Get predictable results with immediate dentin sealing, powerful adhesives

The presentations feature Frank Milnar DDS, AAACD, speaking on two topics that naturally flow together: “Immediate Dentin Sealing and Contemporary Adhesive Strategies” and “Incorporating Minimally Invasive Concepts to Ensure Predictable Restorative Results.” Milnar agreed to answer a number of questions from Dental Tribune to give attendees a little better idea of what to expect from the sessions.

Would you provide brief overviews of your sessions?
Regarding “Immediate Dentin Sealing and Contemporary Adhesive Strategies,” today's dental practices must know when and how to use total etch, selective etch and universal self-etch adhesives.

I’ll provide easy-to-understand guidelines for each. Attendees will leave with an understanding of the technologies, greater knowledge about the benefits of immediate dentin sealing and a better understanding of why the adhesive layer is the most important layer of a restoration.

In “Incorporating Minimally Invasive Concepts to Ensure Predictable Restorative Results,” I provide information and tips that will help practitioners quickly select products and develop the techniques required to create minimally invasive injectable composite restorations and prevent sensitivity. Attendees will learn how the properties of composite resins affect their longevity — which is critical to the goal of maximizing lifelong preservation of as much natural tooth structure as possible.

I’ll also provide simple-to-follow explanations of the chemistry that creates adhesion — and the next generation of injectable composites, with a focus on understanding when and where to use them.

Have there been some recent advancements in immediate dentin sealing products or techniques? Do you cover these in your session?
Yes. First, most clinicians don’t know what “immediate dentin sealing” is. I would bet 95 percent have not heard of the concept. Brännström's hydrodynamic theory of 1966 showed that the movement of fluids in the tooth due to trauma promotes dentin sensitivity. Sealing exposed dental tubes prevents movement of fluid, thus reducing postoperative sensitivity. Immediate dentin sealing also protects the tooth from bacterial invasion. It’s often referred to as “sealing for healing.”

Cutting into deep, vital dentin creates a portal for bacterial invasion. Also, according to Dr. Franklin Tay, when cut dentin bleeds water — there can be a signigficant negative effect on the restorative bonding sequencce.

Writing about immediate dentin sealing in 2006, Pascal Magne advocates sealing the dentin at the time of the preparation appointment; then the enamel can be bonded at the final appointment of cementation.

How to you determine which new products or techniques you need to be using with your patients — and when?
That goes to adhesion. The adhesion layer is the most important layer in your restoration. Universal dentin bonding agents, or DBAs, are simpler, faster and employ easy-to-understand methods and techniques.

One example is VOCO’s Futurabond U (universal) dentin bonding agent. The challenge of determining which of these various products or techniques to use on the patient spills over to the next seminar, which gets into techniques connected to minimally invasive dentistry. The two go hand in hand. First, you have to have materials, adhesion and chemistry that correspond to smaller preparations. Then you need to know how to master the techniques.

Who should attend your sessions?
The entire staff. It’s helpful when the entire team understands the chemistry, the preparation, the indications, the contra-indications and the proper implementation of all these next-generation products.

If there’s just one or two core concepts you’d like attendees of your sessions to leave with, what are those?
When you pre-cure DBAs prior to impressioning, you don’t get collapse of the collagen fibers during cementation. Immediate dentin sealing is ideal for minimally invasive preps. Also you seal fresh-cut dentin on the spot, to eliminate the adverse effects of microbiology.

Adhesion, today — in any form — creates repairability. And that’s the new gold standard of our time: Preserve as much dentin and enamel as possible, with minimal trauma to the tooth. Immediate dentin sealing really promotes all of this.

Worth noting, too, in terms of other products offered by the sponsor, VOCO: There are various products that support immediate dentin sealing and adhesion by stabilizing the oral environment prior to and following restorative dentistry. An example from VOCO is Remin Pro, which has calcium phosphate fluoride and xylitol. VOCO Pro, Profluorid L and Profluorid Varnish also are great products to use with immediate dentin sealing and non-invasive dentistry.

