Indirect and Direct Restorative Protocols - Caulk

Indirect and Direct Restorative Protocols 

PROSTHETICS 

CAULK 

PROFESSIONAL 

Handpieces 

Carbide Burs 

Impression Materials 

Ceramic Systems 

Resin Cements 

Bonding Systems 

Composite Materials 

Polishing Instruments 

A Supplement to a 

Montage Media Corporation Publication 

Supported by an unrestricted educational 

grant provided by DENTSPLY International.

Indirect and Direct Restorative Protocols 

Incorporating Contemporary 

Restorative Techniques 

The key to successful direct 

and indirect dental 

treatment lies in precise 

data capture and procedural 

excellence. Concepts 

in tooth preparation, a 

fundamental component 

of both direct and indirect 

restorations, continue 

to evolve in conjunction 

with advances in clinical 

techniques and increasing 

patient demand for conservative 

dentistry. 

Gregori M. Kurtzman, DDS 

Private practice, 

Silver Spring, Maryland. 

While material selection and treatment modalities 

continue to dictate the preparation design and amount of 

reduction required, contemporary 

instrumentation 

and materials have 

“The DENTSPLY 

family of products progressed as well, allowing 

dental professionals to 

gives the clinician an 

combine innovative technologies 

with traditional 

array of instruments 

and materials that techniques using an integrated 

family of restor- 

work seamlessly 

ative products. 

for any restorative 

Recent innovations in 

procedure.” 

material science and clinical 

instrumentation better 

enable one to monitor the 

degree of pressure being applied to the tooth surface and 

thereby preserve sound tissue structures whenever possible. 

Using contemporary bur systems to create an optimal 

preparation design with smooth undercuts and margins, 

such innovations enable optimal data capture and transfer 

to be predictably achieved. 

Principles & Practices: Indirect and Direct Restorative 

Protocols addresses tooth preparation considerations and 

techniques, as well as the clinical procedures associated 

with aesthetic crown-and-bridge dentistry and direct resin 

restorations. This publication represents a cohesive review 

of practical techniques and a dedicated family of restorative 

products that can be applied to everyday dentistry, 

allowing the clinician to deliver optimal restorative care as 

a matter of routine. ■ 

TABLE OF CONTENTS 

03 | Handpiece Selection for Optimal Results 

in Restorative Dentistry 

07 | Appropriate Bur Selection: Proper Tooth 

Reduction for Indirect Restorations 

09 | Predictable Tissue Retraction: Methods 

and Techniques 

11 | Accurate Impression Making: Material 

Selection and Clinical Considerations 

15 | Aesthetic Provisional Restorations: 

Considerations and Influences on 

Prosthetic Outcomes 

18 | Developments in CAD/CAM: Ceramic 

Materials and Techniques 

21 | Cementation Guidelines: Clinical 

Recommendations and Requisites 

23 | Aesthetic Finishing and Polishing: 

Techniques for Ceramic Restorations 

25 | Instrumentation and Bur Selection for 

Minimally Invasive Tooth Preparation 

27 | Direct Resin Procedures for Aesthetics 

in Anterior Restorations 

29 | Direct Resin Restorations: 

Considerations for Adhesive Bonding 

31 | Finishing and Polishing Composite Resin 

Restorations: Clinical Parameters 

© 2008 Montage Media Corporation. All rights reserved. 

1

› PRINCIPLES & PRACTICES 

Handpiece Selection 

for Optimal Results in 

Restorative Dentistry 

› Abstract: 

The dental handpiece is a 

mainstay in clinical practice. 

Numerous handpieces are 

available, and selecting 

among their various features 

can have a considerable 

influence on the restorative 

outcome. The Midwest ® 

Stylus ATC handpiece 

(DENTSPLY Professional, 

York, PA), developed through 

a close partnership between 

manufacturer and clinician, 

combines the features 

of air-driven and electric 

handpieces into a single 

instrument that provides the 

superior access, light weight, 

and comfort of the former 

with the power and efficiency 

of the latter. 

One of the most ubiquitous 

instruments in 

all of dentistry is the 

handpiece. Selecting the 

appropriate handpiece 

for any dental procedure solves many of 

the clinician’s concerns prior to his or 

her initiation of tooth reduction. The use 

of a handpiece that will address the full 

range of clinical applications is, therefore, 

critical to restorative success (Figure 1). 

The primary considerations when one is 

choosing a handpiece include: its power 

and torque (Figure 2), the cutting efficiency 

of the device, the access and 

visibility it requires, and the unit’s ergonomics 

(Figure 3). A handpiece with 

constant cutting speed and adaptive 

capabilities affords the benefits of a highpowered 

handpiece and a precision refining 

instrument. The Midwest® Stylus 

ATC (DENTSPLY Professional, York, 

PA) handpiece offers the unique ability 

to instantly adapt to increased loads by 

increasing the power of the handpiece. 

Selection of a device with a rigid bur 

suspension will offer superior precision 

control for the development of precise 

margins. Ergonomics also play a key role 

in the practitioner’s selection of an appropriate 

unit. As handpieces are used 

in virtually every aspect of dentistry, a 

lightweight, balanced unit such as the 

Stylus ATC will ensure operator comfort, 

improved tactile feel, and enhanced 

patient care. 

Visibility of the treatment site is important 

throughout care. Handpieces 

equipped with air and water spray not 

only aid in the cooling of the device but 

also help maintain a clear operating 

field for the operator, due to their small 

head size (Figure 4). 

In comparison to electric options, 

air-driven handpieces are lighter in 

weight and offer smaller head designs 

Dentistry and photography 

courtesy of David A. Little, DDS, 

San Antonio, TX. 

Figure 1. The use of a 

powerful, hybrid air- and 

electric-driven handpiece 

provides increased power 

and torque, with enhanced 

effi ciency for any type of 

tooth reduction. 

Removal of preexisting 

restorations is enhanced 

with a high-powered 

handpiece operating at 

a constant speed. 

3

Table. Combining Technologies: 

Air- and Electric-Driven Handpiece 

For the fi rst time ever, air-driven and electric 

handpieces are fused into a single handpiece 

system that delivers the power and effi ciency of 

an electric unit without sacrifi cing the superior 

access, lighter weight, and comfort of an airdriven 

handpiece. 

