Large MOD amalgam with recurrent mesial decay replaced with BAARD Overlay

This is the full case of the photo I posted a few weeks back.

Removal of large Amalgam revealed lingual cusps undermined by oblique fracture and large undercut present from amalgam at DB cusp

According to my own criteria the MB cusp probably could have been spared but I felt more confident doing an Overlay here

Dentin cracks & recurrent decay removed. Immediate Dentin Sealing with Resin Coating performed with Clearfil SE Protect & Majesty Flow

Deep amalgam left steep transitions to anatomic reduction. Following BAARD ceramic design rules & Biomimetic principles - stress reduced ceramic platform created with incremental placement of Clearfil AP-X composite. This serves multiple creates a prep design that minimizes both ceramic stresses and C-Factor stresses at delivery - aids in mimicking original biomechanics of natural tooth restoring dentin with composite of similar modulus & enamel with similar modulus glass ceramic

Buccal & lingual margins were beveled with large fine round diamond. E. Max MT A1 overlay delivered same day with Warm Clearfil AP-X composite

#biomimeticrestorativedentistry

#BAARD #overlay #onlay #Biomimetics #biomimeticdentistry #immediatedentinsealing #compressiondome #preservethebiorim #cerec #cadcamdentistry #cadcamdentists #tooth #teeth #dentistry #digitaldentistry #kuraraynoritake #clearfilseprotect #dentalphotography #dentalhealth #dentistrymyworld #dentistlife #dentistrylove #dentalgram #dentistsofinstagram #dentallabor #labtechnician #dentalclinic ...

I find deep lesions fascinating and one of my favorite things to treat. Tooth tested vital and normal. Despite the size of the lesion there was a good amount of Dentin thickness radiographically. While my goal is not complete removal - the goal is to maintain pulp vitality - based on the x-Ray it appeared this would be likely with good RDT (remaining dentin thickness)

Prep design was a challenge - due to buccal decal/arrested lesion (not the buccal “pit” - area around it)

Peripheral seal zone achieved and final Caries removal achieved with air abrasion. Immediate Dentin Sealing with Resin Coating performed with CLEARFIL SE PROTECT and MAJESTY FLOW. Ribbond placed over discolored dentin area. Biobase completed with CLEARFIL AP-X.

E. Max A1 HT bonded with CLEARFIL SE PROTECT & CLEARFIL AP-X Heated Restorative composite

On the final there was some slight excess composite to clean up on the mesial and a lot on the distal, thought I had removed it but all I did was burnish it 🤦🏻‍♂️ took awhile to remove, but we got it

#biomimeticrestorativedentistry

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Biomimetic Restorative Dentistry - the best kind of addiction & this prep, IDS, & WARM Composite delivery are taught at The BAARD Institute online with the new BAARD Onlay & Advanced Adhesion Courses

Broken cusp/restoration removed & prepped for BAARD Onlay

Immediate Dentin Sealing performed with Gold Standard Clearfil SE Protect & Majesty Flow

e.Max A1 HT Delivered with Warm Clearfil AP-X & Clearfil SE Protect

#BiomimeticRestorativeDentistry

#BAARD #onlay #Biomimetics #biomimeticdentistry #immediatedentinsealing #compressiondome #preservethebiorim #cerec #cadcamdentistry #cadcamdentists #tooth #teeth #dentistry #digitaldentistry #kuraraynoritake #clearfilseprotect #dentalphotography #dentalhealth #dentistrymyworld #dentistlife #dentistrylove #dentalgram #dentistsofinstagram #dentallabor #labtechnician #dentalclinic ...

The BAARD Overlay Prep Protocol

This is the protocol I follow to get consistent results with my Overlay preps. Everyone has their own approach that works in their hands, but I can say that many of my students have benefited from following this similar protocol.

Unfortunately do to limitations on quantity of photos I cannot include more photos from this case.

For Online & Live Courses visit:

https://thebaardinstitute.com

#biomimeticrestorativedentistry

#BAARD #Biomimetics #biomimeticdentistry #immediatedentinsealing #compressiondome #preservethebiorim #cerec #cadcamdentistry #cadcamdentists #tooth #teeth #dentistry #digitaldentistry #kuraraynoritake #clearfilseprotect #dentalphotography #dentalhealth #dentistrymyworld #dentistlife #dentistrylove #dentalgram #dentistsofinstagram #dentallabor #labtechnician #dentalclinic ...

Fun case, great patient

Patient presented recurrent decay on large amalgam on previously RCT tooth….. PA & CBCT showed cleaned apices

Old restorative removed & decay cleaned. Recommended to patient it would be ideal to re-retreat endo - patient preferred to proceed without endo retreatment…..

