1. Luting Cements And Delivering the final restoration Dr: Sharifa ALShehri B.D.S,M.Sc. 431 SDS Reference: Rosenstiel. Land. Fujimoto.4 th ed. pages: 909-927.

2. Removing Provisional Restoration Removing Provisional Restoration Bachhous forceps

3. Removing Provisional Restoration Richwill remover Hayer bridge remover

4. Try-in Procedures for Cast Metal Restorations Try-in Procedures for Cast Metal Restorations Proximal contact Proximal contact Marginal integrity Marginal integrity Stability Stability Occlusion Occlusion

5. Try-in of FPD

6. Try-in of Cast Post&Core

7. Checking for Proximal Contacts The most common problem seen in relation to a proximal contact is excessive tightness. The most common problem seen in relation to a proximal contact is excessive tightness. Ideally the contacts should be stable and easy to maintain. Ideally the contacts should be stable and easy to maintain.  The proximal contact between the crown and a natural tooth should allow the passage of floss The operator should compare the contact of other teeth in the dentition. The operator should compare the contact of other teeth in the dentition. Subjective symptoms (patients response) are sufficient to confirm a tight contact. Subjective symptoms (patients response) are sufficient to confirm a tight contact.

8. Proximal Contacts Adjustment Proximal Contacts Adjustment

9. Checking for Proximal Contacts (Cont’d) Checking for Proximal Contacts (Cont’d) Excessive tightness can be corrected by: Excessive tightness can be corrected by: Adjusting with a rubber wheel (all metal restoration) Adjusting with a rubber wheel (all metal restoration) Adjusting with a cylindrical mounted stone (porcelain restoration) Adjusting with a cylindrical mounted stone (porcelain restoration) Deficient proximal contacts in a gold casting can be corrected by soldering. Deficient proximal contacts in a gold casting can be corrected by soldering.

10. Checking for Marginal Integrity  Margin adaptation with a gap around 30  m is clinically acceptable. Marginal integrity can be assessed by moving a sharp explorer from the restoration to the tooth and from the tooth to the restoration (open margin= 50 µm the tip of sharp explorer can be inserted between the restoration and the tooth). Marginal integrity can be assessed by moving a sharp explorer from the restoration to the tooth and from the tooth to the restoration (open margin= 50 µm the tip of sharp explorer can be inserted between the restoration and the tooth). What is the most common cause of poorly adapted margins? What is the most common cause of poorly adapted margins?

11. Checking for Marginal Integrity (Cont’d) Testing whether the casting binds to the tooth surface, is helpful to determine the marginal integrity. This can be done using the following materials: Testing whether the casting binds to the tooth surface, is helpful to determine the marginal integrity. This can be done using the following materials: Disclosing waxes Disclosing waxes Suspension of rouge in chloroform or ether (Pressure indicating paste) Suspension of rouge in chloroform or ether (Pressure indicating paste) Air abrasion to form a matte finish Air abrasion to form a matte finish Powdered sprays Powdered sprays Water soluble marking agents Water soluble marking agents Elastomeric detection paste (by far the most reliable-fit checker) Elastomeric detection paste (by far the most reliable-fit checker)

12. Types Of Defective Margins

13. Checking for Stability The restoration should not rock or rotate when a force is applied. The restoration should not rock or rotate when a force is applied. Instability produced by a small positive nodule on the fitting surface can be corrected by trimming. Instability produced by a small positive nodule on the fitting surface can be corrected by trimming. If the instability is due to a distorted wax pattern, the casting procedure should be repeated. If the instability is due to a distorted wax pattern, the casting procedure should be repeated.

14. Checking for Occlusion Nonworking side interferenceworking side interferenceprotrusive interference

15. Checking for Occlusion

16. Evaluation of Aesthetics in Ceramic Restorations  Checking for the location of the incisal edge Aesthetic Characterizations Aesthetic Characterizations  Enamel cracks  Stained crack lines  Exposed Occlusal dentin  Incisal halo.

