you prepare a fillet finish line in here , couldn’t we place the onlay on the preapared tooth structure without the fillet finish line or it is a form of retention ?
always amazed by your work!
Thanks Kia - Hope you are staying safe.
What a nice prep! Love it
Thank you Doctor.
Excellent work Doctor
Thank you Doctor.
Welcome back master
Thank you Zaid!
Dear Dr
Thank you for this video.it was quite interesting to see GIC being used for DME.
You mentioned in your comments that you perceive some dentists do not know how to use GIC'S and RMGIC's.
I completely agree.I come across works where GIC's work for years and in others hands they don't last 6 months.
What could be the reasons for success/failures?? Inadequate isolation? Poor adaptation? Waiting /setting times?
Thanks .
Hi Justin - I think there is a long and slow learning curve with GIs. Attention to detail with everything is required - they are fussy and require a commitment. User errors are almost always the reason for early failures. Good chatting with you!
Thank you so much Dr. S,
beautiful.
would you please let us know in the case of cracked teeth
any classification and tx plans?
Cracked teeth is a huge topic, I'll try to cover some of this topic in future videos. Thank you.
Thank you so much Dr ❤️❤️, Can you please clarify why we didn't do a fillet margin on the buccal like we did on the palatal ?
I reserve the capping of cusps(vs showing like we did in this case) for areas with very thin remaining tooth structure, or cracks or other weakness (like an RCT) that would require a more robust final restoration. Also, the sheer forces on the facial cusps are usually less than the lingual cusps of maxillary posterior teeth assuming canine guidance. Thank you
Thank you for your great work Dr. Steve! Why did you use Poly acrylic acid to etch instead of Phosphoric ?
To remove the smear layer for the RMGI - more gentle and usually the indicated material for RMGI bonding.
Hi Dr. Stevenson,
Can you make a video about the indication and contraindication of restoration?
For example,
When it's better to make a crown and when it's better to make a onlay/inlay?
Will inlay cause or how to avoid tooth/cusp fracture?
Thanks!
Will try - this is a very tough topic!
Thank you Dr S
My pleasure.
this video is so underrated!
Thank you Doctor.
Hi Dr, stevenson
I was wondering about IDS in this prep, should you light cure via glycerine gel? Thankyou, love all your videos
Yes, IDS with glycerin, per usual. Thank you!
Thank you very much.
My pleasure Doctor!
Hi Dr, Stevenson, can this technique be used in very deep margins too?, when there is no more enamel and only root cement? Amazing work! thank you for sharing your knowledge with us .
Yes, for sure. It’s a great option to save a tooth from more aggressive procedures like crown lengthening or even extraction.
great job.. nice to hear what seems to be in my brain when i am in the chair but no one hears but me
Cool!
Thanx for all detailed explanation mu question is will gic used for margin elevation will be be ok
GIC is better than composite for many reasons - it has proven long-term seal to root surfaces, composite does not, and it has a coefficient of thermal expansion nearly identical to dentin...etc.
Hi Dr Stevenson,
I was curious about why you used Fuji Lining LC on just the inlay portion of the prep and not on the other areas after you converted it to an onlay?
Wouldn't the added uniformity be beneficial on the prepped cusps as well?
Thanks for the great video!
The use of the Fuji Lining LC was primariliy to create a uniform thickness to the pressed or milled ceramic restoration. The material was placed into significant defected caused by caries removal. THe onlay areas were reduced to 1,5 mm and were ideal in thickness and wouldn't need covering. Thank you!
another thing I want to mention: GC capsules need to be activated with clicker first before mixing in amalgmator ... I think I read this on the brochure of the company and I always do that
Not for the GC brand - yes for the ESPE type. I used the GC type - activated by pushing in the plunger in the video.
Fantastic video doc. Just a few questions. How would you then bond to the gic on the elevated margin? What would be the protocol if I were to use heated composite for example. Will the composite bond to the gic?
Secondly why use regular gic and not resin modified gic for the elevation?
Thank you in advance
Bonding to GIC is performed as if it were tooth structure - the bond is very strong. I prefer GI because after obtaining a matte finish it may be easily condensed into the box. RMGIs are a bit sticky and more prone to voids in this critical area.