Steps outline in photos

#biomimeticrestorativedentistry

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Deceptively difficult Onlay case:

Fracturing DL cusp, sorry for the poor angle on the pre-op, there were stained fractures on distal marginal ridge & lingual groove...

Initial plan was to only cover DL cusp and preserve ML cusp, after removal of amalgam & recurrent Caries the decision was made to cover ML cusp.....

Difficult prep design due to the shape of the proximal box from existing amalgam and the aggressive lingual tilt of the molar....

Immediate dentin sealing performed with Clearfil SE Protect & Clearfil Majesty Flow

e. Max A1 MT luted with Warm Clearfil AP-X & Clearfil SE Protect

#BiomimeticRestorativeDentistry

#BAARD #onlay #Biomimetics #biomimeticdentistry #immediatedentinsealing #compressiondome #preservethebiorim #cerec #cadcamdentistry #cadcamdentists #tooth #teeth #dentistry #digitaldentistry #kuraraynoritake #clearfilseprotect #dentalphotography #dentalhealth #dentistrymyworld #dentistlife #dentistrylove #dentalgram #dentistsofinstagram #dentallabor #labtechnician #dentalclinic ...

Haven’t used e. Max HT in awhile, very happy with the final

Tough case, lots of decal enamel, especially on the distal - I left some decal on distal buccal I had been chasing, did not extend into dentin, long term I do not think it should be an issue but I don’t love it

There was also a distal crack extending 1/4 into dentin, thankfully I dissected it out pretty quick for a change 😅

Immediate Dentin Sealing with CLEARFIL SE PROTECT & MAJESTY FLOW

Biobase constructed with CLEARFIL AP-X & MAJESTY FLOW

E. Max B1 HT bonded with WARM CLEARFIL AP-X & CLEARFIL SE PROTECT

#biomimeticrestorativedentistry

#BAARD #overlay #Biomimetics #biomimeticdentistry #immediatedentinsealing #compressiondome #preservethebiorim #cerec #cadcamdentistry #cadcamdentists #tooth #teeth #dentistry #digitaldentistry #kuraraynoritake #clearfilseprotect #dentalphotography #dentalhealth #dentistrymyworld #dentistlife #dentistrylove #dentalgram #dentistsofinstagram #dentallabor #labtechnician #dentalclinic ...

The restoration in composite of adjacent pre-molar contacts maybe one of the hardest restorative things we do IMHO. Deep margins & poor positioning can only amplify this.

Patient presented broken contact and recurrent decay on both pre-molars. Patient was having pain from food lodgement but the teeth tested vital and normal.

Spent a long time setting up the first dam only to significantly tear it in the first few seconds. I removed most the old composite and the replaced the dam.

As I got the first half of composite removed on the first pre-molar I realized how debonded it was and easily peeled the rest out with a scaler. Amazingly there wasn’t much Caries Dye staining under the deep resin on the first pre-molar. Caries End Points reached followed by air abrasion, bonding, and resin coating.

The safest way to approach restoring adjacent contacts is to do them one at a time. It is more time consuming but minimizes the chance of error. Additionally when restoring a direct that has a deep sub-gingival margin - its best to separate the steps into a margin elevation and then proximal contact restoration. This allows for better adaptation of the sub-gingival margin and better overall emergence profile in two planes.

There were a lot of steps to restoring this case, but isolating out each one allowed for more meticulous attention to detail. 1) Reel matrix placed for margin elevation with Teflon to aid in adaptation for 1st pre-molar 2) placement of Ribbond on 1st pre-molar 2) restoration of 2nd pre-molar 3) contouring of 2nd pre-molar contact 4) restoration of 1st pre-molar

The pre-molars were restored in the same way: proximal enamel shell created with Clearfil Majesty Universal, first dentin floor increment on EverX Flow, rest of dentin replaced with EverX Posterior, Final Enamel Replacement with Clearfil Majesty Universal

#biomimeticrestorativedentistry

#BAARD #overlay #Biomimetics #biomimeticdentistry #immediatedentinsealing #compressiondome #preservethebiorim #cerec #cadcamdentistry #cadcamdentists #tooth #teeth #dentistry #digitaldentistry #kuraraynoritake #clearfilseprotect #dentalphotography #dentalhealth #dentistrymyworld #dentistlife ...

Tough Deep Margin Elevation on extremely structurally compromised pre-molar - the whole bag of techniques was emptied out on this one.....

First, I literally tried talking the patient out of saving the tooth, not that I didn’t think it could be done, but wanted to make sure the patient had clear expectations of what we were about to take on....