17. CEMENTATION Cementation is defined as, “The process of attaching parts by means of a cement” –GPT. Cementation is defined as, “The process of attaching parts by means of a cement” –GPT.

18. Ideal Luting Agent Long working time. Long working time. Adhere well to both tooth structure and cast alloy. Adhere well to both tooth structure and cast alloy. Provide a good seal. Provide a good seal. Non-irritating, non-toxic to both pulp and surrounding supporting structure. Non-irritating, non-toxic to both pulp and surrounding supporting structure. Have adequate strength properties. Have adequate strength properties. Being compressible to thin layers i.e. have low viscosity; low solubility. Being compressible to thin layers i.e. have low viscosity; low solubility. Exhibit good working and setting characteristic. Exhibit good working and setting characteristic. Easily to be removed after setting. Easily to be removed after setting. Fluoride release. Fluoride release.

19. Types of luting agent Zinc phosphate Zinc phosphate Zinc silicophosphate Zinc silicophosphate Zinc polycarboxylate Zinc polycarboxylate Zinc oxide-eugenol with/without EBA Zinc oxide-eugenol with/without EBA Glass ionomer Glass ionomer Adhesive resins Adhesive resins Resin modified GIs Resin modified GIs

20. Cements bonding mechanisms Non-adhesive mechanical luting Non-adhesive mechanical luting Micro-mechanical bonding Micro-mechanical bonding Molecular adhesive Molecular adhesive

21. Zinc phosphate cement

22. Zinc phosphate cement (1878) Composition: Composition: ZnO powder and phosphoric acid ZnO powder and phosphoric acid Advantages: Advantages: Long clinical track record (used clinically for over 50 years). Long clinical track record (used clinically for over 50 years). Specimens of cement retrieved from old castings (>40 yrs) show high chemical stability. Specimens of cement retrieved from old castings (>40 yrs) show high chemical stability. Adequate strength (80-110 MPa c.s,5-7 MPa t.s). Adequate strength (80-110 MPa c.s,5-7 MPa t.s). Reasonable working time (3-6min w.t, 5-14 s.t). Reasonable working time (3-6min w.t, 5-14 s.t). Excess material can be easily removed. Excess material can be easily removed.

23. Zinc phosphate cement (1878) Disadvantages: Disadvantages: Water-sensitive during setting; microleakage; high solubility especially in acid environment (0.05 to 3.3% in d.w, 20 to 30 times higher in acids). Water-sensitive during setting; microleakage; high solubility especially in acid environment (0.05 to 3.3% in d.w, 20 to 30 times higher in acids). Pulp irritation Low initial pH (1-2 after mixing, below 4 to 1 h,6-7 after 24 h); (use of varnishes?). Pulp irritation Low initial pH (1-2 after mixing, below 4 to 1 h,6-7 after 24 h); (use of varnishes?). Lack of antimicrobial action Lack of antimicrobial action Brittleness, Brittleness, lack of adhesion. lack of adhesion.

24. Zinc silicophosphate (1878) High compressive strength (152 MPa) and a moderate tensile strength (9.3MPa). High compressive strength (152 MPa) and a moderate tensile strength (9.3MPa). Excessive film thickness 88 µm at the occlusal surface under an actual casting. Excessive film thickness 88 µm at the occlusal surface under an actual casting. An acidic pH that may be harmful to the pulp. An acidic pH that may be harmful to the pulp.

25. Zinc Polycarboxylate Cement

26. Zinc Polycarboxylate Cement 1960s Composition: Composition: The powder is zinc oxide with 1% to 5% tin or magnesium oxide, 10% to 40% aluminum oxide or other reinforcing filler, the acid is 40% (high MW) polyacrylic acid or acrylic acid coplymer with other organic acids. The powder is zinc oxide with 1% to 5% tin or magnesium oxide, 10% to 40% aluminum oxide or other reinforcing filler, the acid is 40% (high MW) polyacrylic acid or acrylic acid coplymer with other organic acids. Good for cementing crowns and 3-unit bridges. Good for cementing crowns and 3-unit bridges.

