David and Friends - Bioclearmatrix.com

10 most common reasons for post-operative sensitivity with composite restorations: Why it happens and solutions to fix it

2011-06-23T22:58:00.000-07:00

Reason 1: Poor dentin engagement by bonding agent. Solution A: Apply two or more coats of your bonding agent, air thinning and curing each layer individually. Solution B: Switch to a one bottle, self etch resin like 3M’s new Easy Bond that still allows you to use a rinse etch step to maximize the enamel bond. SE (Self Etch) resins are the most foolproof way to eliminate post operative sensitivity but you must also read and understand Reason #6. (see below)

Reason 2: Not curing the bonding agent over the dentin before placing flowable composite and paste for injection molding. Solution C: ALWAYS air thin and then light cure the bonding agent over the dentin before re-wetting the cavity with a second application of bonding agent (used as a simple wetting agent) before injecting the flowable followed by the paste. Enamel doesn’t need to have the bonding resin cured first, but dentin does. If you are unfamiliar with the Injection Molded Technique please visit the Bioclear website.

Reason 3: Boxy prep with bad C Factor, especially small, shallow composite restorations cut with retentive features. It is mind boggling that a conservative class I composite can cause terrible post-operative pain and on the same patient a deep restorations has no post-operative sensitivity. The problem is C factor. Please contact me for a full description of modern cavity preparations. Most schools, journals and opinion leaders are married to a cavity preparation that is a modified amalgam or silicate preparation. Those 100 year old retentive preparations do not serve modern composites, the tooth, or the clinician. Cutting and restoring a non-retentive class II composite is at once liberating and frightening. Thousands of doctors are now preparing non retentive class II’s with great success, but we remain a small minority Solution D: Cut a non-retentive prep as I have described in other documents and videos available online.

Reason 4: Dealing with retreatment of old boxy amalgam and composite preps. Solution E: You can always play it safe and cover all of the dentin with glass ionomer before placing the composite. Solution F: Use strategic and incremental layering of flowable to rebuild the dentin, then place the paste composite “helmet” with cusps built and cured individually to eliminate cross tooth shrinkage and then injection mold the interproximals. For severely broken down molars I would prefer to do a nice PFM. Most composite margins on cementum will microleak. Period.

Reason 5: Using flowable as a liner straight over the dentin without a bonding agent. This will cause bizarre and strong post-operative pain. Solution F: Always use a bonding agent which has been air thinned and light cured, or a glass ionomer base underneath flowable composite. (There are some self etching flowables that have just been introduced, check back with me in 2 years to see if they are worth trying)

Reason 6: Acid etching (rinse etching) the dentin before using any Self Etch bonding agent other than 3M Easy Bond. Examples: Self Etching adhesives like SE bond or Optibond FL. See solution B above

Reason 7: Old, contaminated, or unshaken bonding resins. Solution G and H: Get a new bottle and or check the expiration, and makes sure to shake the bottle each time you dispense a one bottle resin such as Optibond Solo Plus. (The primer and bonding agents can separate like oil and water) If in doubt email me and we will send advice for your favorite bonding resin or a complimentary sample of a bonding resin that is more foolproof.

Reason 8: Not following orders. Solutions I, J, and K: Make sure and agitate the bonding resin on the tooth for the time prescribed if the manufacturer calls for that. Air thinning the resin also drives off the solvents if you are using a one bottle bonding agent. Read the directions.

Reason 9: Inadvertent and unknowing pulp horn exposure without subsequent hemostasis. Mechanical exposure of a pulp horn is common, especially in young patients and when not using enough magnification. If pulp horn bleeding or weeping is present, placing a bonding agent will nearly always kill the pulp, even on microscopic exposures. Solution L: Use more magnification to avoid and also to identify tiny exposures. Stop the bleeding or oozing with Hemodent, sodium hypochlorite, even sterile water or saline and mild pressure. Once you think that things are dry, count to 20 to make sure it stays absolutely dry. MTA or Biodentine by Septodont show promise as direct pulp capping agents but indirect pulp caps are proven better than direct exposures in outcome studies. Composite or glass ionomer will only work as a pulp capping agent when there is absolute hemostasis. Carious exposures are very high risk to kill the pulp, although the makers of Biodentine think they can predictably treat carious exposures. Check with me in 5 years on that one, and in the meantime stick with indirect pulp caps where you cut a clean margin but leave a little “beret” of carious dentin in the middle of the cavity prep over the pulp. The pre-dentin and pulp will subsequently begin to heal the dentin. Over time the body will harden, disinfect, and dry out that little spot of soggy dentin lying next to a pulp horn. See the Journal of Endodontics 9/2010

Reason 10: Occlusal trauma. Solution M: Understand that composites absorb at least 1% of their volume in water after they are placed. In our new preparations, there is a larger cavosurface area covered with composite. I recommend leaving all new composites slightly out of occlusion because in 24 hours the composite will swell. Unless the restoration is in hypo-occlusion when you dismiss the patient, it will likely be in hyper-occlusion within 24 hours.

