Dr. John C. Comisi, DDS, MAGD

	Contacts and contour: Two very important parts of every direct restoration placed by dentists around the world. When placing any direct restorative material in a dental preparation that involves a proximal box, the dilemma is often how do you get optimal contacts and contour in the final restoration? The matrix used and how it is placed is critical for the overall success of the restoration.

	There are a multitude of matrix bands and retainers in the dental marketplace, including circumferential, tofflemire-type retainers and sectional matrix bands. Each has its place and effective use in the dental practice, and having each of these types available is valuable in the day-to-day workings of the office.  

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	One of the sectional retainers we use at my office is the V3 Ring by Triodent

, distributed by Ultradent Products Inc. This “go-to” system features unique “V”-shaped tines that help to ensure that the retainer places equal gripping pressure on the wedge and the embrasures of the adjacent teeth and provides optimal separation force to help produce consistently tight contacts. These V3 Rings have wonderfully high strength and stability, with reliable long-term use being a highlight of these products. They can essentially “take a licking” - they work consistently well even after multiple uses over a long time period and repeated autoclaving of the rings.

The design and elasticity of the NiTi ring structure provides optimal spring strength, and the glass fiber reinforced plastic tines with their “V” shape enable great adaptation around wedges. These rings are “stackable” and come in two types: the universal (green) V3 Rings for large teeth and the narrow (yellow) rings for small teeth. And of course, the V3 rings are autoclavable. They also are available in a blue plastic disposable type, which are designed for single use. They provide the same wonderful results as their sister V3 rings, but they are disposable.

	The V3 Sectional Tab-Matrices have a pronounced ridge at the occlusal margin of the matrix, helping to produce a very natural-looking Class II composite restoration, which aides in the quick and easy finishing of that area of the restoration. Also, the contour of the matrix helps to develop the final contour of the restoration very nicely. They are super thin (30 μm) yet very strong. Also, the tab at the occlusal of the matrix makes placement of the V3 Sectional

	Matrix band easy to place with the Triodent Pin-Tweezers. The size of the matrices ranges from 3.5 mm to 7.5 mm, and they come in SuperCurve and ClearMetal types, too.

	The SuperCurve Matrices are color-coded, so size differentiation is easy, and they have a nonstick coating to make the removal of the matrix easier. The extra curve dimension also helps with those wider buccal-lingual extensions that we run across when preparing for some Class II restorations and, once again, assures the operator wonderful contacts and excellent contour of the final restoration.

	The ClearMetal matrices are wonderfully unique matrix bands. They are the only transparent metal matrix bands. They have hundreds of clear resin-filled micro-windows that allow light to pass though the matrix while curing, yet they are strong and function just like the Tab matrix or the SuperCurve matrix with the V3 Ring System. Because of the clear resin-filled coating in the micro windows, they are nonstick for easy removal and enable a super smooth interproximal surface. You can really be sure you have a fully cured composite with these matrices, since light can easily pass through the windows of the ClearMetal with great contacts and fabulous contour.

More from the author: How to get protection under all composite restorations

	Probably my favorite feature of the Triodent™ V3 Ring system is the WedgeGuard preparation wedges. These WedgeGuards help prevent nicks and damage from your rotary instruments on the adjacent teeth during preparation. Once you are finished with the preparation, simply pull off the metal guard and slide the V3 matrix band of your choice next to the remaining Wave-Wedge-like wedge of the WedgeGuard, apply the appropriate V3 Ring and restore. It’s that simple. The Wave-Wedge has a great anatomic design that keeps the matrix easily in place, seals the gingival margin of the restoration and protects the interproximal papilla. Its triangular-like profile works splendidly with the V3 Ring, enabling an interlocking of the wedge and the V3 ring.

	Having the V3 Ring in our armamentarium at the office has helped me solve many interesting and complicated restorative issues, since it is very versatile and makes posterior Class II restoration work so much more predictable and reliable.

Articles

How this sectional matrix system can be used to ensure excellent contacts and contour of every restoration.

How the Triodent V3 Ring solves restorative issues

	In this new column, one clinician addresses these unique, comfortable wooden stools.