With activation of the rheostat, the Stylus 

ATC system: 

■ Accelerates to an optimal cutting speed. 

■ Continually monitors bur load. 

■ Automatically adjusts torque to maintain 

peak power. 

■ Limits speed when the bur is not under 

load to minimize potential wear on the 

handpiece bearings. 

Figure 2. A handpiece with powerful torque and adaptive power facilitates 

an effi cient, smooth preparation. 

Handpiece water spray assists 

in cooling the bur and area 

being cut, and fl ushes away 

debris, improving visibility as 

the tooth is prepared. 

Figure 3. Handpiece size and weight, as 

well as the size of the user’s hand and 

his or her preferred position, should be 

considered when purchasing a high-speed 

handpiece for improved tactile feel during 

tooth reduction. 

4

“When using the Stylus ATC, the 

automated torque control feature 

eliminates the need for excess pressure 

during tooth reduction.” 

David A. Little, DDS 

Private practice, San Antonio, TX. 

Design Innovations of the Stylus ATC 

#4 The control source adjusts 

the torque over 700 times a 

second for a seamless delivery 

of performance, consistently 

maintaining peak power even 

under heavy loads. 

#1 A rigid suspension system allows for 

enhanced control for precise margins. In addition, 

the Midwest ® Stylus ATC handpiece 

system offers exceptional visibility, access, 

and maneuverability with both mini and 

midsized heads. 

#2 An atomized 

cooling spray offers 

reliable cooling, while 

a fl ushing spray 

minimizes debris 

to provide greater 

visibility. 

#3 The Midwest ® 

Stylus ATC 

features brilliant 

fi ber optic 

illumination. 

#5 Integrated coupler and 

tubing continually monitors 

bur speed and works with the 

control source to maintain 

performance and effi ciency. 

5

Figure 4. The small head of the Stylus ATC (DENTSPLY Professional, 

York, PA) enables visualization of the preparation site. 

A 

Figure 5A. The cutting effi ciency of the bur can be optimized by the 

Stylus ATC handpiece. 5B. Note the smooth tooth preparation 

achieved with minimal structural removal. 

B 

Table. Practical Tips for Using the Midwest ® Stylus ATC 

Tip 

Rationale 

Avoid excess 

pressure on the 

bur during tooth 

preparation ; there 

is no need to feather 

Lubricate and sterilize the handpiece 

prior to use in the operatory 

and between patients. 

Review proper 

air and water 

spray output 

prior to use. 

Verify that the bur 

is fully seated into 

the handpiece 

chuck. 

The device’s adaptive torque 

control reduces the amount of 

pressure needed for enhanced 

patient control and clinician 

comfort. 

Proper sterilization prevents 

cross contamination and potential 

health hazards, and it prolongs 

the life of the handpiece. 

A fi ne mist of water should be 

expressed using the unit, not 

a steady stream; increase the 

coolant air as needed until the 

desired mist is achieved. 

Full seating ensures most 

safe and effective use of the 

handpiece. 

for superior access in the oral cavity. The 

selection of an appropriate type of handpiece 

is dependent on the individual clinician 

and his or her practice. A handpiece 

system with an air-powered adaptive control 

combines air and electric control in a 

single unit (eg, Midwest® Stylus ATC, 

DENTSPLY Professional, York, PA) to 

provide the power and efficiency of electric 

handpieces, without sacrificing the 

superior access, lighter weight, and familiar 

comfort of conventional high-speed 

units (Table). 

Developed through a unique partnership 

between industry manufacturers and 

professionals, this instrument is the culmination 

of dental handpiece technology 

and unifies the leading features of previous 

electric and air-driven devices. As optimizing 

chairtime remains a key consideration 

motivating dental professionals, instrumentation 

such as the Stylus ATC thus 

represents a valuable addition to the clinical 

armamentarium used for proper tooth 

preparation and finishing (Figure 5). ■ 

6

››Principles & Practices 

Appropriate Bur Selection: 

Proper Tooth Reduction 

for Indirect Restorations 

››Abstract: 

The continued evolution of 

dental adhesives and resin 

cements has modified the 

way clinicians approach the 

tooth preparation required 

for indirect restorations. 

While the biomechanical, 

micromechanical, and chemical 

properties of these adhesives 

have increased the potential for 

conservative tooth preparation, 

the instrumentation used to 

create such preparations 

must still perform the 

desired tooth reduction. This 

presentation highlights the role 

of proper bur selection in fixed 

prosthodontic care. 

The biomechanical, micromechanical, 

and chemical properties 

of contemporary dental 

adhesives and resin cements 

enable practitioners to adapt a 

more conservative approach to tooth preparation. 

In each such instance, the type of 

restorative procedure being performed will 

dictate the clinician’s choice of appropriately 

sized and shaped instrumentation. 

■ ■Straight, flat-end burs—Multi- 

Prep carbides (DENTSPLY Professional, 

York, PA) facilitate effective 

removal of existing composite, metal, 

or porcelain restorations. Their 

cross-cut shape ensures removal of 

debris from the preparation site and 

requires less force to achieve the desired 

cutting action. 

■■Tapered, dome-end carbides—This 

MultiPrep shape enables rapid, efficient 

removal of composite resin, 

porcelain, and natural tooth structure 

and produces the divergent 

preparation walls required for allceramic 

crowns and aesthetic intracoronal 

restorations. 

■ ■ Flame-shaped, safe-end burs— 

In order to reduce the potential 

of injury to gingival tissues, some 

Midwest® burs such as the Flame 

include a smooth, non-cutting end 

that is less likely to cause damage or 

irritation when used at the gingival 

margin. 

In consideration for the varying tooth 

sizes among pediatric and adult patients, 

as well as the occlusal clearances that differ 

among younger and geriatric patients, 

it is also important to select a bur with the 

right shank length and style. Midwest® 

MultiPrep Burs (DENTSPLY Professional, 

York, PA) are available in numerous 

sizes and shapes to ensure the right option 

is available for the anatomical requisites of 

a given patient (Figure 1). 

When treating previously restored 

dentition, care should be taken to select 

Figure 1. Prior to initiating tooth reduction, care should be taken to 

ensure that the bur is properly secured in the handpiece chuck. 