"...Bioclear is proof of an intelligent mind and professional dedication"

2010-01-04T22:39:00.000-08:00

Dear Dr. Clark,

You will probably not remember me but we met at ESMD in Amsterdam, september 2008. I was in your masterclass there and you introduced us to the Bioclear system. Thanks for these inspiring hours and also for the samples that were sent later on! As my practice is limited to endodontics, I don't have the kind of cases to do saucer shaped class II preps, but now and then I have to do a 'pre-endodontic buildup'. That's where the Bioclear matrices come in handy.

Below are images from a case where I used the 'average curved molar' matrix to restore a distal cavity (Fuji II LC was used for that) on a necrotic 14 before starting endodontic procedure. The matrix is great since it is convex in all directions and fits intimately with the remaining tooth structure. Together with the interproximators it results in very natural and physiological interdental contacts, minimal surplus filling material, and less finishing work.

The development of Bioclear is proof of an intelligent mind and professional dedication.

Congrats with this achievement,

Best regards, Maarten Meire, DDS, MSc Belgium

Is this true or are the matrices in the porcelain kit different from the matrices in the other composite kits?

2009-07-09T23:44:00.000-07:00

The marketing material states that the matrices in the porcelain kit are ultra-thin. When I asked my CRD rep to order the porcelain kit she told me the only difference between the porcelain kit and the other kits is the inclusion of porcelain etch and silane. Is this true or are the matrices in the porcelain kit different from the matrices in the other composite kits?

- Dr. Stephen Tsotsos
416-486-8644
www.drtsotsos.com

DR. CLARK'S RESPONSE:

No the porcelain kit also has a roll of ultra-thin mylar that is 5 mil versus 20 mil which means it's only about 19 microns instead of 75 microns thick. That is an addition to regular thickness Bioclear Matrices that are also in anterior and posterior kits. It also has some neat opaquers.

Do Dental Composites Always Shrink Toward the Light?

2009-06-25T22:53:00.000-07:00

David,

Watched your video of restoring a biscuspid, very interesting system. Did you bulk cure the restoration, and if so did you use the curing light on each side in an attempt to pull the material outward towards the light to compensate for shrinkage? I believe studies have shown that composite does not shrink towards the light, it shrinks towards the strongest bond in the prep boundaries also influenced by the C factor.

Do Dental Composites Always Shrink Toward the Light?: J Dent Res 77(66) June 1998

David

DR. CLARK'S RESPONSE:

Dear David

You are correct, we do not have any evidence that the composite shrinks toward the light. There is, however, some consensus that the composite that cures first has the first foothold and that it may have an advantage. Because the gingival margin is always the weak link, It doesn't hurt to do all that we can to help it. C factor, the amount of enamel rods and the angle of engagement (saucer versus GV Black walls) are probably more important to determine which margin experiences the most "suck back".

The C factor of the Clark Class II is so low that we can fill in one increment. I am currently doing an article on these topics at the request of 3M which I will send the final draft of if you promise NOT TO DISSEMINATE until it publishes. My 2 hour lecture on the topic will be available shortly on dentaledu.tv (Just taped it this weekend). It gives a very thorough discussion of C-factor and other topics that you have interest in. I am so happy that you have such a good feel for these issues, not too many dentists take the time. Good for you.

Warm regards,
David

David,

Thanks for the response. I do like playing devil's advocate on stuff like this. I didn't watch all of the videos so I don't know what you do with say an MOD. The case shown is saucer but in restorations that extend well into the central fossa areas it might be a higher C factor. Also when you create the flare for the saucer the ends of polymerization are farther apart so potentially more shrinkage between ends. I remember someone years ago was putting composite over flow and curing together. I cure the flow first so it gets a maximum foothold before the filled resin.

I promise not to share any of the article with anyone until published and would be glad to read it and give you my feedback. There is a huge need for the average general dentist to improve direct composites and I'm glad dentists like you are thinking about it and making it better.

