Posterior_Direct_Restorations Salvatore_compressed

FIG 3-46 (a) Radiograph showing a noncavitated E1-E2 lesion involving the distal surface of the maxillary left second premolar. (b) Occlusal view of the quadrant. (c) Isolation of the operating field and slight separation of the gap. Because the patient is young (aged 12 years), the dam hook was positioned on the tooth immediately subject to treatment. The isolation should preferably be performed starting from the most distal tooth that can be isolated with the aim of facilitating procedural operations. (d) Operating field cleaned with air-water jet and glycine. (e) Once the operating field has been washed and dried, the first applicator fitting is applied with the aim of etching the surface to be treated (hydrochloric acid for 2 minutes). (f) Prolonged washing (30 seconds) and aspiration of the etching product. (g) Once the field has been dried, ethanol is applied and thoroughly blown dry to promote surface dehydration. (h) Application of the second applicator fitting, which is used to apply the infiltrating resin twice. Application is for 3 minutes the first time and 1 minute the second time. In addition to reducing ambient lighting, it is also useful to perform small movements of the applicator to promote resin infiltration. (i) Excess resin is aspirated, and the surface is blown dry. It is essential to use dental floss prior to curing. (j) Curing for 40 seconds. (k) After the resin application and curing steps are repeated, final curing is carried out under glycerin gel. (l) Final polishing using a polishing paste and nylon brush. (m) Appearance at the end of treatment, on dam removal. (n) Follow-up radiograph after 1 year.

1.Clean the operating field.

2.Isolate the field, and then adequately clean the grooves.

3.Etch the enamel for 120 seconds with 15% hydrochloric acid gel, using

a special applicator fitting.

4.Use abundant water spray.

5.Apply the dehydrating agent (ethanol) and dry the enamel.

6.Make first application of impregnating resin, using a special applicator fitting that only releases liquid from the required side. Leave in contact for 3 minutes, making small movements with the applicator.

7.Remove the applicator fitting, blow dry, aspirate excess resin, and apply floss or spread slightly (to prevent bonding).

8.Cure for 40 seconds.

9.Make second application of impregnating resin using the special applicator fitting (same one as before). Leave in contact for 1 minute,

making small movements with the applicator.

0.Remove the applicator fitting, blow dry, aspirate excess resin, and apply floss or spread slightly (to prevent bonding).

1.Cure for 40 seconds.

2.Apply glycerin gel to the treated surfaces and re-cure. The purpose of this step is to cure the more superficial resin layers to reduce the likelihood of poorly cured resin becoming pigmented.68,69

3.Complete final polishing with special pastes.

To date, there is no consensus among the scientific community regarding the effectiveness of resin impregnation in halting early and noncavitated caries lesions even though the results show clear improvements compared with exclusive use of standard preventive procedures such as daily interproximal cleaning with dental floss with and without localized fluoride application at home.70–74 Pending scientific evidence to support the long-term efficacy of this type of treatment, it is advisable to maintain caution, although so far this system seems to offer a conservative approach in situations where conventional treatment would be too aggressive, but failure to act would be a mistake.75

Advantages:

Tooth tissue sparing

Short learning curve

Limitations:

Need to check for the absence of cavitation

Possibly difficult to fit the applicator fitting

Difficult to check extruded material quantity

Continued visibility of the lesion at subsequent checkups because the procedure leaves no trace radiographically

References

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Patients with rubber dam at the dental clinic of The University of Iowa, 1890s. (Courtesy of the Frederick W. Kent Collection, The University of Iowa Libraries.)

4

Isolation

Every day we are bombarded with new dental products. Everything is new, state-of-the-art. It belongs to the future and has no past. Today’s products must be a complete departure from the old. They must have evolved. Everything changes, advances, and (apparently) gets better.

But not rubber dam. Rubber dam has remained the same since March 15, 1864, when Sanford Christie Barnum of New York invented it.1 After more than one and a half centuries, there is no better method for absolute isolation.

Even though isolation with rubber dam offers many advantages,2 it is not used commonly.3–7 The main reason for this is clinician ability with rubber dam. If isolation is carried out quickly and effectively, very few patients refuse its use. However, if patients experience fumbled and failed attempts, they may ask for it not to be used. Therefore, it is recommended to practice for a long time on simulators or on colleagues and start with simple treatments such as Class 1 restorations.

Cases where positioning rubber dam is particularly tricky or even impossible are very rare:

Third molars with incomplete eruption or specific morphology

Malpositioned teeth

Some Class 5 lesions (in the cervical third)

Patients with psychologic disorders or breathing difficulties

Teeth that have not fully erupted can be successfully isolated with some assistance, even though it is difficult and complicated. Except for fissure sealing and small Class 1 lesions where single-tooth isolation is preferred, it is almost always advisable to isolate by sector. Even though a Class 2 restoration could be performed by isolating only two teeth, it is advisable to extend the isolation as far as possible in order to achieve

better visibility and accessibility. Isolation by sextant is carried out from the first or second molar to the central incisor, and even if it is not necessary, it can be useful to extend the isolation to a tooth in the contralateral arch (as far as the canine).

Benefits to the clinician include:

Constant retraction of the lips and tongue (clinician does not need to hold in place)

Easy analysis of the tissue to be treated (aided by contrast with the dam color)

No noise from the aspirator (the patient can swallow)

Less conversation with the patient

Easier to treat by quadrant

Optimum performance of bonding materials

No contamination of the working field or adjacent tissues

Advantages for the patient include:

No swallowing of instruments/materials

Shorter working times

Protection of the tongue, soft tissues, and perioral tissues

Required Materials

Isolation requires dam sheets, dam punch, clamps, clamp forceps, frame, and dental floss (Fig 4-1). A template (see Fig 4-1e) is optional, but highly recommended. One of the most common mistakes, particularly at the beginning, is to space the holes too close together or too far apart. A template makes for fewer mistakes.