Figure 2. Midwest ® dome-shaped crosscut burs facilitate removal of 

amalgam or other existing restorative materials and allow for easier 

entry into the tooth than flat-end burs. 

7

››“The Midwest metal-cutting burs have made 

removal of old crowns a quicker, less stressful 

experience, and they efficiently cut through whatever 

metal is used to fabricate the restoration.” 


Private practice, Silver Spring, MD. 

Figure 3. Cross-section view of the divergent walls, created with the tapered, 

round-end bur (MultiPrep, DENTSPLY Professional, York, PA), 

for the cavity preparation. 

Figure 4. Straight, flat-end burs can be utilized to finalize the walls and 

floor of the preparation. Tapered burs create divergent walls with 

rounded internal line angles. 

Table. Tracking Individual Bur Usage 

It is important to track use on a bur-by-bur basis to reduce 

premature disposal or overuse of burs. Overuse may 

result in: 

■■ Instrument separation; 

■■ Excessive heat generation; 

■■ Damage to the handpiece; and 

■■ Potential patient injury. 

Sterilization is also critical using a Cresent® Germicide Tray (DENTSPLY 

Rinn, Elgin, IL) and Bur Caddy / Bur Block (DENTSPLY Professional, 

York, PA) to safely disinfect bur systems with glutaraldehyde- and 

phenol-based disinfectants. These caddies allow burs to be: 

■■ Individually sterilized; 

■■ Cleansed using a hands-free approach to prevent 

contamination; 

■■ Kept separate from other burs in the kit; and 

■■ Easily restocked following autoclaving. 

a bur and torque speed that will remove 

the existing restoration without 

impinging on the underlying tooth 

structures (Figure 2). Copious irrigation 

is also paramount to keeping the 

bur cool, prolonging its use (Table), 

and improving its cutting efficiency. It 

also ensures that the clinician can view 

the structures being removed, thereby 

reducing the potential for excessive 

tooth reduction. Once the preexisting 

restoration and carious structures have 

been removed, it is imperative to create 

divergent angles to facilitate retention 

of the definitive indirect restoration or 

convergent preparation walls to retain 

the restoration (Figure 3). Application 

of a cross-cut bur should only be implemented 

if additional gross reduction 

is required for extensive preparation 

designs (Figure 4). Once the desired 

preparation design has been achieved, 

the burs should be cleaned and carefully 

returned to the bur kit. n 

8


Predictable 

Tissue Retraction: 

Methods and Techniques 


Accurate data transfer 

between the clinician and 

ceramist is critical for any 

indirect restorative procedure. 

A precise retraction technique 

is necessary to allow for 

reliable information transfer 

during impression making. 

Since different surfaces 

(eg, gingival tissues, dentin, 

enamels, and metals) have 

such varied moisture content, 

friction resistance, and surface 

tensions, clinicians should also 

use a reliable methodology 

in which each surface can be 

predictably optimized prior to 

impressing for the best 

possible results. 

S 

uccessful placement of a fixed 

dental prosthesis requires the 

clinician to accurately communicate 

the details of the patient’s 

intraoral environment to 

the laboratory technician. To capture this 

information, the practitioner must first 

control systemic factors (eg, periodontal 

health, crevicular fluid, inflammation) at 

the restorative site, create a proper margin 

design, and then make an impression of 

the required preparation. Additionally, he 

or she must displace or remove the gingival 

tissues that prevent the subsequently 

applied impression material from gaining 

access to a subgingival finish line. 

Care should, therefore, be taken to utilize 

proper methods of exposing subgingival 

finish line and to select a retraction cord 

that is resistant to fraying or tearing and that 

will not adhere to the dental tissues or the 

impression material. Although some cords 

are available in a pre-impregnated format to 

assist in hemostasis, it is generally advisable 

to utilize a hemostatic agent in order to limit 

the presence of fluids during impression 

capture and to ensure a clear, detailed margin 

(Figure 1). Localized anesthesia may be 

indicated for patients who require it, and 

can be applied to one or several periodontal 

pockets in a needle-free application. 

Retraction Cords and Pastes 

When employing retraction devices, the 

primary concern is maintenance of clear 

finish lines and margins in order to ensure 

their capture and transfer to a detailed impression. 

Whether using a cord or paste retraction 

material (Table), proper packing 

also allows the impression material to flow 

subgingivally, which enables the soft tissue 

topography and prepared hard tissues 

to be properly recorded (Figure 2). When 

using retraction cord techniques, the clinician 

should: 

■■ 

Create a lateral space of >0.5 mm; 

■■ Take care when using a heavy/rigid 

tray material to avoid locking an 

impression in undercuts; 

■■ Delay the impression procedure if 

adequate hemostasis cannot be 

achieved; and 

■■ Maintain proper moisture control 

subgingivally. 

Figure 1. The retraction cord should be placed carefully to avoid soft 

tissue trauma and ensure precise marginal detail in the impression. 

Figure 2. Correct positioning of the retraction cord should be verified 

prior to impression making. 

9

››“The B4 Surface Optimizer helps me 

work faster by adapting each surface 

and readying the tissues for precise 

impression capture.” 

David Parker, DDS 

Private practice, Smithtown, NY. 

Figure 3. The cord is removed immediately prior to taking the impression, 

with caution exercised to avoid tearing the cord or damaging the 

soft tissues, which will cause sulcular bleeding and obscure marginal 

detail in the resulting impression. 

Figure 4. Use of the B4 ® Pre-impression Surface Optimizer (DENTSPLY 

Caulk, Milford, DE) coats the hard and soft tissue surfaces to allow 

the syringed wash material to pass more easily over and around the 

surfaces to be impressed. 

Table. Achieving Predictable Tissue Retraction: Treatment Rationale 

Method Rationale Considerations 

Cords 

n Enhanced degree of mechanical displacement 

n Available with or without a hemostatic agent 

n Available in a variety of types and thicknessesto 

accommodate a range of procedures 

n Care must be taken to avoid soft tissue trauma 

n Often requires the use of local anesthesia 

n The ability to absorb hemostatic agents must 

be taken into account during cord selection 

Pastes 

n Completely atraumatic to soft tissue 

n Local anesthesia is not required 

n Expeditious application may be advantageous 

in multi-abutment situations 

n Vigorous rinsing is required for removal 

n Does not work well in narrow or shallow sulci 

n Does not provide the same degree of displacement 

as the cord technique 

Insertion and removal of the retraction 

cord should be performed 

with great care to avoid inflicting 

trauma to the soft tissue and ensure 

optimal patient comfort (Figure 3). 