David

DR. CLARK'S RESPONSE:

For all medium, large, and amalgam retreatment cases I suggest rebuilding the occlusal separately, then prepping the interproximal and restoring each saucer independently so the C factor remains favorable. As far as a larger size impacting shrinkage, everything that we have seen shows that a feather edge on a flattened restoration (assuming enamel margins) will not have any problems. My theory is that a feather edge over a flat surface area encourages the composite to dissipate the stress and shrinkage by simply shrinking toward the tooth instead of toward the center of the composite mass and since there are no opposing walls in the prep, the tooth is too strong to accept any stress,

So in the end, no white lines no micro fracturing,
Think about placing a large thin composite on the facial of an upper incisor to cover decalcification or stain. The margins look perfect year after year.

Dentin is another story.

Cheers

Is the Bioclear light a pulse light?

2009-06-25T22:02:00.000-07:00

Hello,
Is the bioclear light a pulse light. I don't want it getting too hot is the reason I ask. I couldn't find any info on it to say one way or another and I know that 5 sec LED lights can heat up without the pulse.

Thank you.

Ryan

DR. CLARK'S RESPONSE:

Dear Ryan,

You have a very good question.

While I did research and lecturing for CRA I learned an awful lot about curing lights.

Pulsed and ramped curing have never been shown to have any clinical significance in their attempt to reduce stress of curing.

There is stress from asymmetrical curing, that's why the bioclear method encourages simultaneous curing from buccal and lingual with 2 lights.

The Bioclear /Vector light does not get hot at the tip after 5 seconds. HOWEVER all rapid cure lights have a tremendous photon transfer to the tooth, that's why hey cure so fast. All of these rapid cure lights can create heat in the tooth because so many photons are hitting the tooth at once. The recommendation that we gave at the CRA lectures was to begin to air cool or air suction after 3 or 4 seconds to keep the tooth cool We have several thousand doctors who are doing the Bioclear method and post operative sensitivity is very low. If we were heating the pulp xcessively, we would be seeing problems, and we are not.

Please let me how how else I can help,

Warm regards,
David

How do I get the resin in and pack it if the matrix is over the buccal and lingual aspects of the prep?

2009-06-02T21:28:00.000-07:00

I have had quite good results so far from my trial anterior and diastema closure kits. One problem I have experienced is that once in place, the matrix blocks off the access for resin placement. I have bent it out of the way, but this sometimes runs the risk of disturbing the soft tissue /gingival seal or distorts the matrix. Any advice as to how to get the resin in and pack it if the matrix is over the buccal and lingual aspects of the prep?

Dr. Lisa Chong
3006 Bloor St. West
Toronto, ON M8X 1C2

DR. CLARK'S RESPONSE:

If you are having access problems you can:

Place the paste composite indirectly by syringing it on the facial and or palatal, and then "patty cake" it into the interproximal with a flat composite instrument (I like our Bioclear/Hartzell titanium coated B6-7T "Composite Placing Instrument") and then you can bend the matrix less. I am doing that technique more and more. Place a small dollop of flowable first to eliminate voids. The flowable canula is small enough that you should be able to insert it directly under the teased matrix without excessive distortion of the matrix. The larger paste syringe creates a lot more matrix movement.

Cut back a small area of the flange that is blocking your access.

Have the assistant tease the matrix away with an explorer while you are placing material

Change mirror position

Use the Universal 10 mm matrices (Flat Universal 10 or Curved Universal 10). These are more "open matrices" with good cervical shapes.

I use all of the above, depending on the case.

Hope that helps,
David

Which materials (matrix and interproximator) would be suitable for an in-the-mouth repair?

2009-05-22T21:26:00.000-07:00

Hi, Dr Clark,

I have been, for some time, what I consider to be a practitioner and advocate of MID but your article raised my consciousness about aspects of our contemporary approach. The use of microscopes over loupes is inarguably an advantage. But the paradigm shift of class 2 preparation design is most thought provoking. I plan to begin using the Bioclear matrices with the interproximators.

I saw a patient today who had a 1mm diastema between the upper first and second molars.This was produced by a relatively small mesial marginal ridge fracture of the porcelain on a porcelain-fused to-metal crown on the second molar. I was interested in attempting an in-the-mouth repair using your system. Which materials (matrix and interproximator) would be suitable for this type of repair? Is there a description of the technique on the Bioclear website? Do you think these repairs are durable?

Thanks for your help.
Joseph Ritz, DMD
Wayne, PA

DR. CLARK'S RESPONSE:

Dear Joseph,

I have repaired several of these marginal ridge fractures and most have done well. (Including one on my wife!). The website or your DVD have a step by step in the "yellow" or porcelain section.

http://www.bioclearmatrix.com/Articles.asp?ID=170

Remember that many of these fractures may have been precipitated by marginal ridges that were either just too tall or were too "sharp" and were unsupported with a bit of a point contact. This stems from an under-contoured emergence profile in some cases, or a poor contact on the adjacent tooth that probably could have been smoothed or contoured at the time the crown was done. Make sure and address those to increase your chance of success.

