1. Why are the premolars of higher value at the end of this restorative appointment? 11) Bonus Question:

2. RSD 810 NONFUNCTIONAL CUSP REPLACEMENT By Rodriguez Referenced: Fundamentals of Operative Dentistry by Summitt Art and Science of Operative Dentistry Sturdevant

3. NON Functional Cusp Cusps that do not occlude or fit into fossae or marginal ridge areas on the opposite arch. Though they are not used for grinding food they allow the dentition to move apart, out of occlusion. Dental Anatomy by Karst and Smith An understanding of the hard and soft tissues involved in mastication, speech and parafunction is essential for the correct restoration of dental anatomy.

4. Does this look familiar? Group Function

5. Group Function Canine Guidance

6. Class II Class I Canine Esthetic modifications with direct bonding An understanding of occlusion is essential for correct restoration.

7. Only with an understanding of occlusion can one make knowledgeable decisions regarding restoration of dentition. Which cusps are functional and nonfunctional in this case? Not all patients will be candidates for orthodontic treatment. How will you treat their needs?

8. Full mouth reconstruction This cannot be accomplished without a complete understanding of form and function..

9. Clinical situations will arise for which multiple treatment options must be presented. It is the responsibility of the professional to provide well-planned therapeutic options after thorough history and clinical exam and signed consent in order to perform treatment. If the doctor is unable to perform the “best option”, it behooves them to have referral sources which can. It is your job to serve your patients, and to treat them with the knowledge, skill and care that you would your own family. Remember…

10. Clinical Case: Nonfunctional Cusp Replacement

11. How might these be restored?

12. Chip is a 30 y/o male with no medical contraindications for routine dental treatment. His chief concern is chipping of his molars which have become slightly sensitive to cold food and drink. Chip was injured in a fall 2 years ago in which his molars were fractured due to forceful clamping down of his dentition. Clinical exam reveals good OH and no periodontal concerns, no parafunctional habits, and minor restorative needs other than these fractured maxillary first molars which test vital.

13. What are the treatment choices ? 1) Indirect restoration of missing cusps 2) Pin amalgam restoration 3) Direct composite restoration

14. Indirect restorations are esthetic, but require more than one appointment and the removal of sound tooth structure. Because lab procedures are necessary cost is the highest of all 3 choices. 1.

15. Fig 11-39a Horizontal pins (H) are used to attach the wall of a cusp to the amalgam restoration. Vertical pins (V) attach the restoration to the radicular portion of the tooth. Fig 11-39b Horizontal pins can be used in conjunction with vertical pins. In this clinical situation, a proximal box had to be extended significantly facially to eliminate caries and unsupported enamel. Fig 11-40 Horizontal pins are used to cross splint the cusps of a maxillary premolar. Amalgam requires elaborate retention, sometimes at the expense of sound tooth structure. As a direct technique it requires one appointment and is relatively inexpensive. 2.

16. Composite requires isolation to prevent contamination, awareness and respect for occlusion and proper technique. It is esthetic, requires one appointment and cost is comparable to amalgam restoration. Loss of sound tooth structure is minimal. 3.

17. Chip chooses #3 Today we will restore #3 MB cusp

18. Occlusion is mapped and shade matched. Patient is anesthetized and surgical site isolated with dental dam.

19. A wingless clamp is the convenient choice for maxillary posterior isolation. What anatomical structure might make this a tight fit?

20. All old amalgam, carious dentin and enamel are removed. Note the darkened appearance of the dentin. Can you identify it’s type? Note also the stain imparted by the breakdown of amalgam. A small amount of glass ionomer has been placed upon a deep portion of the preparation. Since there are no necessary retentive design elements other than facial beveling sound tooth structure removal is minimal.

21. Sectional matrix is placed, wedge and bitine ring positioned. Care should be taken to make sure the matrix is burnished against the adjacent tooth. No gaps should be present between the matrix and the tooth, and the ring must be pushing the wedge down or against the matrix. 37% phosphoric acid is applied for 15 seconds being careful to apply to enamel first. Wash and suction dry. Enamel will be frosty while dentin will slightly glisten.

22. The automatrix may also be used since it is thinner material than the traditional tofflemire, however the BEST contour is accomplished with the preformed sectional matrix and bitine rings.

23. Chlorhexidine is applied and left for 60 seconds. Suctioned dry but not washed.

24. A generous drop of Optibond Dentin Primer is applied for 60 seconds. Suction to evaporate the solvents.

25. A drop of Optibond Adhesive is applied to the prepared enamel surfaces. The layer is thin with no pooling.

26. Light Cure for 20 seconds.

27. The preparation may now be filled incrementally starting with a thin layer of highly filled flowable composite placed to line the interproximal box and pulpal floor.

28. There are many flowable composites on the market. Make sure to use highly filled for this purpose.

29. The first increment of Filtek Supreme Ultra nanofill is Placed in a layer approximately 1.5mm thick immediately adjacent to the matrix. The cure must be for 20 seconds

30. Second and third layers are placed against the first layer and then against the structurally strongest portion of the tooth (here the ML cusp). Increments are 1.5 to 2 mm in depth and do not connect buccal and lingual walls. 3 2

31. The increments which follow should be placed no thicker than 2mm in a “tulip” like fashion. The last layer of composite may be a lighter shade than the dentin shade beneath.

32. Build to anatomical form

33. The football burnisher is a fine instrument to use for contouring anatomy. It fits nicely into pits and can be used to create cuspal ridges.

34. After removal of the bitine ring, DO NOT REMOVE WEDGE OR MATRIX !!!!!! Immediately cure the interproximal surface from the buccal and lingual. Check buccal contour for voids and defects. Now is the time to create a smooth and anatomic form. It is necessary to use wetting resin on the smooth surface which has been under the matrix band because there is no air inhibited layer.

35. Use 12-fluted carbide finishing burs to contour and finish.

36. Remove matrix and wedge. Cure 20 seconds from buccal and lingual. Class II composites most often fail in the interproximal due to lack of complete cure. Contour, finish and polish prior to dental dam removal.

37. Use the 12-fluted finishing bur to adjust occlusion.

38. Open the occlusal embrasure with a 12-fluted flame bur or #12 blade. Notice the orientation of the bur.

39. Again use the 12-fluted finishing carbide or #12 blade to finish interproximals. Make sure to keep the bur orientation parallel to the long axis of the tooth and move from composite to tooth only. When using the #12 blade the direction of finish is from tooth to composite.

40. Occlusion is adjusted. Note that there are Occlusal stops in MI but there is NO LATERAL GUIDANCE on the nonfunctional cusp.

41. Care must be taken to remove the restored cusp from lateral occlusion. Chip had group function. Where are the working contacts in group function found?

42. Finish and polish with cups and points maintaining occlusal stops and anatomic contours.

44. Does this look familiar? Group Function x

45. It is essential to develop a tight interproximal contact. If using a sanding strip for gingival margin smoothing do not remove the interproximal contact.

46. Why are the premolars of such high value ? HINT:

49. A market oriented economy has some good points but strays when it becomes exclusively about profit. Profit that hurts the populace is too much exploitation. Dalai Lama Yum Center Louisville, Ky. May 19, 2013

50. D611, lab pix and instructions Buccal wall is continuation of interproximal box and extends to the buccal groove.

51. Make sure to round pulpo- axial line angle.

52. Floor of box must be deep enough to allow for matrix placement.

53. BRING TO CLINIC: Your patient with #3. Can have existing class II amalgam Everything we have given you All of your instruments, including dental dam set up. Lab Instructions PLEASE Clean Your Darwin and the WORK AREA SURROUNDING