Use of a pre-impression surface optimizer 

(B4®, DENTSPLY Caulk, 

Milford, DE) will further ensure 

predictable marginal accuracy and 

precise data capture by coating the 

hard and soft tissues and allowing 

the wash material to better flow over 

and around them for improved accuracy 

(Figure 4). 

The highly wettable Aquasil Ultra 

Smart Wetting® Impression Material 

(DENTSPLY Caulk, Milford, DE) is designed 

to aid the clinician in maintaining 

adequate moisture control during 

the process. When using this hydrophilic 

material, the preparation area should be 

moist, but pooled liquid should first be 

removed with an evacuator to avoid the 

creation of an excessively moist field. 

When conducted accordingly, an impression 

material can thus flow subgingivally 

and capture the details of the tooth 

and ensure proper integration with the 

periodontal tissues. In fixed prosthodontic 

care, where the smallest subtleties have 

a considerable impact on the outcome of 

treatment, proper tissue management 

and tissue retraction are critical. n 

10


Accurate Impression Making: 

Material Selection and 

Clinical Considerations 


Correct impression capture 

is paramount to overall 

restorative success. Clinicians 

are constantly challenged to 

provide clear margins free 

from tears and voids in order 

to allow multiple pours and 

accurate reproduction of the 

intraoral environment within 

the laboratory. Communication 

is enhanced by the use of 

predictable materials that 

optimize this data transfer 

while creating a simplified, 

systematic approach designed 

for success. 

The impression remains the 

technician’s most valuable 

tool when developing an indirect 

restoration. Properly 

fitting restorations can only 

be fabricated if the dental laboratory is provided 

with a precise replica of the existing 

intraoral condition. Impression making, 

therefore, can be considered the most critical 

technique required for data transfer. A 

predictable execution of this procedure is 

subsequently required to ensure that the 

first impression captured is as accurate and 

clear as possible (Figure 1; Table). 

As a precursor to the impression procedure, 

use of B4® Pre-Impression Surface 

Optimizer (DENTSPLY Caulk, Milford, 

DE) can equalize the surface tension of 

multiple substrates (eg, tooth, gingiva, 

implant), thereby allowing the impression 

material to achieve the desired flowability 

and detail. Voids and bubbles will be minimized 

for a more practicable impression, 

improving model surface details. A durable 

material such as Aquasil Ultra Smart Wetting® 

Impression Material (DENTSPLY 

Caulk, Milford, DE) should then be selected 

to avoid tears, distortions, pulls, or drags 

in the impression itself. Its ability to adapt 

to tooth structures and the below the sulcus 

enables the practitioner to capture the 

details of the intraoral environment. Use of 

Aquasil Ultra Smart Wetting® Impression 

Material, with its favorable viscosities and 

working time, ensures that the clinician is 

able to maintain and capture well-defined 

margins during the impression procedure 

(Figures 2 and 3). It can also be delivered 

via 50 mL cartridge, the digit® targeted delivery 

system (DENTSPLY Caulk, Milford, 

DE), or DECA 380 mL dynamic mixing 

machine cartridge (DENTSPLY Caulk, 

Milford, DE) according to the preference 

of the clinician. 

Once the impression is made to the clinician’s 

satisfaction, it must demonstrate 

Figure 1. Aquasil Ultra Smart Wetting ® Impression Material (DENTSPLY 

Caulk, Milford, DE) can be used for all indirect restorative procedures. 

Figure 2. The dual-cord technique provides gingival retraction and 

hemostasis at the treatment site during impression making. 

11

›› 

“By combining the use of the B4 Surface Optimizer and 

the Aquasil Ultra Smart Wetting Impression Material, 

even ultra thin margins are maintained, allowing multiple 

pours for increased communication with the laboratory.” 

Robert G. Ritter, DMD 

Private practice, Palm Beach Gardens, FL. 

Table. Clinical Considerations for Impression Capture 

Clinical Requisite 

Adequate 

gingival health 

Biologic space 

requirement 

Rationale 

Gingival inflammation may complicate hemostasis and moisture control; gingival 

assessment and transfer can also be compromised. Impressions should not be taken 

if inflammation cannot be controlled. 

Approximately 2 mm of distance is required between the restoration’s finish line and the 

alveolar crest to maintain the crestal bone level in comparison to the gingival margin. 

Appropriate 

tissue retraction 

Regardless of the specific technique selected, it is advisable to create a lateral space of 

approximately 1 mm and an apical extension beyond the finish line of approximately 1 mm. 

Bilateral cheek 

retraction 

Patients may bite asymmetrically if the cheek is retracted on one side only as the 

impression is taken; this technique may help to ensure proper centric occlusion is captured. 

Proper patient 

education 

Once the tray is seated, patients should refrain from any movements that could shift the 

position of the tray, thereby distorting the impression maintained. 

Figure 3. The impression is made using Aquasil Ultra Smart Wetting ® 

Impression Material (DENTSPLY Caulk, Milford, DE). Note its precise 

marginal detail. 

Figure 4. A centric bite registration should be captured for precise 

laboratory communication. 

12

››“Data transfer is critical to the fabrication of any restoration; 

use of a reliable impression material like Aquasil Ultra Smart 

Wetting allows development of models with precise 

margins devoid of undercuts and voids.” 

Nelson Rego, CDT 

Laboratory Technician and Owner, Rego Smiles, Santa Fe Springs, CA. 

Figure 5. A repeatable impression-making technique and Aquasil Ultra 

(DENTSPLY Caulk, Milford, DE) facilitate the fabrication of accurate 

restorations in the dental laboratory. 

Figure 6. Postoperative appearance demonstrates harmonious integration 

that was only possible due to precise data transfer and thorough 

communication with the laboratory. 

››Achieving Predictable Impression Capture 

■■ 

■■ 

■■ 

■■ 

■■ 

Ensure proper tissue retraction and hemostasis. 

Properly dry the prepared tooth structures prior 

to impression capture (but do not desiccate). 

Apply B4 ® Pre-Impression Surface Optimizer to the 

prepared tooth, then air-thin, taking care not 

to rinse or dry the applied material. 