Let me know how it goes and take some pictures if you can. Call technical support also with any questions.

Cheers,
David

Can you comment on the use of the interproximator and finishing tips that are quick and effective?

2009-03-17T22:16:00.000-07:00

Hi David,

As you know, I am writing an article that features some of the concepts the Opinion Leaders conveyed upon.

I have attached an anterior case. It does not use an interproximator, and I am still not rockin’ w/the rock star finish, but I think it is good.

I tried to outline the infinity margin – can you elaborate on it so we are on the same page.

Can you comment on the use of the interproximator and finishing tips that are quick and effective? I still can’t seem to use the rubber points to my advantage.

Best,

Jeffrey

Dr. Jeffrey M. Rosenberg
413 Bainbridge St
Philadelphia, PA 19147

DR. CLARK'S RESPONSE:

The outline is nicely displayed and looks just right. Remember that caries resistance is augmented by the distance that we create between the cavosurface and the dentin or the DEJ. You also have ten times the enamel rods and they are all cut at an oblique angle, so this should be a bulletproof restoration.

Polishing sequence

Carbide or diamond to remove gross excess. (if I get it just right I try to skip this step) Try not to touch any enamel.

Brownie at right angles, wet and at medium speed, preferably in an electric handpiece

Medium grit 3M disc,typically inverted

Coarse pumice, the world's best pre-polisher. Evaluate the matt finish of the composite at high magnification which contrasts nicely from the shiny enamel. Back up and touch up as needed use the special Hartzell handle with a 12 blade as needed in both traditional and back action to clear the margins of flash.

Finish with the SS White polisher. Deeper interprox areas can be reached with fine and extra fine 3M discs, usually inverted on the manual.

The DVD or the web shows the polish if you want to take another peek

Be patient, polishing and sculpting are a very finesse art form that very few clinicians ever master when it comes to resins or porcelain. It remains a challenge to all of us.

Cheers,

David

Has any one tried modifiying the matrix by trimming off some of the facial plastic

2009-03-15T23:03:00.000-07:00

Hello, Dr. Clark. Our office has ordered our first kit of Bioclear matrices. We look forward to trying them. We also enjoyed the step by step article in Dentistry Today magazine.

Has any one tried modifiying the matrix by trimming off some of the facial plastic above where the new contact will be? It seems like it would provide better access for adhesive and flowable. We usually close diastemata by building the fillings either directly against each other and do the Mopper Pop or use teflon tape. So not having the buccal portion of the matrix towards the incisal edge might not be a bad idea.

Please let me know if this has been tried and doesn't work so I can save some time. Thank you for your time.

Blair VanNostrand D.M.D

DR. CLARK'S RESPONSE:

Hello Dr. VanNostrand,

Try it both ways, and if you can take some photographs I promise to use them in my lectures. I encourage everyone to trim the matrices as needed. I am still experimenting myself. Having a closed off matrix is a brand new concept and has advantages and disadvantages. Watch the DVD and you might decide not to trim it back. If you are layering, I would trim it as you have suggested. Either way let me know!

Cheers,

Questions from Dr. Marc Alber

2008-11-04T22:15:00.000-08:00

Dr. Clark,

I took one of your classes at PDA laboratory in Colorado about a month ago and am having awesome results using the techniques I learned. My issues with post op sensitivity are almost completely gone. One question though.

I have had a few patients back for bite adjustments after placing fills using your technique and have notices a yellow tint on parts of the fills that polish away if you apply enough pressure. What is this? Is it bonding agent or flowable? The fillings feel smooth when they come in but they just have a yellowish tint and it is always close to a margin. Any ideas are greatly appreciated.

Thank you for your awesome class. My composites have never looked better.

Sincerely,

Dr. Marc Alber
Boulder Dental Group

DR. CLARK'S RESPONSE:

Dear Marc

Nice to hear from you,

I am always happy to hear about the decrease in sensitivity from the techniques that we have been sharing at the lectures. That's great!

Occlusion: One of the things that we forget is that composite swells when it absorbs water, and all composites absorb water. That means that all of our composite restorations will benefit from being left slightly out of occlusion. Remember that a restoration that is or becomes 1mm "high" on a second molar creates a 3mm open bite on the central incisor because of the way that the mandible rotates. Keep that in mind when restoring molars with composite.