@@StevensonDentalSolutions What are your thoughts on RMGI vs. GI (other than handling, like you mentioned above)? I tried to introduce GI to my practice, but the dental assistants simply couldn't figure it out ("This is the stuff that uses that special delivery gun, right? But I can't find the gun." "Is this the stuff that uses a special conditioner?" "Oops, I didn't activate it before I triturated, is that OK?") Then I found a RMGI product from Fuji, that is paste/paste, and light-cured. It's so much simpler for the assistant, and more like what she's used to with composite. But I feel like I'm compromising with a RMGI instead of a GI. In a DME technique, what are the trade-offs to use a RMGI instead of a GI? Thanks, Dr. Hess (from Indiana)
Thank you so much for sharing the knowledge! I have a question about the tofflemire matrix. The one you showed has a v shape. I've never seen those, the ones I've got in my practice are not v-shaped. They are straight and come in two different widths, 5 and 7 mm, 1 a meter roll more or less. Is it critical or important that v- shape? Thank you very much once again. Cheers from Chile
Thank you! The one you have is fine. Just make sure it's narrow enough to sit around the root area. All the best,
Dr. S
Thank you Dr. for this great demo. I have a question please, can we preform undercut blockage simultaneously as we are doing the deep margin elevation with the same GIC, to gain time and instead of using two separate GIC materials? Thank you
Sure - the key is to get it adapted well and the low-viscosity first step I use helps with this. It can be accomplished well with the restorative type of GI, either resin modified or traditional with care and attention to detail...
Ok Dr. Thank you very much 👍
Dr Stevenson - great explanation. Would the prep differ if a newer softer resin C&B material was going to be used ?
I assume you mean for the elevation? If so, any material that may be bonded to dentin would work well, however, the glass ionomer option has the greatest success rates compared to composites in this difficult area.
Thanks for the reply. My question relates to the final prosthetic material to be used for the overlay. The newer silicate-composite resin blocks APPARENTLY have a greater resilience to crack propergation while reducing the force transmission -- would a more compliant material change aspects that may allow one to conserve greater tooth structure ?
I would not change the prep much, except that you could increase the bevels a bit in order to have a more natural blend form restorative material to tooth structure in esthetic areas. Thank you for the insightful questions and comments!
thank you so much great video as always, i have a small questions,
how does margin elevation with GI affect cementing in an emax onlay and how does the survival rate compare to bonding an emax onlay to enamel? thank you very much for taking the time
Bonded to enamel is the best, but when the enamel is gone and root is the only surviving interface, we must either move towards a crown our consider another option, like Margin Elevation. These are new approaches for sure, but are gaining traction in the literature. Like I mentioned din the video, I have been teaching margin elevation for posterior composites for 24 years and the research for this technique is positive. Applying the same technique to an indirect restoration makes good sense if managed well.
@@StevensonDentalSolutions thank you
Hi dr. I would like to ask Why you didn't keep the preparation as only without cusps reduction ?
Thanks in regard
The wear exposing the dentin on the cusps tips. When a patient pays so much for a restoration, it is ideal to restore the entire tooth, improving all aspects, rather than leaving suseptible area which will worsen over time due to erosion and attrition. These areas could have been restored with direct composites adjacent to the inlay margins, but they would need repeated maintenance and replacment. Hence the onlay...Thank you!
thank you so much ,if polyacrylic acid is just for removing smear layer can we use edta instead??
Possibly - it would be an off-label use. Not aware of any clinical trials testing this approach...
Hi Dr Stevenson, I've been following your videos for a while and they have been excellent in teaching me as a dental student. I have a question regarding using GI for open sandwiches, would the dissolution of these GI open bases be a problem?
Thank you!
Clinical trials running over 15 years done at the University of Indiana show that Traditional GI's do not dissolve over time and that the margins remain caries free. The biggest cause of failure in this class V study was with discolored margins, which occurred in about 15% of the samples after 15 years. I would be much more concerned about a flowable composite interface with dentin in this same situation. Thank you for the insightful question.
@@StevensonDentalSolutions thank you for your detailed reply.
It's interesting to observe that a popular online biomimetic platform advocates flowable composite over GI for reasons revolving bond strength. From a patient's perspective they just want something that lasts/have no problems, I wonder what that would mean for material choice (GI vs flowable) then
Yes, it is a strange thing for us in academics who engage in research that flowable composite would be the goto material. I think that there is significant misunderstanding of GIs and RMGIs in general in my experience.
Hi Dr.Stevenson, Great video!!! Thanks a lot!!!
I have some question,
1. What if choosing composite resin or flowable resin for margin elevation? Which is better? resin or GI?
2. Will margin elevation decrease the bonding strength substantially due to the coverage of enamel?
3. Should the margin elevation be accompanied by gingivectomy in the cases that margin is equal or subgingival?
1. RMGI creates a long term seal - resin with enint does not.
2. Enamel is missing in the deep margin elevation cases, hence, no - it's not an issue.
3. No - use rubber dam.
@@StevensonDentalSolutions thanks!
Perfect
Thank you Doctor - wishing you the best.
Can u tell me please what is the differents between ceramic onlay and gold onlay???as prep??
And when we are prep this
Is the margine from the box is rounded or flat??