Fully load Aquasil Ultra Smart Wetting ® Impression 

Material prior to syringing Aquasil Ultra wash 

material around the final preparations. 

Begin expressing Aquasil Ultra wash material 

at the tissue margin and then cover the entire 

tooth surface. 

■■ 

■■ 

■■ 

■■ 

When coverage of the marginal area is complete, 

proceed coronally and circumferentially, keeping 

the syringe tip in the material as it is expressed. 

Align the First Bite ® impression tray parallel to the 

occlusal plane for proper vertical seating. 

Seat the impression tray using firm, steady pressure 

until Aquasil Ultra Smart Wetting ® Impression 

Material overflows from the tray within approximately 

1 minute from the beginning of syringing. 

Verify proper marginal detail prior to 

forwarding to the laboratory. 

adequate dimensional stability to withstand the subsequent 

transfer to the laboratory prior to model fabrication. This 

required dimensional stability, a defining characteristic of 

Aquasil Ultra, will also influence the technician’s ability to 

produce multiple refractory models following delayed pouring. 

Additional occlusal data can be sent to the laboratory in the 

form of a rigid bite registration (eg, Regisil® Rigid, DENTSPLY 

Caulk, Milford, DE) (Figure 4). To ensure that the occlusal 

data being sent is clearly communicated, excess material that 

extends onto the soft tissue region or to the height of the tooth 

contour should be removed using a scalpel blade or sharp scissors 

when seating the registration onto the model. 

Impression materials and techniques can vary depending 

on the type of restoration or clinical environment. Thus, it is 

beneficial that materials such as Aquasil Ultra and repeatable 

impression-making techniques enable dental professionals to 

deliver a well-integrated restoration for either the anterior or 

posterior region (Figures 5 and 6). n 

13


Aesthetic Provisional Restorations: 

Considerations and Infl uences 

on Prosthetic Outcomes 

› Abstract: 

Provisionalization is one of 

the most critical steps in 

indirect restoration. During 

this stage, the final diagnostic 

requirements are identified; 

patient function, expectations, 

and aesthetics are evaluated; 

and the clinician can ensure 

development of an optimal 

restoration by evaluating the 

patient during temporization. 

Long-term provisionalization 

as facilitated by a wearresistant, 

durable material 

such as Radica ® (DENTSPLY 

Prosthetics, York, PA) allows 

the clinician to assess critical 

aspects of the patient’s 

condition prior to delivery of 

the definitive restorations. 

Provisional restorations are 

essential in maintaining 

the health, aesthetics, 

and function of the 

patient during restorative 

therapy. The provisional restoration 

offers both dental patients and professionals 

an opportunity to evaluate 

the proposed restorative contours, 

length, and function of the definitive 

restoration (Figures 1 and 2). Serving 

as the patient’s “test drive” of the 

final restoration, a Radica® provisional 

(DENTSPLY Prosthetics, York, PA) 

will allow proper soft tissue maintenance 

and sculpting of the papillae 

(Figures 3 and 4). This biocompatible, 

light-cured provisional crown and 

bridge material allows the patient to 

enjoy a natural apperance and function 

during long-term temporization 

periods, where many provisional 

materials (eg, acrylics) lose their ability 

to withstand the forces of the intraoral 

environment. The favorable 

wear resistance of Radica® considerably 

reduces the risk of provisional 

perforation during temporization and 

risk of saliva, bacteria, and thermal 

irritants from compromising the intended 

treatment outcome. 

Due to their shape, color stability, 

and aesthetics, Radica® provisional 

restorations also enable the practitioner 

to establish expectations for patient 

outcomes (Table) and aid in the diagnostic 

phase of treatment. The user’s 

ability to efficiently layer enamel and 

dentin materials, in combination with 

unique characterizations, provides the 

patient with natural-appearing provisional 

restorations during this critical 

interim period. 

In order to ensure the patient maintains 

full function during the temporization 

phase of treatment, occlusal 

adjustments should be performed 

prior to cementing the provisional 

restoration. Next, the Radica® provisional 

should be refined with carbide 

Figure 1. Case 1. Preoperative view demonstrates malalignment and 

disharmony in the anterior aesthetic region. 

Figure 2. The use of an aesthetic provisional system allowed the 

patient to view the anticipated results and harmony while enabling 

the clinician to evaluate function, shape, and alignment. 

15

› “High-quality provisional restorations 

such as Radica are 

critical to my ability to deliver 

a predictable aesthetic result 

for my patients.” 

Mike Malone, DDS 

Private practice, Lafayette, LA. 

Figure 3. Case 2. Note the excessive crowding, malalignment, and 

gingival height discrepancies evident preoperatively. 

Figure 4. Radica ® temporaries allowed the clinician to evaluate the 

anticipated restorative positioning and gingival contours following initial 

crown lengthening. 

Table. Benefits of Radica ® Provisional Restorations 

Characteristic 

Strength 

Aesthetics 

Ease of Use 

Polishing 

Benefit 

With a wear resistance comparable to defi nitive 

composite materials and a strength of 165MPa, 

Radica ® is the most durable provisional system on 

record in today’s market. 

Radica ® offers a variety of shades and dimensional 

stability for enhanced aesthetics, establishing 

expectations for patient outcomes. 

Radica ® is simple to mix and repair, reducing 

chairtime. If needed, Radica ® provisionals 

may be relined with Integrity ® Temporary 

Crown and Bridge Material or Triad ® VLC 

Provisional Material. 

The material possesses a high polishability for a 

plaque- and stain-resistant surface. 

burs such as Midwest® Esthetic Finishing 

Burs (DENTSPLY Professional, York, PA), 

and polished as necessary with a PoGo® 

Diamond Micro-Polisher (DENTSPLY 

Caulk, Milford, DE). It is then imperative 

to select a temporary cement material 

(eg, Integrity® TempGrip, DENTSPLY 

Caulk, Milford, DE) that has the flow and 

consistency for optimal seating, low film 

thickness, and high strengths for reliable 

retention, and cohesive setup to enable 

thorough cleanup. 