27. Zinc polycarboxylate cement (Advantages) Exhibits specific (low) adhesion to tooth structure because it chelates with the calcium. Adhesion to some alloys. Exhibits specific (low) adhesion to tooth structure because it chelates with the calcium. Adhesion to some alloys. Higher tensile strength (8-12 MPa) compared to zinc phosphate cement, but significantly lower compressive strength (55-85 MPa). Higher tensile strength (8-12 MPa) compared to zinc phosphate cement, but significantly lower compressive strength (55-85 MPa). Anticariogenic in nature but this property is less than that of GIC. Anticariogenic in nature but this property is less than that of GIC. Biocompatible to the pulp, rapid rise of the cement PH toward neutrality. Biocompatible to the pulp, rapid rise of the cement PH toward neutrality. Lack of post operative sensitivity. (excellent for sensitive teeth ) Lack of post operative sensitivity. (excellent for sensitive teeth ) Film thickness comparable to those of zinc phosphate cements Film thickness comparable to those of zinc phosphate cements Solubility in distilled water 0.1% to 0.6%. Solubility in distilled water 0.1% to 0.6%.

28. Zinc polycarboxylate cement Disadvantages Disadvantages It is thixotropic in nature. Hence, it may be too thick and will not flow adequately. It is thixotropic in nature. Hence, it may be too thick and will not flow adequately. Short (2.5min)working time as compared to that of Zn/Po cement(5min) makes it difficult to lute long span bridges Short (2.5min)working time as compared to that of Zn/Po cement(5min) makes it difficult to lute long span bridges Residual cement is more difficult to remove. Residual cement is more difficult to remove. Not as strong as Zn/Po. Not as strong as Zn/Po. Shows plastic deformation, so unsuited to high load areas Shows plastic deformation, so unsuited to high load areas

29. Zinc polycarboxylate Cement Manipulation Manipulation The cement should be mixed on the surface that does not absorb liquid; hence, a glass slab is preferred to treated paper pads. The cement should be mixed on the surface that does not absorb liquid; hence, a glass slab is preferred to treated paper pads. The liquid should not be dispensed prior to mixing because it tends lose water The liquid should not be dispensed prior to mixing because it tends lose water The powder is rapidly incorporated in bulk as two increments into the liquid in large quantities within 30 seconds using a Glass slab and stainless steel spatula. The powder is rapidly incorporated in bulk as two increments into the liquid in large quantities within 30 seconds using a Glass slab and stainless steel spatula. Cooling the slab increases the setting time. Cooling the slab increases the setting time. Should not be disturbed in rubbery stage as will pull from margins Should not be disturbed in rubbery stage as will pull from margins

30. Glass ionomer cement

31. Glass Ionomer Cements 1970s Composition: alumino-fluorosilicate glass and weak polyacrylic acids Composition: alumino-fluorosilicate glass and weak polyacrylic acids Adhesive, and reports of reduced microleakage Adhesive, and reports of reduced microleakage Early exposure to water significantly reduces ultimate strength Early exposure to water significantly reduces ultimate strength Low cement film thickness (25 to 35µm) Low cement film thickness (25 to 35µm) Does not appear to be more irritant to pulp, as earlier reports suggested Does not appear to be more irritant to pulp, as earlier reports suggested

32. Glass Ionomer Cement Advantages Advantages Cement has adhesion to enamel and dentin (low bond strength to teeth). Cement has adhesion to enamel and dentin (low bond strength to teeth). Exhibits good biocompatibility (no pulpal protection is required). Exhibits good biocompatibility (no pulpal protection is required). It releases fluoride (anticariogenic effect). It releases fluoride (anticariogenic effect). Easy to mix, good resistance to acid dissloution. Easy to mix, good resistance to acid dissloution. Set cement is translucent (advantage when used with porcelain labial margin). Set cement is translucent (advantage when used with porcelain labial margin). Mechanical properties are comparable with zinc phosphate cement (medium-high compressive strength 90 to 140 MPa, T.S 6 to 8 MPa). Mechanical properties are comparable with zinc phosphate cement (medium-high compressive strength 90 to 140 MPa, T.S 6 to 8 MPa).