I planned this out into two different appointments, 1st appointment would be to excavate Caries, determine restorability - this was based on amount of tooth structure remaking, I was actually amazed at how much coronal tooth structure was remaining AND if we could isolate for DME - I told the patient if I couldn’t reliably isolate for DME we should extract....

I removed gross decay, access the pulp, sealed off pulp with Teflon, sealed off deep excavation with Teflon packed between dam and tooth, completed Caries removal through use of Caries Detector Dye - Immediate Dentin Sealing performed and then utilized a copper band & matrix within matrix technique to complete DME...... with then placed Cavit and had patient come back for 2nd appointment.....

At second appointment - RCT completed (that is sealer puff at the apex) - two Ribbond fibers utilized, first one placed Mesial-Distal followed by a piece Buccal-Lingual.... EverX Flow was used incrementally to create the majority of the Biobase along with AP-X and top layer of Majesty Flow

Katana Avencia A3 composite block was utilized as opposed to a hard glass ceramic to better absorb and shield the underlying compromised sub-structure from stresses - in fact the entire Biobase and restoration were constructed to be a optimized stress shielding apparatus to protect the structurally compromised tooth

#biomimeticrestorativedentistry

#BAARD #overlay #Biomimetics #biomimeticdentistry #immediatedentinsealing #compressiondome #preservethebiorim #cerec #cadcamdentistry #cadcamdentists #tooth #teeth #dentistry #digitaldentistry #kuraraynoritake #clearfilseprotect #dentalphotography #dentalhealth #dentistrymyworld #dentistlife #dentistrylove #dentalgram #dentistsofinstagram #dentallabor #labtechnician #dentalclinic ...

I utilize immediate dentin sealing for all ceramic restorations - especially crown preparations which are the least fracture resistant design for glass ceramics (Huang 2020)

We talk about a lot of the benefits of immediate dentin sealing but what is often not discussed is the increased fracture resistance it provides.

It is well known that bonding ceramic restorations increases their fracture resistance, so it should go without saying that higher bond strengths yield higher fracture resistance. In fact, this is well supported in the literature.

Dentin bonding can be tricky. Immediate dentin sealing allows us to bond dentin predictably & reliably. IDS provides durable dentin bond strengths that exceed enamel bond strengths.

It is no surprise then that multiple studies show higher ceramic fracture resistance when using IDS vs conventional resin cement bonding procedures - (Gresnigt 2016), (Yazigi 2017), (van den Breemer 2017), (Hosteegne 2020)

There are many reasons to implement IDS into your daily practice, this is just one of them.

This case is a case where I was replacing an existing crown - pretty much the only time I do crowns anymore

#biomimeticrestorativedentistry

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Is mechanical retention over-rated? It depends on your philosophy

In Biomimetic Restorative Dentistry we try to emulate the Dentin-Enamel Complex as our model for bonding.A key feature of the DEC is that it is a SECURE BOND. Failures are directed away from the underlying dentin & pulp.Swipe left once.Having the hardest material & mechanical retention will aid in the longevity of the restoration, but what about the dentin and pulp underneath?

All studies of Immediate Dentin Sealing & Resin Coating show zero failures below the hybrid layer.In other words, failures do not breach the bond, just the DEC is designed to do (until we start cutting away tooth structure)

If the restoration is failing, personally I do not what it to stay on and mask the failure underneath.Swipe left twice & you will see a situation you will never see under a ceramic Onlay or Overlay - the tooth would never get to this point - the restoration would come out - we can’t rely on patient sensitivity - patients don’t always present with sensitivity on gross carious lesions & definitely not with RCT teeth.At the very least, staying above the BioRim puts potential microleakage further from the pulp.Numerous studies have reported the importance of Remaining Dentin Thickness between the restoration and the pulp.

The idea that overlays & onlays have lower long term success rates vs crowns is not well supported in the literature.In fact, most modern meta-analysis & retrospective analysis show similar if not higher success rates for these types of partial coverage restorations. (Morimoto 2018) is a good one.While clinical trials are nice, they are very difficult to achieve past 10 years, which is why few exist and after that point we mainly rely on clinical follow up studies.Of which for partial coverage Ceramics there are many with as good as or better comparative results to full coverage.While I appreciate the anecdotal evidence of 20-40 year old crowns, it is purely anecdotal and very difficult to compare realistic survival rate to other crowns placed 20-40 years ago.

IMHO retentive vs non-retentive is not a matter of right vs wrong, but your restorative philosophy.
#biomimeticdentistry #onlay ...