As with any cemented restoration, 

care should be taken to clean the gingival 

margins following seating to prevent 

potential irritation of the soft tissues and 

even potential subgingival post-procedure 

infection. Gradual pressure should be used 

to seat the provisional restoration, and 

may be accompanied by a gentle rocking 

motion for optimal security. Care should 

be taken to avoid moving the restoration 

during the removal of excess cement. Once 

properly seated, adjustments may be made 

to the provisional as needed. ■ 

16


Developments in CAD/CAM: 

Ceramic Materials 

and Techniques 

› Abstract: 

Advances in CAD/CAM technology 

have resulted in zirconia-based 

ceramic materials that offer 

exceptional strength, fracture 

toughness, and biocompatibility. 

The CAD/CAM process provides 

immediate data capture and accurate 

fit in the prosthesis, and it enables 

the dental technician to focus 

on aesthetics during restoration 

fabrication. Use of predictable 

clinical and laboratory techniques 

with CERCON ® Zirconia restorations 

offers dental professionals and their 

patients a high-strength, predictable 

restorative solution. 

The evolution of dental 

technologies such as 

CAD/CAM and zirconia 

ceramics continues to 

expand the restorative 

alternatives available to the contemporary 

dental patient. The biocompatibility, 

strength, and durability of 

zirconia restorations fabricated via 

CAD/CAM makes them attractive 

for anterior and posterior indications. 

Although different philosophies may 

exist regarding the details of metalfree 

restoration preparation (eg, where 

to trim the occlusal edge), goals 

such as minimal, uniform reduction 

(Figures 1 and 2) and replication of 

the facial contours of the natural 

dentition remain critical in achieving 

aesthetic, lasting restorations. 

While these treatment objectives may 

have remained relatively fixed, the technology 

surrounding these procedures 

has advanced significantly with the 

introduction of the CERCON® system 

(DENTSPLY Prosthetics, York, PA), offering 

clinicians and laboratory technicians 

several opportunities to provide excellent 

patient care and superior aesthetic results 

(Table). Its modular offerings of CER- 

CON CAD design (Eye and Art) and the 

CERCON CAM (Brain) milling component 

enables users to add specific service 

offerings as warranted by business growth. 

CERCON® provides considerable flexibility 

in material selection as well. This 

Figure 1. A chamfer margin enables effi cient scanning using CERCON ® 

(DENTSPLY Prosthetics, York, PA). Buccolingual reduction of 0.8 mm to 

1.5 mm and 1.5 mm of occlusal reduction using a #7345 bur (Multi- 

Prep, DENTSPLY Midwest, York, PA) is optimal to ensure strength 

and prevent fracture. 

Figure 2. Following fabrication of the CERCON ® Zirconia substructure, 

the aesthetic porcelain layer is applied. Ceramco ® PFZ 

porcelains are then applied to deliver natural-looking results. 

18

› “The use of CERCON Zirconia frameworks allows 

clinicians the necessary load-bearing capability 

(>1,300 MPa) required to support both single-unit 

and long-span restorations.” 

David A. Little, DDS 

Private practice, San Antonio, TX. 

CAD/CAM system has the ability to mill 

all-ceramic zirconia restoration copings, 

as well as to mill a new polyurethane 

material, CERCON Base Cast, and then 

burn it out to fabricate PFMs conventionally. 

Dental restorations from systems 

such as CERCON® not only produce 

exceedingly accurate scans and digital 

models—virtually matching the 

patient’s natural intraoral morphology—but 

they also allow clinicians and 

technicians to provide faster service, 

Benefits of CERCON ® 

■ Accuracy—Fast, precise CAD 

scans to 10 µm with the CERCON® 

Eye laser scanner. 

■ Aesthetics—The natural translucency 

of CERCON® Zirconia provides 

an excellent aesthetic foundation, 

which is further enhanced with 

the fluorescence of Ceramco® 

PFZ porcelain. 

■ Performance —At over 1,300 MPa 

of flexural strength, CERCON® 

crowns and bridges have a higher 

fracture resistance than other allceramics 

and are suitable for anterior 

or posterior restorations up to 47 mm 

in length. 

■ Versatility—Offers dental laboratories 

versatility with Compartis, an 

outsourcing service, and CERCON® 

Cast, a resin block for milling PFM 

and other frameworks. 

■ Simplicity—CERCON® restorations 

are cementable or bondable 

and use the same conservative tooth 

preparation as PFMs. 

■ Confidence—Proven to withstand 

the test of time with over 

10 years of clinical success and a 

seven-year warranty against zirconia 

framework breakage. 

Figure 3. Translucent characterizations 

are then applied. 

Figure 4. Using an aesthetic layering 

technique with Ceramco ® PFZ porcelains, 

lifelike results are achieved. 

Figure 5. Preoperative view of failing 

PFM crowns that require replacement. 

Figure 6. View of the aesthetic CERCON ® 

crowns postoperatively, demonstrating 

harmonious integration. 

19

› “A distinct chamfer or rounded shoulder, very similar 

to a PFM preparation, enables effi cient scanning of my 

preparation and ensures the proper fi t of my CERCON 

Zirconia restorations.” 

Lou Graham, DDS 

Private practice, Chicago, IL. 

› Protecting Your Investment 

All-ceramic restorations offer superior 

aesthetics and represent a signifi cant investment 

on the part of the patient. Bruxism 

following treatment can cause fracturing, 

resulting in a failed restoration 

and the need for additional treatment. 

iNterra INoffi ce Nightguard (DENTSPLY 

Caulk, Milford, DE) can help protect the 

investment by: 

■ Providing a comfortable fi t to ensure 

patient compliance; 

■ Cushioning the teeth to prevent 

damage to the restoration; 

■ Providing wear resistance to ensure 

that the restorations will remain 

protected for many years; and 

■ Enabling a single-visit, in-offi ce solution 

that protects the patient’s new smile. 

With more than 45 million patients affected 

by bruxism, prescribing an iNterra 

INoffi ce Nightguard (DENTSPLY Caulk, 

Milford, DE) nightguard represents a clear 

long-term benefi t to the longevity of the 

restorations and the health of the patient. 

Nightguard images appear courtesy of Dr. Mike Malone, Lafayette, LA. 

to the benefit of both dental patient and professional. The 

development of complementary material technologies 

(eg, zirconia) has furthered the benefit of CAD/CAM to 

the dental field by ensuring long-lasting, durable results 

in all-ceramic restorations. 