That is especially crucial with modern restorations like that Clark Class II or Cala Lilly Class 1 that covers more of the occlusal table than the old fashioned G.V. Black preps. Take it from me, I learned this lesson after several patients returning for occlusal adjustments in the beginning of my change in prep design.

The yellow tint could be several things. If you could snap a photo and email it to me, that would be very helpful.

My first guess is that you have some resin, either bonding agent or flowable composite, that extended to an area just past the margin where the enamel was not etched. The microleakge will discolor.
Another possibility is that that resin is on part of the infinity edge margin just past where the bur cut the enamel and there was plaque on the uncut enamel. Most teeth are covered with a nearly invisible layer of biofilm (plaque) that DOES NOT remove easily. Phosphoric acid won't touch it. I or my assistant routinely place disclosing solution on the teeth to be restored so that the dental assistant can see the plaque and remove as much as she can before I get started. Invariably I will go in again with coarse pumice on a rubber cup and also sodium bicarbonate spray (The Bioclear/Vector unit-do you have one or access to a prophy jet?). The bicarb spray is very effective for hard to reach areas. Or if you use air abrasion, same thing, very effective at plaque removal. A lightning strip in the interproximal is often the only way to break through the biofilm along the gingival margin. These steps, once they become part of the routine, really don't take much time.

I know that scrubbing plaque doesn't seem as sexy as veneers or implants, but it is a huge problem with composite dentistry and does not get the attention it deserves. Trust me, if everyone who lectured used a microscope, there would be a lot more attention to this issue. I battle it all day, every day.

These are guesses on the "yellow" problem. It could be something else. Let me know how the trouble shooting goes. If it's ok with you I would like to put your questions and my answers on the Bioclear "blog" so that others can benefit.

We have new developments that I would love to share with you, I'll be back at PDA in 08 and 09. Hopefully I will see you then.

Sincerely, David

Would you recommend covering exposed dentin with Vitrebond prior to etching?

2008-06-09T22:42:00.000-07:00

Any time you have exposed dentin in a Clark Class II, would you recommend covering it with Vitrebond prior to etching?

DR CLARK'S RESPONSE

Actually I have gone back to bonding resin and flowable composite because glass ionomer doesn't fully set for 24 hours. When I re-prep the saucer or simply cut Vitreond that has inadvertantly flowed onto the enamel, I see it delaminating (at 16X under the microscope).

Is curing with two lights necessary?

2008-06-09T22:35:00.001-07:00

In your video, you always cure with two lights.............but I don't recall that being mentioned in the course. Is that always necessary?

DR CLARK'S RESPONSE

No but symmetrical curing is better. You can use one light but move it around at first if you want a less stressful cure. Its probably not a big deal. Once again it is a lot slower to use one light.

Does the type of curing light have any affect on the injection molded process?

2008-06-09T22:28:00.000-07:00

I have four halogen lights in my office which I accumulated from dental school. I have not gone to LED b/c I've had good success with the halogen. Does the type of curing light have any affect on the injection molded process?

DR CLARK'S RESPONSE

No, it's just slow. Talk to anyone with rapid cure lights, they could never go back to the wait. Our light is only about $700, and there are a few other good rapid cure lights out there that are reasonably priced. Your light won't hurt the outcome, just the speed.

Do you feel a self-etch adhesive like Brush and Bond is a good product to use for your technique (injection molded fills)?

2008-06-09T22:01:00.000-07:00

I have used Brush and Bond from Parkell for almost 3 years with practically ZERO post-op sensitivity. It is a single bottle, self-etch adhesive. According to their literature, Parkell does not feel that etching is necessary with their product, so I haven't etched in about two years. In their newsletter, they say if you do etch, that only enamel should be etched so that the dentin is not dessicated which would prevent the hydrophyllic Brush and Bond from creating a hybrid dentin-adhesive layer. They have also spoken rather negatively about curing Brush and Bond, flowable, and paste at the same time. They recommend separate cures. So my question is: Do you feel a self-etch adhesive like Brush and Bond is a good product to use for your technique (injection molded fills)? I have no problem going to etch-optibond, but I do love the fact that nobody comes back with complaints after using Brush and Bond.

DR CLARK'S RESPONSE

The short answer is that the Parkell product is excellent for dentin and for sensitvity but your enamel bond is good, not great. Your ability to bond past the margins on uncut enamel is mediocre. If you have enamel margins, try it my way for a while. If you have mostly dentin, such as a crown build-up, stick with Parkell self etch. Most of the opinion leaders would agree.