	DPR is very fortunate to have an editorial advisory board consisting of some of the brightest, talented dentists around. Debuting this month, we bring you this new “From Our Board” column designed  to allow these great minds to share their stories.

	Performing dentistry today requires the doctor and staff to have ergonomic, efficient and comfortable seating so the long day of treating our patients can be a bit more manageable.

	If you’re not seated properly during a procedure, it can become a tedious event that can take its toll on your back and backside by the end of the day.

I know this because I have experienced some really long days over the course of my dental career, and without comfortable seating that helps to care for my back and “seat” during the course of the day, it would be hard to make it through the day.

	I discovered an interesting take on dental seating when I presented at 

 this past January. My wife, Karen, was drawn to a vendor there with interesting handmade wooden chairs that looked like an owl’s face. She talked to the very nice people there and discovered they created these 

Owl® Stools and other Owl® Furniture pieces

 they believed would be very useful in the dental field.

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	The master wood carver, Geoffrey Warner, owner of 

Geoffrey Warner Studio in Stonington, Maine

, had worked on this design and found it had great usefulness in so many other places in the home and office that he decided to put his creations on polymer casters and created the Rolling Owl® Stool. These provide a smooth ride on hardwood floors, linoleum and low pile carpet, and the seat height is easily adjustable from 18” to 24”. The Rolling Owl base comes in a range of six colors that can fit any treatment room motif.

	For the few days I lectured, I borrowed a seat each day-one day an Owl® Bar/Counter Stool and one day the rolling chair. I sat in these chairs for most of my lectures and found the unique design to be perfectly comfortable for the many hours of presentation to my audiences. The Owl® seat is so comfortable and helps you sit properly all day long. It is simply marvelous. We decided we needed to have one of the rolling stools at the office and had one sent to us.

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	The beautiful hard woods (solid cherry or walnut) of these remarkable ergonomic seats are sealed with a clear polyurethane finish that makes cleaning and disinfecting in the treatment room a snap. The addition of the optional lumbar support accessory makes for a perfect operatory or office chair. You really have to try one of these. Once you do, you’ll wonder why you would ever want to use any other seat during your day. The cost for these exquisite handmade chairs is really no more than what you would normally pay for a conventional operatory stool, but the quality and durability will far outlast any upholstered chair.

 to find out more about the options for your Owl Stool.

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	Owl Furniture’s Owl Stools are said to be more than just stools. The stools are made in the United States and designed to relieve pressure points, cradle the pelvis at an optimal angle for spinal alignment and reduce spinal pressures. Endorsed by health practitioners, they are designed to provide hours of sitting comfort and include optional lumbar support accessories. They are made of beautiful handcrafted hardwood with a durable tung oil finish. A lab-tested SEFA-finish is also available.

 has been in private practice in Ithaca, N.Y., since 1983 and is president and CEO of “Dental Care with a Difference”®, PC, where “Knowledge Brings Health”®. He is a graduate of Northwestern University Dental School and received his bachelor’s degree in biology at Fordham University. He is a respected key opinion leader, has lectured nationally and internationally and has contributed to the dental literature in several journals.

Video: How to get protection under all composite restorations

If you’re not seated properly during a procedure, it can become a tedious event that can take its toll on your back and backside by the end of the day.

From Our Board: Seated in comfort

Historically, none have been more effective and beneficial than calcium hydroxide ions, which is considered to be the “gold standard” by which vital pulp therapy modalities are measured. Today, more regenerative-type materials have been introduced that have effectively elevated this “standard” to a new level.

In our daily clinical practice, we encounter many situations that require attention to the protection of vital asymptomatic pulpal tissue including: 1) small pinpoint mechanical exposures, 2) carious pulpal exposures and 3) very deep caries, but no pulpal exposure. This is where the “magic” of calcium hydroxide ions comes into play. It 1) has a high pH and is bactericidal, stimulates formation of reparative dentin with its ability to extract growth factors from the dentin matrix, 2) has the ability to neutralize bacterial by-products and 3) has clinically been proven as a direct pulp-capping agent. 