33. Glass Ionomer Cement (Cont’d) Disadvantages Disadvantages long term sensitivity can result if tooth is over dried. long term sensitivity can result if tooth is over dried. High susceptibility to moisture contamination. during setting, (more recent formulations may be less susceptible than the earlier products). High susceptibility to moisture contamination. during setting, (more recent formulations may be less susceptible than the earlier products). Slow setting, possible pulp irritation. Slow setting, possible pulp irritation. variable adhesive characteristic. variable adhesive characteristic. Residual cement is more difficult to remove. Residual cement is more difficult to remove.

34. Hybrid Ionomer Cements Resin modified polyalkenoate cement (Mixture of resin and glass ionomer powder) Resin modified polyalkenoate cement (Mixture of resin and glass ionomer powder) Combines the strength and insolubility of resin with the fluoride release of glass ionomer. Combines the strength and insolubility of resin with the fluoride release of glass ionomer. Manufacturers recommend their use for all- metal or ceramo-metal crowns and bridges,, but not for posts (risk of expansion induced root fracture) Manufacturers recommend their use for all- metal or ceramo-metal crowns and bridges,, but not for posts (risk of expansion induced root fracture) Not recommended for all-ceramic restorations, because delayed cement expansion can result in ceramic fracture Not recommended for all-ceramic restorations, because delayed cement expansion can result in ceramic fracture

35. Hybrid Ionomer Cementation (Cont.'s) Working time can be lengthened by using refrigerated liquid, mixing on cold slab or decreasing powder-liquid ratio. Higher temperature shorten working time. Working time can be lengthened by using refrigerated liquid, mixing on cold slab or decreasing powder-liquid ratio. Higher temperature shorten working time. Use microetching to prepare internal metal surfaces for increased bonding. Use microetching to prepare internal metal surfaces for increased bonding. Remove excess cement before final set. Remove excess cement before final set. Use desensitizing liquid to reduce possible sensitivity without dramatically affecting bond to tooth. Use desensitizing liquid to reduce possible sensitivity without dramatically affecting bond to tooth.

36. Adhesive resin agents

37. Composition: Bis-GMA resins and other methacrylates. Composition: Bis-GMA resins and other methacrylates. Available in a wide range for formulation. These can be categorized on the basis of polymerization into :(Chemical-, photo- and dual- cure) Available in a wide range for formulation. These can be categorized on the basis of polymerization into :(Chemical-, photo- and dual- cure) Adhesion to enamel by micromechanical retention to dentine by more complex penetration of hydrophilic monomers through collagen layer overlying partially demineralized apatite of etched dentine Adhesion to enamel by micromechanical retention to dentine by more complex penetration of hydrophilic monomers through collagen layer overlying partially demineralized apatite of etched dentine

38. Adhesive resin agents

39. Adhesive resin agents (cont.) Conditioning: removal of smear layer, and demineralize top 2-5 microns Conditioning: removal of smear layer, and demineralize top 2-5 microns Primer: wetting agent such as HEMA (Hydroxy Ethyl Metacrylate ) applied; bifunctionality enables hydrophilic bond to dentine and hydrophobic bond to adhesive Primer: wetting agent such as HEMA (Hydroxy Ethyl Metacrylate ) applied; bifunctionality enables hydrophilic bond to dentine and hydrophobic bond to adhesive Adhesive cement: e.g. 4-META(Methacryloxy Ethyl Ttimillitic Anhydride) penetrates into tubules Adhesive cement: e.g. 4-META(Methacryloxy Ethyl Ttimillitic Anhydride) penetrates into tubules Polymerization shrinkage remains a problem Polymerization shrinkage remains a problem

40. Adhesive Resins The manipulative techniques may be very different with different brands of resin cements. The manipulative techniques may be very different with different brands of resin cements. Shade of veneers can be modified by the shade of the luting agent Shade of veneers can be modified by the shade of the luting agent Colour-match try-in pastes are available to facilitate selecting the best cement shade. Colour-match try-in pastes are available to facilitate selecting the best cement shade.