If you are really in love with Parkell, you could etch just the enamel, use Brush and Bond on the dentin, cure, then use Opitbond Solo Plus which is compatible with the chemistry of Brush and Bond for the injection molding portion. Hey we all have our 'warm blankeys' that we trust.

I think that Parkell is mostly concerned about not curing the resin first on the dentin. They are probably not yet aware of this technique where we cure two coats on the dentin then apply a third coat that acts as a wetting agent. I have worked with the bigger companies and tested the technique. I will give the Parkell folks a call when I get a chance.

Could you please tell me who makes this explorer so that I may procure one myself?

2008-05-05T23:29:00.000-07:00

I am going to use my new bioclear matrix on a deeply restored anterior tooth today. I'm very excited about it. In anticipation of today's appointment, I reviewed the DVD again and noticed Dr. Clark's beautiful explorer. I believe it had an endodontic tip on one end and a regular explorer tip on the other. It was titanium nitride coated. Could you please tell me who makes this explorer so that I may procure one myself. I would greatly appreciate it.

Thank you very much.
Sincerely,
Daniel M. Whiteman, D.M.D.

..............................

(Reply from Dr. Clark to Daniel)
Dear Daniel,

When I get a moment I try to answer a few emails.

I am so pleased that you are excited about the Bioclear system. It has been a very long journey...

We are carrying all of the micro-restorative instruments including the"Clark Explorer". It does not leave grey streaks on enamel or layered composite like normal explorers. Yes, I sweat the little stuff!

The instruments are available from us now, they will not be on the website for another month or so. I will have Kristin send one, and I will also have her send one set of the micro-pliers. Let us know how you like them.

Cheers
David

..............................

(Reply from Daniel to Dr. Clark)
Hi David,

I can't imagine what it takes to take a product to market. Congratulations on your success so far. I'm sure it is only the beginning.

I first became aware of your product/techniques in Dentistry Today. I have always been a fan of microdentistry, even before it had a name associated with it. I always hated the "extension for prevention" concepts and pretty much rejected them once I got out of school (back in '93). I eventually started to do slot preps on my own (to the chagrin of my bosses I have to say). I love your saucer technique in that it really is conceptualized for composites. How right you were when you stated that our previous preparations for composites were simply amalgam preps filled with composite. In addition, the logical idea to bring the finish-able margin into the accessible zone by finishing the "flash" (so to speak) is quite simply brilliant. Anyhow, I'm really just writing to say thanks for your email and of course, thanks for sending me the instruments. That is most generous... I just thought some positive feedback on your products and techniques are deserved. Looks like you're leaving your mark on our profession.

Much thanks,
Daniel.

Do you suggest IPX for each matrix?

2008-05-05T23:18:00.000-07:00

Yes it is recommended to use the IPX with each matrix. In a restorative case such as diastema closure or deep decay you would need to first create a home ("NEST" or undercut) first to hold the IPX then the placement of IPX will allow for a secure matrix and slight separation of the teeth.

- David

Am I doing something wrong or is the learning curve fairly steep to make your system fly?

2008-05-05T23:14:00.000-07:00

Dave,

I was an attendee at your recent class in Lafayette Co, I was excited to see an alternative to the old composite system. I have tried the bioclear on three different occasions and have not been happy with the contact, it seems the plastic wedge rides a little high in the box area. I did not use a ring on any of my attempts, in the class you only thought that to be necessary when doing back to back class 2 restorations. my question is, am I doing something wrong or is the learning curve fairly steep to make your system fly? thanks, and by the way I am seriously looking into buying a microscope, the exposure to that kind of visibility was eye opening.
--Gordon

It is very nice to hear from you.

First things first, I couldn't sleep when I read your email about your problems using the Bioclear system and for your Class II's. There is a learning curve but only because the process is so different than in the past. When you have it down pat it will be EASIER FASTER and BETTER than the old approach.

There are at least 3 things that could happen that would be giving you trouble. Here are some tips. I am going to cc my friend Dr. Steve Urback who has actually done more of these than I have.