However, there are some difficulties with calcium hydroxide. It is very soluble and has a very slow self-cure process. Additionally, its physical properties make it inadequate to directly restore upon, since it will “cave in” when put under compression. With the advent and use of bonded composite materials, the dissimilar properties prevented it from being a good material to place directly beneath a composite restoration. Various versions of “light-cured” calcium hydroxides were introduced to overcome the challenges of the poor physical properties encountered in calcium hydroxide paste. However, since these materials used a hydrophobic resin, the therapeutic benefit and calcium release just didn’t match up to the traditional calcium hydroxide formulations.

In recent years, newer materials have been developed to help overcome some of these difficulties. Some materials were created with resins that were hydrophobic in nature; therefore, they never release significant levels of calcium from within those matrices. Other materials (calcium oxides) were created that could release significant calcium, but again, the mixing and handling properties made them difficult to use in many situations. 

, many of the challenges associated with previous materials were eliminated. This light-cured resin modified calcium silicate material uses a hydrophilic resin matrix which allows for the significant release of calcium and hydroxide ions to aid in pulp tissue therapy. Since it is resin based and light-cured, it is an easy solution for pulp protection under all composite restorations. The hydrophilic resin matrix allows for water exchange from the tooth allowing transfer of calcium and hydroxide ions, while at the same time being relatively insoluble with the expectation of achieving a more durable restoration.  

 acts as a scaffold onto which new dentin can form. It has an alkaline pH, as does calcium hydroxide, and can promote healing and apatite formation

44-year-old female presented for restoration of teeth #17, #18 and #19. New restoration treatment was planned for the failing existing composite restorations 

After administration of a local anesthetic and placement of Isolite isolation device, removal of existing composite restorations was performed. Using a #8 Cerabur (

) in a 10:1 reduction contra angle slow speed handpiece (3000-6000 rpm) with water cooling, the infected dentin was removed, leaving the stained affected dentin in preps #18 and 19 

 was placed in the deep areas of the preparations in a thickness no more then one millimeter and cured for 20 seconds. Placement is very quick and easy using the syringe delivery system. The material’s opaque white color is very helpful in knowing where the material has been placed, so excess removal is easy prior to curing. Pulp protection on tooth #17 was not deemed to be necessary in this instance, since the preparation was not excessively deep, as were #18 and #19 

 (BISCO Dental) using the selective etching technique (per directions by BISCO Dental) and then final restoration of 

) material was placed and cured to within two millimeters of cavo-surface margin (this material is not recommended to be placed in the functional area of the tooth surface) and then 

 (Shofu Dental) was incrementally placed and cured in the final two millimeters to finalize the restorations and enable chewing function

TheraCal LC is a light-cured, resin-modified calcium silicate filled liner designed for use in direct and indirect pulp capping and as a protective liner under composites, amalgams, cements, and other base materials. It can be used as an alternative to calcium hydroxide, glass ionomer, RMGI, IRM/ZOE and other restorative materials. TheraCal LC performs as a barrier and protectant of the dental pulpal complex. 

TheraCal LC’s precise placement allows its use in all deep cavity preparations. The light-cured set permits immediate placement and condensation of the restorative material. Its proprietary formulation allows for a command set with a light curing unit while maintaining ease of placement due to thixotropic properties. The proprietary hydrophilic resin formulation creates a stable and durable liner.

 There are significant challenges in clinical dentistry when trying to maintain a vital pulp. Dentin replacement due to caries has been attempted via various mechanisms and materials over the years.   

How to get protection under all composite restorations [VIDEO]

With the use of newer materials on the rise, the world of cements (luting agents) in dentistry has rapidly evolved to meet the needs of today’s practitioners. It’s more critical now to understand the science behind the products and behind the materials, and to know just what you can expect from the products you use.

The world of cements (luting agents) in dentistry is rapidly evolving. Years ago we had it fairly simple. There were three basic types of cements; cements based on Zinc Oxide (ZOE, ZOP and Polycarboxylate), cements based on Alumino-Silicates (glass ionomers and silicate cements), and eventually resin cements.

Life also was simpler because the substrates we were trying to cement to tooth structure were basically one of two types: metal (castings/porcelain fused to metal casting) or “Porcelain Jacket” (PJC) type crowns. These PJCs were brittle and problematic, but they were certainly a leap forward, from an esthetic viewpoint.

