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| Mastery is a product of consistently going beyond our limits. |
Placing the restoration |
Marking internal discrepancies |
Fitting the Restoration Providing that the steps outlined in the previous sections were done properly, there should be little adjustment to get the restoration to seat. I tend to make my contacts just a little heavy in the design phase so that polishing the proximal areas of the restoration does not eliminate a snug contact. Occasionally even when the contact areas are properly adjusted, the restoration appears to not fully seat. Use single sided Accufilm articulating paper by Parkell (available through Patterson Dental) between the preparation and the restoration. Placing pressure on the restoration and removing it will clearly show minute discrepancies on the internal surface of the restoration. |
Areas marked that prevent full seating |
Lightly dusting these areas with a fine diamond will allow the restoration to completely seat. The areas most commonly needing this kind of slight adjusting are the surfaces of the porcelain fitting into the buccal and lingual walls of the proximal boxes and the porcelain near the cavosurface margin on the occlusal where there are relatively sharp curves. This technique can be helpful in identifying where to make adjustments on the proximal contact areas. |
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Rubber Dam Use Using a rubber dam is very helpful for predictable bonding. The CEREC "power user" who routinely restores difficult to reach second molar areas will occasionally come across a situation where rubber dam use is impossible. These situations, while infrequently encountered, can be accomplished. However, to do so requires an excellent assistant and impeccable technique. Some clinicians insist that the high humididy caused by the patient's breathing endangers the bonding process and requires the use of the rubber dam. Since most bonding agents contain a high percentage of water, there is likely to be little truth in those fears. There are those who can routinely provide excellent bonding procedures without the use of the rubber dam. If done carefully, this is absolutely not sloppy technique, but rather personal clinical choice. There are some clinical situations that are best done with the rubber dam, and some best accomplished without it. It is good to have a technique for both situations. |
 Handidam |
If you find placing a rubber dam even slightly difficult, I would urge you to try the Handidam, by Aseptico, and available through Patterson Dental. The Handidam is a rubber dam with a built-in frame. The first time we tried it, my assistant and I were both shocked at how easy it was to place. While it is more expensive than the traditional rubber dam, the time and energy savings are well worth the investment. Use Glide floss by Gore to floss the rubber dam to place. Again, this is more expensive than regular floss, but we are trying to make this process easy and efficient! |
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A significant part of the ease of rubber dam placement is dependent upon the right rubber dam clamp. The Ivory 56T can be used for 95% of molars. For small molars the Ivory 12 A and 13A work great. Bicuspids are easily grasped with an Ivory 2A. |
 OrasealCaulking |
Occasionally, even with proper rubber dam placement, some saliva can leak through the dam. Place Oraseal Caulking, by Ultradent (800) 552-5512 in the area of the rubber dam where saliva is coming through. This stuff is amazing! With enough of this, the Titanic could have been saved. |
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There are those that are resistant to the idea of porcelain bonding in subgingival areas because of the concern of moisture contamination from blood or saliva. Those same clinicians cement crowns routinely in these very same areas. It is just as important to have a dry margin on which to apply cement as it is to have a dry margin on which to bond. I routinely see inflamed tissue around crowns that have acceptable fits, in the mouths of patients with excellent oral hygiene. When these crowns are removed, an odor is often noticed as well as a black area around the margin. This is the effect of moisture contamination during the cementation process causing the cement to wash out. Moisture control is essential in both bonding and cementing and, with the proper hemostatic technique and diligence, it can be accomplished. |
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Eliminating Postoperative Sensitivity
There are few things as frustrating to both the clinician and the patient as postoperative sensitivity. The patient has just received a very high-tech and impressive procedure with the placement of a CEREC restoration. With such clinical sophistocation they expect, and deserve, a restoration that is comfortable. If temperature sensitivity exists postoperatively, not only is the patient disappointed, but the day's schedule is disrupted with a return visit by a disgruntled patient. Luckily, this unfortunate situation can be virtually eliminated. |
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Gluma
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The following technique has provided me months of being able to deliver consistantly sensitivity-free
restorations: Isolate the tooth to be bonded with a rubber dam. Meticulous moisture control is required.
Etch both enamel and dentin for 15 seconds. Rinse thoroughly, lightly dry, and then place Gluma on the
preparation. Let the Gluma stay on the preparation for 30 seconds and lightly blow away excess moisture.
Place Kerr's Optibond Dentinal Primer on the
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