The prep must clear the neighboring tooth by at least 3/4ths of a millimeter. Otherwise the Interproximator will not pass by and it will "hang up" inside or slightly inside of the saucer prep. Because the Interproximator is so soft, It can actually end up part way inside the prep and part way past the gingival margin. Plus, it is translucent so it can be deceiving to your eyes at first. That is the most common mistake that we made in the beginning. REMEDY: Try the interproximator first, before the matrix. If it doesn't slide easily you will need more clearance. Make the saucer a little bigger. More enamel rods will be opened up. Better bond!
The prep may have ended up more like a slice rather than a saucer. REMEDY: Well now we have a bit of a problem. If there is no undercut apical to the prep. then there is nothing to keep the Interproximator from riding up. In that case or in a deep case I will do minor electrosurgery on the "col" or papilla to make a home for the matrix and interproximator. Then I will use a Narrow Isthmus or the Thin Interproximator that will lightly stabilize the matrix without deforming it.
What about using a separator routinely? ANSWER: There is no problem using a separator routinely, it just takes a little more time but the contact will be more snug. This will not help, however, if the Interproximator is stuck partly or completely inside of the prep.
The prep is ok but the Interproximator is still having trouble passing through to the undercut. REMEDY: Use a little liquid hand soap when you slide the interproximator into position. I'm using liquid soap nearly every time now to make it easier and to not disturb the matrix. I use soap for every Narrow Isthmus Interproximator to avoid breakage.
What else helps? REMEDY: Once you have snugged the Interproximator into position, release the ends, relax, and then grab the ends or the hemostats again, apply see-saw pressure and at the same time apical pressure while giving the Interproximator a good hard stretch. Often this second round of pressure is better because you have repositioned your fingertips or hemostats to a more favorable or more apical orientation. Or maybe my hands were tired. Either way I do this "second snug" quite often.
What more? REMEDY: Did you aggressively pre-wedge to "deflate" the papilla? The Interproximator is too gentle to do this on its own. YOU MUST PRE-WEDGE EACH CASE!
What helps in severe cases such as altered active eruption or Dilantin hyperplasia where the papilla won't go away. REMEDY: I use a tiny electrosurgery tip to trench a nice area for the Bioclear Matrix and Interproximator. If that seems aggressive, compare that to the problems that will ensue if the restoration leaks, packs food, or you give up and cut a normal prep that predisposes the tooth to fracture.

Be patient! It is worth the effort!

P.S. Dear Gordon, I am forwarding a note from Dr. Steve Urback regarding the Bioclear Matrix system.
-- Cheers, David

Dave, I think you gave him great suggestions. All I would add is that, as you said, sometimes it is hard to see if the interproximator is riding up and creating a concavity above the gingival margin. I routinely use a cord placement instrument to push the interproximator down. The clear matrix can be pushed towards the prep to do this, and it springs back into place once you remove the instrument. I would suggest using the bitine ring for a while, and after he has created some very tight contacts, he will have the confidence to try some without. You have to be extra careful with the rings, because when it squeezes the interproximator it can push it up into the prep if it isn’t far enough down to begin with. Encourage him not to give up, this is the best thing that has happened to posterior composites since they came into existence.

Bioclear is an interesting concept, but I'm leary about the proximal bonding to the occlusal. Does this present problems?

2008-05-05T23:00:00.000-07:00

-- Kenneth

Dear Kenneth,

Great question. We have had no problems placing composite next to freshly cut composite, especially freshly placed composite. We treat it just like enamel.

I am far more concerned about creating ideal shapes to control C factor and this is a very nice way to accomplish that, and to be able to create ideal rounded profiles, good solid contacts and well sealed gingival margins. Those things I worry about.
In fact, most of the composites on the market other than 3M Filtek Supreme Plus are actually made from chunks of pre-polymerized composite that are essentially ground up and then remanufactured/remixed with thinner composite. That is how the fumed silica based composites are able to get such high filler content. The 3M product has a robust patent on their zirconia filler system, and are able to pack more filler without having to grind and re-mix.

Regardless, we have seen nearly perfect results on follow up. I will cc to my friends at 3M to see if they have anything further to add.

Warm regards,
David

Does the bioclear matrix system cause a slight diastema due to it's thickness?

2008-05-05T22:59:00.000-07:00

-- Rich

Dear Rich,

Thanks for your question.

It is interesting that contacts are a fairly complex issue that don't receive a lot of attention. One of the things that we have seen is that with the anatomic, rounded contacts from the Bioclear prototypes is that the tightness issue is less crucial. In other words, a broad, rounded contact is much safer than a "point contact" that is tight. I very rarely have a problem with the diastema closures even when I don't use the "Interproximaor".
For the posteriors/Class II cases, I always use an interproximator and the contacts are very snug.
For back to back posteriors I use a bi-tine ring that has a specific resting area on the interproximator that provides even more separation and back to back simultaneously injection molded posteriors have snug contacts, even though there are 2 thicknesses of Mylar.
The Bioclear anatomically created matrices are heated and pressed which thins the contact area to less than the 2 mil original thickness.
In 6 months we plan to introduce the "butterfly, which will be a one piece matrix for back to back anteriors and posteriors that will have a single thickness of Mylar at the contact.
For anteriors diastema closures, from now on I will always do them simultaneously because one at a time is a miserable and problematic procedure. If contacts are not as tight as I would like when finished (which hasn't been a problem so far) I will:
- place an interproximator
- prophy-jet or sand blast the incisal half of both
- remove the interproximator, replace the Bioclear matrices then place the largest Interproximator to spread the teeth, then quickly etch and rinse, apply bonding resin, air thin slightly but don't core, then inject paste to augment the contact. I haven't had to do it yet but we teach it in the hands-on courses.