I wasn’t going to post this case…..

But after the response I got privately from specialists & colleagues I am more comfortable sharing……

Older patient presented with pain on 2nd premolar keeping him up at night….

Patient had irreversible pulpitis with a massive abfraction filling with plaque and essentially communicating with pulp…..

It was late so I did an open & med through the abfraction/communication…..

I scheduled him back to finish the endo…. I had some decisions to make 1) how was I going to do the endo - going through the abfraction would be the least invasive but the angulation would be really difficult with the files and run a high risk of ledging- conversely accessing from the occlusal would be difficult and destructive and I’d probably have to fill and seal off the buccal for it to even work….

2)What would be the definitive restoration - just a resin or a “full coverage restoration”?

When the patient came back, after numbing I used the Komet Ceratip Bur that @dissidentist graciously sent me to trim so tissue for a clamp to gain purchase on - first I tried using a 212 clamp - actively modifying it (heating, bending, cooling in water) but it kept rotating and would work - I settled on a modified 00X pre-molar clamp that lucky held on…..

I cut a little notch in the tooth to give a little path/bend relief for the files….

Endo was completed - luckily I had a CBCT and was able to map out the canal ahead of time - I accessed the pulp horn above and cleaned it out as well…..

I sandblasted than used DC Activator that contains a reducing agent to help reduce the reactive oxygen from the bleach - bonded with Clearfil SE Protect - Resin Coated with Majesty Flow - layered the Interior with EverX Flow - followed by AP-X HO Shade and outer layer with Majesty Universal - I did not get a photo after final polishing….

I told the patient the traditional approach was to do a post and crown - but with a tooth this structurally compromised I felt that would only accelerate the loss of the tooth but that’s normal approach and it was up to him - he agreed and do not want to go the crown route - (There’s more but out of room) ...

This case turned out to be a textbook BAARD Overlay Case

The initial treatment plan was an overlay based on the pre-treatment Caries and Structural Assessment

For borderline cases I will excavate to evaluate first, starting with reduction of the central fissure and obviously compromised cusps and marginal ridges...

When following the BAARD Prep Protocol for Non-retentive Overlays these cases go smooth, fast, & very stress free - for the operator and the bonding/ceramic

The enhanced visual access the overlay preparation design gives after cross reduction allows for more efficient Caries and crack diagnosis & removal

Caries removal end points utilized here

Air Abrasion followed for Immediate Dentin Sealing with Resin coating with CLEARFIL SE PROTECT & CLEARFIL MAJESTY FLOW

E. Max B1 HT bonded with WARM CLEARFIL AP-X & CLEARFIL SE PROTECT

#biomimeticrestorativedentistry

#BAARD #overlay #Biomimetics #biomimeticdentistry #immediatedentinsealing #compressiondome #preservethebiorim #cerec #cadcamdentistry #cadcamdentists #tooth #teeth #dentistry #digitaldentistry #kuraraynoritake #clearfilseprotect #dentalphotography #dentalhealth #dentistrymyworld #dentistlife #dentistrylove #dentalgram #dentistsofinstagram #dentallabor #labtechnician #dentalclinic ...

Photos can only tell part of the story..... (crown replacement case)

Sometimes things look like they are easy when they are done well, I assure you this was an extremely difficult case & isolation situation....

The key I have found with difficult isolation cases is that skill will only get you so far, the rest is determination & perseverance.....

Above all faith that you have the right plan in place and things WILL work out - this is very difficult in the beginning when trying new things and something I’ve noticed the “masters” have, the confidence that things will work BECAUSE they have worked in the past..... the more success I’ve have had the easier it has become to have a steady hand and hang in there when the going gets tough.....

For those trying new things whether it’s advanced adhesive dentistry, Biomimetics, and/or rubber dam isolation - hang in there, we all crawl before we walk and then sooner than later we are running..... don’t try to do too much, start with attainable victories and celebrate those victories, share them with us, and use them as the platform to keep climbing towards confidence and excellence

Stay bonded 🤞

#BAARD #Biomimetics #biomimeticdentistry #immediatedentinsealing #compressiondome #preservethebiorim #cerec #cadcamdentistry #cadcamdentists #tooth #teeth #dentistry #digitaldentistry #kuraraynoritake #clearfilseprotect #dentalphotography #dentalhealth #dentistrymyworld #dentistlife #dentistrylove #dentalgram #dentistsofinstagram #dentallabor #labtechnician #dentalclinic ...

Still working on my anterior composite reconstructions....

Very old patient presented with broken distal filling with gross decay, the mesial filling was also chipped....