Accurate preparation and impression taking are still 

required of the clinician to ensure accurate scanning by 

the selected CAD/CAM system. Precise fit of the final 

restoration and the artistry of the laboratory technician 

are also necessary to develop natural aesthetics (Figures 

3 through 6). The benefit of CAD/CAM technology is 

that it allows these professionals to dedicate more time to 

their art and their practice, while providing strong, aesthetic 

results faster. ■ 

20


Cementation Guidelines: 

Clinical Recommendations 

and Requisites 

› Abstract: 

Cementation of an indirect 

restoration involves numerous 

variables that include the 

luting material itself and the 

clinical technique used to seat 

the veneer, crown, bridge, 

or inlay/onlay. Composite 

resin cements are often used 

in conjunction with dental 

adhesives and chemically 

bond to numerous restorative 

materials, facilitating their 

adaptation to a properly 

conditioned tooth surface. This 

presentation discusses a series 

of considerations and clinical 

requisites that can aid the 

practitioner in this important 

phase of treatment. 

In fixed prosthodontics, the clinician’s 

ability to achieve an aesthetic, 

functional outcome depends 

on a variety of factors that 

include the cementation protocol. 

The luting cement used in such procedures 

has to possess high compressive 

and tensile strengths in addition to serving 

as an adherent between the natural 

tooth structures and the selected restorative 

material. Among numerous other 

favorable characteristics of an ideal cement 

are its biocompatibility, radiopacity, 

ease of delivery (eg, handling, working 

time), and low film thickness. For 

their part, resin cements are categorized 

as one of the following based on their activation 

mechanism: 

■ Light-cured: Recommended for indirect 

ceramic or composite restorations 

less than 1.5 mm in thickness; 

■ Dual-cured: Ideal in porcelain veneers, 

composite veneers, and other 

indications in which light penetration 

is limited to 1.5 mm to 2.5 mm 

through a dental restoration; 

■ Chemically cured: Indicated for restorations 

(eg, all-ceramic crowns, metal 

restorations, intracoronal restorations 

greater than 2.5 mm in thickness) that 

will not transmit light upon seating. 

Care should always be taken to ensure 

that the cement’s shade is compatible with 

the desired restoration upon seating of a 

ceramic restoration (Figure 1). An ideal 

resin cement will possess strong adhesive 

properties and marginal integrity, and will 

protect against marginal microleakage (see 

Sidebar). Furthermore, its flow will be defined 

by the height and taper of the preparation; 

the higher and more cylindrical the 

preparation, the less cement will escape, 

and a greater cement line will be present. 

Once the fit of the ceramic restoration 

has been confirmed and its intaglio surface 

has been treated, the prepared teeth should 

be conditioned (Figures 2 and 3). Today’s 

total-etch and self-etch adhesives simplify 

the seating appointment by combining 

steps (ie, etching, priming, bonding) previously 

involving multiple components. If the 

total-etch technique is selected, the clinician 

Figure 1. Shade selection of the resin cement may signifi cantly affect 

the fi nal shade of all-ceramic restorations (Courtesy: D. Greenhalgh, Mill 

Creek, WA). 

Figure 2. Once the tooth is conditioned, the interior of the ceramic restoration 

should be treated with a silane coupling agent to improve adhesion 

and ensure a durable bond. 

21

› “SmartCem2 is a valuable addition to my practice 

because of the effi ciency and time savings it affords me 

as well as my patient during the seating appointment.” 

Ronald A. Feinman, DMD 

Private practice, Atlanta, GA. 

Figure 3. A coat of the resin cement (ie, SmartCem2, DENTSPLY 

Caulk, Milford, DE) is applied to all surfaces that will contact the prepared 

tooth to eliminate any voids that may occur during the seating of 

the restoration (Courtesy: R.A. Feinman, Atlanta, GA). 

Figure 4. A tack cure of the cement can often allow the clinician to 

remove gross excess prior to fi nal curing of the luting cement without 

dislodging the restoration. Interproximal fl ossing can complete removal 

of excess cement prior to fi nal curing. 

› Recommendations 

for Cement Selection 

and Application 

■ The resin cement and 

adhesive should have 

compatible activation 

mechanisms (eg, dualcured 

resin with 

dual-cured adhesive); 

■ Conventional resin 

cements are often indicated 

for less-retentive 

tooth preparations; 

■ Postoperative sensitivity 

can be minimized 

through agents such 

as Calm-It Desensitizer 

(DENTSPLY Caulk, 

Milford, DE); and 

■ The radiopacity of the 

cement should enable 

subsequesnt evaluation 

for marginal decay. 

can opt for Prime & Bond® NT or XP 

BOND (DENTSPLY Caulk, Milford, DE) 

prior to light curing and application of 

the resin cement. Each of these materials 

provides versatility for use in light- and 

dual-cured indications and favorable 

bond strengths that surpass those of similar 

etch-and-rinse adhesives. For a less 

technique-sensitive adhesive procedure, 

a self-etching system such as Xeno® IV 

(DENTSPLY Caulk, Milford, DE) may be 

employed to facilitate bonding. 

A resin-based, self-adhesive cement 

such as SmartCem2 (DENTSPLY 

Caulk, Milford, DE) might also be 

selected for its high strength and 

convenience. Bonding is generally unnecessary 

with self-adhesive cements. 

This cement can be dispensed either 

via automix syringe or automix digit 

targeted delivery system according to 

the clinician’s preference; SmartCem2 

eliminates the time and inconveniences 

often associated with mixing or capsule 

activation. Its excellent retentive and mechanical 

strengths to dentin and enamel 

ensure that the cement bonds effectively 

to porcelain, composite, and metal 

restorations, and that SmartCem2 

effectively seals margins. 