Warm regards,
David

What Bioclear Matrix should I use for the distal of a canine?

2008-05-05T22:55:00.000-07:00

-- John

Dear John,

Thanks for your question.

For the time being I would use an ETCM or TCM or (Extra Tall Curved Molar or a Tall Curved Molar) for an upper canine.
For a lower canine that is typically a little flatter, I would use an ETFM or TFM (Extra Tall Flat Molar or Tall Flat Molar).
The other option is to use an incisor matrix, and those would include a Universal or side specific (Right Hand/Left Hand) Incisor Matrix

Warm regards,
David

Dr. Mike Szarek, DMD - Case Study

2008-05-05T22:49:00.000-07:00

Dr. Mike Szarek, DMD - Part 1

Dr. Clark,

Here are the pre-op (image 1) and post-op (image 2) photos for the pt. who was moving to Japan--the Bioclear matrix worked awesome and we did the case in one day--it is a great invention and it is so easy to use--thank you so much for sending me the prototypes--I know it was a huge favor but I really appreciate it and so did the pt.--Thank you so much and I look forward to more of your articles and inventions.

Dr. Mike Szarek

Image 1 - Pre-op Image 2 - Post-op

Dr. Mike Szarek, DMD - Part 2

Dr. Clark,

Thank you so much for the Bioclear matrix. My patient and I really appreciate you sending us the prototype overnight so we could complete her case before she moved to Japan the following week. I just wanted to describe the step by step procedure we used to close the cervical embrasures:

No local anesthesia was used
Isolate tooth with traditional matrix and microetch
Slide Bioclear matrix into sulcus effortlessly--matrix will hug tooth and no need to wedge--hold matrix on lingual with finger or Hollenback
Etch and bond
Flowable composite into sulcus--do not cure
Renamel composite--sandwich technique--do not cure
Contour facial composite
Cure--contour--polish

* The procedure was very simple and quick
* The Bioclear matrix does all the work for you
* Excellent product!!

Thank you for everything,

Dr. Mike Szarek

Do the sealants make it harder to detect the decay? Can the sealant be removed?

2008-04-05T22:47:00.000-07:00

Dear Dr. Clark,

I just read your article on sealants.

I have two (grown) children. They had sealants years ago, and now, at
age 24 and 26, they are both experiencing decay under the sealants.
Their dentists say that over time, the sealants have minute cracks that
allow bacteria to grow unchecked. This is heartbreaking for all of us,
and a real hardship, because neither of them have any dental insurance!

Is there anything at all they can do besides continue to treat the decay
as it occurs? Also, the (two different) dentists seem to be unsure about
the state of their teeth. Do the sealants make it harder to detect the
decay? Can the sealant be removed?

I'm so distressed by this! Here we thought we were giving our children
the very best dental care and I feel like I've actually created a
lifetime of potential dental problems! I feel so guilty.

Mindy
Kensington, CT

DR. CLARK'S RESPONSE:

Dear Mindy,

I was very moved by your email. I have been lecturing , publishing and
doing research on this topic for nearly a decade and your situation
reminds me that there is yet a long journey ahead for my profession!

I recently spoke with some of my colleagues who have needed to perform
Root Canal Therapy on their own children because previously placed
sealants did not protect the teeth as they had hoped. These dentists,
just like you, are extremely disappointed in the sealant "promise". I
don't want to vilify the sealant philosophy, but it is a much more
complex issue than many people believe.

I will have Linda contact you to set up a quick phone call to discuss
your children's situation. I am confident that you we can find a
wonderful outcome to your unfortunate dilemma.

Warm regards,
David

From: "Gordon J. Christensen"
To: "Dr. David Clark"
Sent: Tuesday, April 08, 2008 10:09 AM
Subject: Re: sealants

David: Sealants have been placed in millions of teeth, and in my opinion,
only a very few have been adequately placed. Keep up the good work!

Gordon

How do I post something or make a comment on this blog

2008-04-04T22:44:00.000-07:00

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