I did not want to chop down the remaining tooth structure for a crown so we opted for a Biomimetic reconstruction.....

Caries removal end points achieved (Alleman & Magne 2012) air particle abrasion followed by selective enamel etching, Clearfil SE Protect bonded followed by resin coating of the dentin. Ribbond placed over distal deep dentin......

I pre-op putty guide was taken and fabricated - essentially putty template made by copying lingual and incisal of existing and then a rough ideal lingual-incisal outline carved out of putty with a fine narrow shoulder diamond...... a thin layer of enamel replacing composite was placed on this putty and place on the tooth and bonded in place....

Next, a molar garrison matrix was used to construct the distal proximal enamel shell, this was then repeated on the mesial, the dentin was then replaced incrementally with Clearfil AP-X, enamel was replaced with Estelite Omega EA2 shade (in hindsight EA1 may have been a better choice, we’ll see when it rehydrates)

I am still working on my line angles and the mesial emergence was kind of tough, but overall I am pretty pleased with the overall result as was the patient. I hope you find some of these tips helpful.....

#biomimeticrestorativedentistry

#BAARD #overlay #Biomimetics #biomimeticdentistry #immediatedentinsealing #compressiondome #preservethebiorim #cerec #cadcamdentistry #cadcamdentists #tooth #teeth #dentistry #digitaldentistry #kuraraynoritake #clearfilseprotect #dentalphotography #dentalhealth #dentistrymyworld #dentistlife #dentistrylove #dentalgram #dentistsofinstagram #dentallabor #labtechnician #dentalclinic ...

“I’m really not a fan of crowns”, I said to the student shadowing me……..

This patient had presented with an open crown margin over a year ago, despite being open there was no decay on the X-Ray. I told the patient, as I do all patients with this scenario- that I find RCT teeth with crown’s with open margins particularly worrisome, especially zirconia or pfm - they are leaking into already heavily damaged and compromised teeth. A lot of the time the decay is not apparent at the margin and is obscured by the radio-opacity - therefore it continues to rot and by the time we get an indication - whether failed endo, decay finally large enough to be apparent, or crown breaks off - the prognosis becomes very poor……

In the patient’s defense there was a legit reason for putting off the treatment for a period of time….. the weekend before treatment date the patient developed throbbing pain. PA was inconclusive but CBCT revealed large lesion on distal root - retreat meant would be required….. but what is the best way to sequence this? We already a few hours reserved for the patient?

First, we called the endodontist to make sure the patient could be seen within 24 hours. I wanted to remove the crown and evaluate the situation first. The patient agreed. I cut off the zirconia crown quite easily with my Bien Air electric handpiece. I was very sad to see so much destruction underneath. There was not much too structure and the build up had quite a bit of leakage and decay. I was able to preserve most of the lingual axial wall and height but most everything else was down to the gum level.
(Caption Continued in pinned comment)

I will be discussing this case in detail tonight on BRD After Dark!

#biomimeticrestorativedentistry

#BAARD #Biomimetics #biomimeticdentistry #immediatedentinsealing #cerec #cadcamdentistry #cadcamdentists #tooth #teeth #dentistry ...

Patient presented with some intermittent cold sensitivity on lower left first molar......

From the look clinically and from the X-Ray it almost looks completely fine, I just treatment planned an OB Resin (should have caught the mesial fracture line and planned an MOB)

Well, once I opened it up things changed quickly, lots of cracks....

First major crack dealt with was under the MB cusp, next the mesial crack - thought I got it but final photo reveals the maybe it could have used a touch more.....

Last crack was the Buccal-Lingual - it was quite large, I successfully disconnected it in several places but it got about as deep as my comfort level - if you look closely you can see the channel I cut for it and later filled with Ribbond

Immediate Dentin Sealing with Clearfil SE Protect & Majesty Flow performed followed by Ribbond placement & Biobase construction with Clearfil AP-X

Restored Same Day with Katana Avencia A2 luted with Warm AP-X

I went with a low modulus hybrid composite block to help “nurse” this tooth along, FE studies have confirmed that low modulus materials act more as a stress absorber vs stress transfer of higher modulus materials

#biomimeticrestorativedentistry

#BAARD #composite #Biomimetics #biomimeticdentistry #immediatedentinsealing #compressiondome #preservethebiorim #cerec #cadcamdentistry #cadcamdentists #tooth #teeth #dentistry #digitaldentistry #kuraraynoritake #clearfilseprotect #dentalphotography #dentalhealth #dentistrymyworld #dentistlife #dentistrylove #dentalgram #dentistsofinstagram #dentallabor #labtechnician #dentalclinic ...