Some might argue that “minimally invasive” and “maximum esthetics” can be a “one or the other” decision. Is that ever the case?
Not really. Everything you do has a consequence in dentistry. Short or long term. You decide which one it is. And then you employ the techniques, materials and chemistry that support being minimally invasive.

The good news is, for maximally esthetic results, we now have minimally invasive materials in flowable materials that can ensure we can still be esthetic at the same time. This is a new era. Minimally invasive dentistry is based on emerging science.

What are some of the newer products you’re using that make “minimally invasive” and “maximum esthetics” easier to mutually achieve?
We now have new flowable composites that have high fill rates, which means they are enduring. You can actually use these as universal composites for minimally invasive preparations. We can have a variety of opacities, translucencies and effects, which is to say “enamel effects” in a flowable syringe to achieve esthetics. This is the key to the whole thing. That’s why I’m really keen on these new flowables such as VOCO’s GrandioSO Flow.

There are two flowable types: heavy body and regular, depending on if you want the material to move or stay in place once put in the preparation.

How to you determine which new products or techniques you should be using?
The essence of this is for the dentist and the auxiliary to determine where you are in the sequence before you prepare.

The minimally invasive dentist understands the product and the chemistries and the preparation guidelines before he or she takes a handpiece and puts it on the tooth. The minimally invasive dentist will focus more on the enamel that can be reminerialized — and use that in the preparation instead of simply focusing on removal of decay and much of the enamel around it.

The minimally invasive dentist would stabilize the oral environment using a variety of the aforementioned products, such as Remin Pro or Profluorid, before starting the restorative sequence. Otherwise you are building in an undesirable environment that will decrease the longevity of your work. You must answer the basic question: Are you a physician who diagnoses? Or are you a surgeon who cuts? Those are big questions today. Are you going to be “proactive” or “reactive” in you mindset?

Ultimately, we want to avoid a repeat restorative cycle. We want to keep it minimal, so you can repair. We want to keep the repair small. If you’re orthodox, like a surgeon, every time you cut that tooth open again to replace, there’s more trauma to the tooth. You want to avoid that. If you conserve the tooth structure, you have more strength surrounding the tooth instead of more vulnerability.

Your sessions are sponsored by VOCO. How did you end up associated with the company, and what attracted you to its products and services?
When VOCO was first coming into this country, I was asked to try its provisional materials. That’s how I got introduced to German chemistry. I published an article about it, and that’s when I met the people from VOCO America. I was one of the first teachers in the U.S. for VOCO composites and provisionals. I felt that they had predictable chemistry. They had predictable products that were easy to understand.

I used the products predictably in my office with my assistants. And VOCO is strong on science. I can create artwork when there’s strong science supporting it. I am a very creative person. I rely on science to take care of itself (as with immediate dentin sealing). Then, I can mimic nature and create natural esthetics in a very predictable manner.

Any final thoughts?
I try to base much of my thinking on this simple question: “What technique, what preparation, what adhesion would you like in your mouth, doctor?” I don’t just teach for VOCO. There are lots of other companies with good products out there.

I cross-train myself on many of them. I don’t do detailed scientific analysis on everything. But I watch my assistants to see how rapidly they embrace and adapt to something — and how a product can help us work together.

VOCO’s Futurabond U, which is its newest launch, is an example. It does it all. It does all the chemistries. You can use one bottle for every clinical procedure. It’s one of many new products in this area in the marketplace.

That’s where the industry is today. Everything is universal. One bottle does it all. It’s better when your assistants understand the product, can inventory it — can bring it out and dispense it, knowing this is where we are in the preparation sequence. It’s better when they know when we’re ready for adhesion, whether there’s light or no light, whether we have zirconia or resin. These new products make that easier to accomplish.

I won’t claim a particular product is “the best.” But I’ll teach it to you so you clearly understand it — using the Socratic method of questioning and answering. Then, it’s up to you to decide.

In summary, these two courses really showcase “adhesion” as the Achilles’ heel of restorative dentistry.