Ceramic: internally rounded, near 90 degree cavosurface margins, need for greater bulk. Gold: sharp internal line angles, beveled gingival margins and flared proximal exit angles, and less need for bulk. Ceramic margin is flat with rounded corners.
Hi Dr. Stevenson! Thank you again for an amazing video with awesome work!
Doctor I have a question, I have learned that we should try not to place crowns on a margin made out of a filling, we should strive to achieve a margin made of tooth structure. Does this apply to onlay/inlay restorations? And in this case, by adding GI to the margin wouldn't it affect the longevity of the restoration?
Placing margins on tooth structure would seem to be the best choice, however, if this requires invading the biologic width (supra-crestal attachment) then it may be a less than desirable option. Well placed glass ionomers will serve as excellent gingival seals and are showing promise in the literature.
Dear Dr. Stevenson - thank you for this and previous video demonstrations - they are great, neat and incredibly inspiring. I found a push for GI and RMGI as an undergraduate from Uni of Adel (see Mount and Hume - Preservation and Restoration of Tooth Structure). Post-graduation Professor Ian Meyers strongly advocates their use here in Australia. I have a few questions relating to the open sandwich technique - and sorry in advance for any overlap with your previous responses:
1. What is your experience with the newer bulk fill RMGI (e.g Fuji VIII) compared with the traditional GI (e.g. Fuji IX Fast)?
2. What is your experience of failure (including washout) and second to that - how do you retrieve your indirect work following this? I read from your reply comment with Dylan Fu you quoted research relating to the class V GI. How about the class II GI? From my limited reading it has been quoted as being “sacrificial” with loss of material preferential to loss of tooth structure from disease.
3. When do you use amalgam preferentially for a deep class II and will you ever use this a core material for your indirect restorative work (i.e. as a substitute to your deep margin elevation technique) in lieu of crown lengthening?
Thank you again for your efforts and sorry for the extended comment - time in lockdown does give you time to ponder and explore the finer details! I hope that you are managing well during this time and look forward to future next videos
Hi Doctor, I haven't yet tried the relatively newer Fuji VIII - looks like it might work well for bases and such but not for final restorations. The loss of GI may be more mechanically lost via flossing and hygiene procedures (scalers, etc) than being washed out. In the most vulnerable cases, namely Class Vs which are subject to the most severe wear, they perform remarkably well. I use amalgams whenever I can for patient who wish a direct restoration in a non-esthetic area. Such a great material for gingival extensive lesions, even if placed transitionally. There are times of course when the supra-crestal attachment zone (formally Biologic Width) does not respond well to invitation - even with an amalgam, and these cases require crown lengthening - I usually try the restorative procedure first and then evaluate the tissue response. If CL is indicated, we really haven't lost any ground. BTW - I am a friend of Rory Hume and know Dr. Mount's son small circles of like minded individuals seem to find each other...
@@StevensonDentalSolutions Thank you for the detailed response. I agree completely with your thoughts. I use amalgam preferentially in the deep direct class II but will come across patients who for whatever reason will object to it’s use. I am excited to use your DME technique as an alternative. Do you find that if you have insulted the supra-crestal attachment zone that it will commonly re-establish given good restorative marginal finish and contour? What time frame will you give to review it? Yes - I’ve heard he practices (or did?) out of Hobart but have yet to meet him. I came across your channel after my involvement with Tucker in BC and marvelled at the finesse of the experienced mentors and club members. I’m excited to get back into it again after the break
@@corydean1099 Hi, The periodontal apparatus usually heals in 12 weeks but sometimes it takes much longer - we monitor it and discuss with the patient about their options when we "cross that bridge". They always know up front before we commence treatment. I still mentor Club #8 here in LA. We are currently dark due to the CV19 but hopefully will be back at it in a few months. So nice to encounter a fellow Tucker disciple! Wishing you the best. Rich
If there is old composite on gingival margin to do DME and looks ok should I remove it to do DME myself before making onlay or should i leave it? I always thought the best is to have no compost or glasjonomer on margins of preparation?
Great questions - you are correct. When making an indirect restoration that is luted (non-adhesively), the ideal would be to have only one material at the interface, however, with a bonded procedure the substrate needs to be considered - in a gingivally extensive case, the substrate is root surface, which is both difficult to isolate and presents us with a challenge for long term seal. The DME (or more accurately GEME) allows us to focus on establishing a clean and optimal bond and a raised margin which may then be sealed in a different step. It all boils dow to access and isolation.
HI DR STEVENSON , donde dara usted un curso me interesa un curso
Los Angeles
Thank you for your education videos i hope one day i can be an amazing dentist like you your follower from syria
Hi - Great goals - you shall achieve this I am sure!