41. Adhesive Resins Advantages: Advantages: high strength, high strength, low oral solubility. low oral solubility. high micromechanical bonding to prepared enamel, dentin, alloys and ceramic surfaces. high micromechanical bonding to prepared enamel, dentin, alloys and ceramic surfaces.

42. Adhesive Resins Disadvantages: Disadvantages: The need for meticulous and critical technique, The need for meticulous and critical technique, More difficult sealing and higher film thickness than traditional cements, More difficult sealing and higher film thickness than traditional cements, Possible leakage and pulp sensitivity, Possible leakage and pulp sensitivity, Difficulty in removal excess cement Difficulty in removal excess cement

43. Provisional cementation Zinc oxide –eugenol: powder zinc oxide, the liquid is purified eugenol. Zinc oxide –eugenol: powder zinc oxide, the liquid is purified eugenol. Low compressive and tensile strength(7-40 MPa, 1000-6000P psi). Low compressive and tensile strength(7-40 MPa, 1000-6000P psi). Film thickness of 40 µm Film thickness of 40 µm High solubility about 1.5%, little anticariogenic action High solubility about 1.5%, little anticariogenic action Abtudent effect on the pulp, good sealing ability and resistance to marginal penetration. Abtudent effect on the pulp, good sealing ability and resistance to marginal penetration. Reinforced zinc oxide-eugenol cements: by adding EBA, alumium oxide and PMM. Reinforced zinc oxide-eugenol cements: by adding EBA, alumium oxide and PMM.

44. Provisional Cements

45. Definitive cementation Primary purpose of luting cement: to seal tooth-restoration interfacial space Primary purpose of luting cement: to seal tooth-restoration interfacial space Choice of luting agent Choice of luting agent Type of restoration: conventional casting or adhesive restoration Type of restoration: conventional casting or adhesive restoration

46. Clinical decision making for dental cements

48. Preparation of Tooth Surface After cleaning the preparation, cavity varnish should be applied if a non- adhesive cement like zinc phosphate is to be used. After cleaning the preparation, cavity varnish should be applied if a non- adhesive cement like zinc phosphate is to be used. Oxalate treatment of the tooth surface can be done to reduce dentin sensitivity. Oxalate treatment of the tooth surface can be done to reduce dentin sensitivity.

49. Preparing the casting: The casting should be cleaned by sandblasting with 50  m alumina or by steam, followed by ultrasonic or organic cleaning. The casting should be cleaned by sandblasting with 50  m alumina or by steam, followed by ultrasonic or organic cleaning. Next the operatory site is isolated with cotton rolls. Next the operatory site is isolated with cotton rolls. The cement should be mixed to a luting consistency. The cement should be mixed to a luting consistency. A thin coat of cement should be applied on the internal surface of the casting. A thin coat of cement should be applied on the internal surface of the casting. The tooth surface is dried and the prosthesis is inserted with a firm, rocking dynamic seating force. A static load will lead to incomplete seating. Excessive force may lead to fracture. The tooth surface is dried and the prosthesis is inserted with a firm, rocking dynamic seating force. A static load will lead to incomplete seating. Excessive force may lead to fracture. Next the margins of the retainers are examined to verify the fit of the prosthesis. Next the margins of the retainers are examined to verify the fit of the prosthesis. Excess cement should be removed with an explorer. Floss can be used to remove the excess cement in the inter-proximal surface. Excess cement should be removed with an explorer. Floss can be used to remove the excess cement in the inter-proximal surface. Occlusion should be checked with Mylar shim stock or articulating paper. Occlusion should be checked with Mylar shim stock or articulating paper. The patient should be advised to avoid loading for the first 24 hours. The patient should be advised to avoid loading for the first 24 hours.