Resin cements gained favor over the course of time because they worked well for both retentive and “non-retentive” preparations. But they also had their inherent challenges as well, because some bonding agents and resin cements created, in some cases, sensitivity.

Fast forward to today. With the introduction and use of our newer ceramics (lithium disilicate, zirconia, etc.) to add to our traditional full cast and PFM crowns we have added a bit of complexity. We now need to understand the steps necessary to get the lithium disilicate- or zirconia-based crowns to properly adhere to the luting cements we are using.

How best do we prepare the intaglio surface and the prepared tooth for cementation and which type of luting agent would be best? In addition to the three luting agents previously mentioned, the recent addition of many new resin modified cements, continued improvements to our resin cements/bonding systems and the introduction of a “nanostructurally integrating cement” bring many new interesting considerations to the cementation equation.

Which claims are valid? How easy or difficult are these materials to work with? What type of longevity can we expect from them? Understanding the science behind the products and behind the materials we intend to use are more important than ever.

Bottom line: 1) Understand if your preparation is a retentive or non-retentive type. 2) Understand how to prepare the intaglio surface properly before cementation. 3) When in doubt, read the instructions. That is what they are there for. 

Below, you’ll find links to articles where you’ll find some of newest and best cements available, along with testimonials from clinicians and industry insights from some of the manufacturers.

How 3M™ ESPE™ RelyX™ Ultimate cement offers industry leading bond strength

How Multilink Automix promotes an easy placement procedure

How PermaCem 2.0 provides outstanding adhesive strength to zirconia

Ceramir® Crown and Bridge changing the cement category with its bioceramic qualities

Dental Cement Guide: Understanding the science behind the products

is ideal to work with-no need for bonding, etching, primers, silane or special cleaners." 

Kelley Reinfelds, Director of North America Sales for Doxa Dental Inc.

What is the most frequent question you hear about the cement category?

We often hear from doctors who are confronted with the growing number of choices in the cement world. They want to know if there’s really something “new” in this category.

How does your product seek to answer that question?

For decades, a doctor’s main choice of cements has been GI, resin or some combination of the two. Many companies have significantly improved the offerings in the GI, resin, and RMGI categories, but no one company has really changed the game and offered a completely new technology platform for permanent cements.

Ceramir to the market-the first bioceramic cement.

 It uses biological concepts and operates with the same principles as natural remineralization.

Because Ceramir works so differently than what was previously available, we seek to educate doctors as much as possible when discussing cements. It’s not something that can be communicated in an ad. So, we work with study clubs, state-level and national meetings and help broaden the discussions on cements so it’s not just about the older technologies. This focus on education has allowed us to reach many doctors on a much deeper level.

What about this product helps dentists in their practice?

Ceramir is ideal to work with-no need for bonding, etching, primers, silane or special cleaners. It allows for easy seating, effortless clean-up, and the patient loves the lack of taste, smell or any sort of “zing” associated with other cements. In the long term, its excellent retention ensures years of proper function, while the patient also enjoys a complete lack of post-op sensitivity. By saving time and keeping the patient happy, the entire practice should benefit.

How is your product leading innovation in this category?

Ceramir® Crown and Bridge is not just a better, stronger version of an existing cement. It really changed the whole category by bringing a new chemistry platform for cements to the market. Ceramir’s unique calcium aluminate chemistry give it benefits that no other cement can claim-apatite formation and a permanent high pH are very clinically significant and unique in this category. Its nano-structural integration also makes it the ideal cement for zirconia, without the need for primers or special cleaners.

Those aspects, combined with ease of use and patient preference because of no pain at placement or post-op sensitivity, make Ceramir truly innovative and unique.

Ceramir Crown and Bridge is a bioceramic dental cement for permanent cementation of conventional prosthetics, including all-ceramic constructions with frames of aluminum oxide or zirconium dioxide (alumina and zirconia).

This cement is easy to use, has excellent retention and provides a permanent and stable seal of the interface with a high pH for permanent acid resistance.

"Ceramir is ideal to work with-no need for bonding, etching, primers, silane or special cleaners." 