@@StevensonDentalSolutions my dream is to continue my master degree in dentistry in usa
Perhaps complete a Prosthodontics Post-Doctoral Residency? This would be awesome.
@@StevensonDentalSolutions thank you for replying im in your debt
@@muhammaddamlakhi5128 Oh thank you, doctor.
Will the GI degrade overtime and cause the failure of the onlay?
GI has been shown to last decades in clinical trials in class Vs which are far more exposed to trauma (tooth brush, etc). The more likely material to degrade, and at the interface with dentin is composite...
So you do caries excavation with water? I was taught in school - slow speed no water. Could you please expand on this?
I think I mentioned that I do this with water in the video - if I missed this, sorry. I always use water for gross removal and only go dry with I'm using the microscope and for minimal areas...
@@StevensonDentalSolutions Yes, you said you do use water, I am just curious why and what is the benefit? Is it faster and more efficient to excavate with water? Am I doing it wrong without water?
@@martinchrom4444 I like the water initially to flood away the debris, and keep the pulp cool. After the gross removal I like using it dry so I can see better, but I use much slower speeds (2,000).
@@StevensonDentalSolutions Thank you! I get it! Many times when the caries is big, there is dust everywhere! One more question please - How strong is the bond between dentin and GIC? I always thought that GIC has a very weak connection to the tooth and that bonded composite is better for this. Mainly because when removing GIC it is much easier to chip off than composite, which can be very hard to remove with proper adhesion. And what is the longevity of GIC in these cases? Is there any risk of it crumbling or falling off?
The tensile bond strength is on the order of 5-7 MPa - very low compared to composite to dentin, BUT, the GI bond lasts much longer and seals much better. The studies have shown this over and over, but most dentists stick with what they know - Composites and DBAs. Using GIs is usually limited to the clinicians who understand how to use GIs.
What is the difference betwin GC Fuji IX GP EXTRA and equia
Equia uses a coating after placement - that's it.
"Fillet" really does describe the shape of the margin. I've never heard it called that before, but it's definitely accurate. en.wikipedia.org/wiki/Fillet_(mechanics)
Right?! Dentistry really has abused the Chamfer term - it's time to clear this up. Thank you for your comment.
Why even do a build up. Why not but a little resin/gi to blockout undercuts, prep the onlay and scan and mill. Have the block of emax or zirconia be thick instead of adding layers of other materials. I may be wrong but just asking.
Thank you Doctor. Question: How will you place a rubber dam to insure proper isolation with the deep margin during restoration delivery? When we place the GI/RESIN to elevate the margin, we have the rubber dam in place and use a sub gingival modified metal matrix. Now the margin is in an easy to isolate position to allow for optimal adhesive properties. If rubber dam is not used in the delivery of adhesive dentistry then that's an entirely different practice model and I'm not demonstrating these alternative as I do not support them in my approach towards dentistry.
Do you use temporary restoration while waiting for the onlay?
Yes, if I'm not milling it chairside.
Thank you..😁
Is 40 mins enough for doing the preparation?
@@alvinlawanto yes - should be about right.
Dr why did you choose to make a finish line in this prep?
Is it for reinforcement because this is the functional cusp?
Also why fillet finish line not a shoulder or a chamfer?
Thank you.
1. Shoulders on ceramic preparations have been shown through research - many published and one in particular as a masters thesis at UCLA are significantly stronger than flat top preparations. The added strength to resist sheer forces on the composite resin cement due to the vertical wall on the lingual provides significantly better resistance form. Flat top preps rely on only sheer strength alone of the resins which is much less than compressive strength. Thats very tapered crowns do so poorly, even when bonded due to the lack of vertical walls. It's interesting that even with bonding, the old principals still hold true...
2. Chamfers by definition have steep declination angles - at least 45 degrees and this creates a difficult edge to fabricate in ceramics. Shoulders are great, as long as they are rounded internally, and are exactly 90 degrees to the root surface - this is hard to do. Angling the finish line slightly 10-15 degrees prevents undermined enamel (mini J margins) and also provides for a better etched interface to maximize seal and support the enamel - also as in the answer above, a slight angle to the finish line converts the forces slightly into compression from strictly sheer - which is always nice. When we speak of "heavy chamfer" "deep chamfer" and " radial or rounded shoulder", the better term from a strict engineering perspective is Fillet.
Thank you for your great questions!
So it is always preferable to make a finish line on the functional cusp whether it is a fillet of a shoulder? As it is subjected to more forces?
That's why you made it on the palatal cusp only but not the buccal?
Thank you so much for your time doctor..
why not RMGIC instead of regular GIC for margin elevation ?
You may - it's just that when the Traditional GI is allowed to reach a matte finish it is easy to condense. RMGIs tend to be more sticky/tacky and harder to adapt.
Thank you for the response !