50. Preparation of the Restoration and Tooth Surface for Final Cementation

51. Cementation with Zinc Phosphate cement Pdr1.2mg+Lq0.6ml

52. Cementation with Zinc Phosphate cement

56. Factors that influence the completeness of seating after cementation Viscosity of the cement. Viscosity of the cement. Morphology of the restoration. Morphology of the restoration. Vibration. Vibration. Seating force. Seating force. Venting. Venting.

57. Venting.

58. Cementation with Glass Ionomer Clean tooth and isolate. Do not use compressed air. If tooth is dry, moisten with a wet cotton roll. Clean tooth and isolate. Do not use compressed air. If tooth is dry, moisten with a wet cotton roll. Excessive air drying of the preparation may cause post-cementation sensitivity. Excessive air drying of the preparation may cause post-cementation sensitivity. Seat casting, then clean up excess cement after it hardens. Seat casting, then clean up excess cement after it hardens. If patient has sensitivity, delay final cementation for 2-3 weeks. If patient has sensitivity, delay final cementation for 2-3 weeks.

59. Technique Tips Fluff powder before dispensing. Hold liquid bottle vertically, and release each drop slowly to ensure equal size drops. Fluff powder before dispensing. Hold liquid bottle vertically, and release each drop slowly to ensure equal size drops. For any powder/liquid cement, incorporate the powder thoroughly. Insure mix is homogeneous. For any powder/liquid cement, incorporate the powder thoroughly. Insure mix is homogeneous. Load the crown evenly with cement. Load the crown evenly with cement. Place crown cement-side done on your palm for the dentist to pick up and seat on the tooth. Place crown cement-side done on your palm for the dentist to pick up and seat on the tooth. As the cement loses its gloss and start to set, it will have a stringy, non-sticky consistency. Start removing excess cement before it hardens. As the cement loses its gloss and start to set, it will have a stringy, non-sticky consistency. Start removing excess cement before it hardens. After removal of excess, use a piece of knotted floss and run it through the interproximal areas to remove remnant cement. After removal of excess, use a piece of knotted floss and run it through the interproximal areas to remove remnant cement. Instruct patients to wait 1 hour after cementation. Instruct patients to wait 1 hour after cementation.

60. Hybrid Ionomer Cementation Clean tooth. Clean tooth. Rinse and dry – do not desiccate the tooth. Rinse and dry – do not desiccate the tooth. Powder is sensitive to moisture – keep container tightly sealed. Powder is sensitive to moisture – keep container tightly sealed. Fluff powder before dispensing. Fluff powder before dispensing. Make sure tip of liquid vial is clean before dispensing. Make sure tip of liquid vial is clean before dispensing. Dispense liquid form vial held vertically to ensure uniform drops. Dispense liquid form vial held vertically to ensure uniform drops. Mix all powder into liquid for 20-30 seconds on a small area of mixing pad. Mix all powder into liquid for 20-30 seconds on a small area of mixing pad.

61. Post-Cementation Instructions  The patient is asked to exercise all oral functions and awareness should be created regarding the initial discomfort.  Sudden impact forces should be avoided in the restored area, e.g. biting on a nut or metallic object.  Maintenance: Oral hygiene procedures with special attention to use of floss, inter-dental brushes in the concerned area. Oral hygiene procedures with special attention to use of floss, inter-dental brushes in the concerned area. De-sensitizing tooth paste or mouth wash can be used if there is sensitivity. De-sensitizing tooth paste or mouth wash can be used if there is sensitivity.  The patient is advised to report immediately if there is pain.  Regular recall visits for review.

62. Follow-up Care Post-cementation appointment (within a week to 10 days) Post-cementation appointment (within a week to 10 days) Periodic recall – patients with cast restoration are recalled at least every six months Periodic recall – patients with cast restoration are recalled at least every six months Patients with extensive fixed prosthesis combined with advanced periodontal disease needs more frequent recall appointments. Patients with extensive fixed prosthesis combined with advanced periodontal disease needs more frequent recall appointments.