Once SmartCem2 is applied to the 

restoration and placed on the prepared 

tooth (Figure 3), the restoration may be 

gently manipulated into place for optimal 

seating. The “gel phase” of SmartCem2 

(DENTSPLY Caulk, Milford, DE) starts 

approximately one to two minutes thereafter 

and lasts about one additional 

minute—providing the clinician with a 

favorable working time chairside. A tack 

cure of less than 10 seconds can also be 

used to initiate the gel phase. A scalpel 

and floss can then be used to remove any 

excess cement material (Figure 4). When 

the final curing has been completed, the 

indirect restoration can be smoothed 

lightly with a carbide finishing bur 

(eg, Midwest® Esthetic Finishing Bur, 

DENTSPLY Professional, York, PA) and 

then polished to the desired appearance, 

with the clinician taking care to ensure 

its final luster and finish. ■ 

22


Aesthetic Finishing & Polishing: 

Techniques for 

Ceramic Restorations 


Contemporary ceramic materials 

enable dental professionals to 

instill natural aesthetics and 

luster in the restorations of 

their patients. The long-term 

function and performance of 

these restorations depend on 

numerous factors that include 

marginal integrity and the 

creation of a proper finish and 

polish. Development of an optimal 

surface reduces stain and plaque 

accumulation, minimizes wear, 

and enhances the appearance of 

the definitive restoration. This 

presentation exhibits a simplified 

protocol for finishing and polishing 

ceramic restorations. 

The increased patient demand 

for restorations that 

closely resemble natural 

dentition in aesthetics 

and function has contributed 

to the development of ceramic materials 

that provide the needed strength, 

durability, and beauty to meet those 

expectations. Although porcelain restorations 

such as CERCON® Zirconia 

and Finesse® (DENTSPLY Prosthetics, 

York, PA) possess intrinsic optical properties 

such as opalescence, fluorescence, 

and translucency that enable clinicians 

to achieve beautiful outcomes for their 

patients, minor marginal finishing is 

needed in virtually every indirect treatment 

to remove excess cement or during 

finalization of aesthetics or the occlusion 

(Figure 1). The use of a systematic finishing 

technique following cementation 

will improve a restoration’s long-term 

performance and maintenance of its 

marginal integrity. 

Once the restoration is seated, excess 

cement must be carefully removed, as 

any residual cement or marginal roughness 

will lead to plaque retention and the 

associated gingival inflammation. This 

will compromise not only the biological 

integration of the restoration with the gingival 

tissues but also the aesthetics, leading 

to chronic marginal inflammation 

and a potential for recurrent marginal 

decay. The restoration, therefore, must 

remain as biocompatible as possible (eg, 

particularly where in contact with soft 

tissues) to provide mechanical strength 

and aesthetics. Non-cutting, safe-end tips, 

which are featured in most tapered burs 

in the Midwest® Esthetic Finishing Bur 

system (DENTSPLY Professional, York, 

PA), enable the clinician to finish gingival 

margins while protecting the soft tissues 

throughout the procedure (Figure 2). 

Prior to selecting or using finishing 

instrumentation of any kind, the 

clinician should examine his or her 

Figure 1. Although ceramic restorations are delivered from the dental 

laboratory with a high luster and accuracy, minimal reduction may be 

necessary following cementation. 

Figure 2. Soft tissues can be effectively protected during marginal finishing 

with a Midwest ® Esthetic Finishing Bur (DENTSPLY Professional, 

York, PA), which features a non-cutting tip on the end of the bur. 

Inset: Cement can be removed marginally without lacerating the soft tissue. 

23

“In comparison to other finishing burs 

I have used, I’ve found that Midwest’s 

Esthetic Finishing Burs create a 

smoother surface for my restorations.” 



Figure 3. Egg-shaped carbides of the Midwest ® Esthetic Finishing line 

(DENTSPLY Professional, York, PA) are well suited for smoothing inconsistencies 

on the lingual aspects of the restorations. 

Figure 4. Midwest ® bullet-shaped and multi-fluted burs and carbides 

may be used to finish the occlusal surface. 

Table. Inspection Criteria for Finishing Burs 

First Use 

n Check for inadvertent damage that may have 

occurred while readying burs for use 

n Cutting edges should be free from defects 

n Long, slender burs should be checked for distortion 

n Discard damaged or distorted burs 

n Sterilize burs prior to first use 

Re-Use* 

n Check for damage that may occur during sterilization 

n Cutting edges should be free from defects 

n Long, slender burs should not be bent or damaged 

n Discard damaged or corroded burs 

n Ensure all contamination has been removed 

* Following sterilization, the instruments may exhibit some evidence of discoloration. This is normal and should not affect their performance. 

instruments to ensure their suitability for use in the intraoral 

environment (Table). Finishing with a bur possessing a low 

blade count can be inefficient, as it will often chatter in 

contact with the restoration surface and will destroy the 

innate properties of the ceramic material. Use of burs with 

a high blade count, such as 30-fluted, finishing carbides 

(Midwest® Esthetic Finishing Burs, DENTSPLY Professional, 

York, PA), however, can enable predictable fine 

finishing around the new restoration. With a wide assortment 

of anatomically adapted shapes in six different blade 

lengths, the Esthetic Finishing Burs ensure the clinician 

has the proper instrument available for finishing the varying 

morphology of the anterior and posterior regions (Figures 

3 and 4). These burs perform well for finishing transitions 

between natural tooth structures and ceramic restorations 

(eg, inlays/onlays, crowns), and for removing excess cement 

and flash from the margin. 

Effective trimming and finishing with Midwest® finishing 

burs ensures that oral health is maintained throughout the entire 

lifespan of the restoration. A rough ceramic surface may 

promote the retention of plaque and bacteria, leading to periodontal 

disease and caries. Gingival irritation resulting from a 

rough surface may exacerbate these problems. These associations 

are not limited to anterior restorations; a poorly finished 

occlusal surface also puts the patient at risk for increased wear 

of the opposing dentition due to the different texture, stain retention, 

and microcracking of the rough ceramic surface. An 

effectively finished and polished ceramic surface is, therefore, 

necessary to ensure optimal oral aesthetics and to increase longevity 

of the restored tooth and dentition. n 

24


Instrumentation and Bur Selection 

for Minimally Invasive 

Tooth Preparation 

› Abstract: 

Significant improvements in the oral 

health of the worldwide population and 

increasing patient interest in aesthetic 

dentistry have resulted in an emphasis 

on minimally invasive treatment 

options. Conservative treatment of 

diseased tooth structures is a valuable 

part of a modern and comprehensive 

approach to the management of 

the dentition. This presentation 

will discuss preparation design and 

instrumentation required to deliver 

minimally invasive dental treatment, 

highlighting key considerations and 

illustrating design requirements. 

Minimally invasive 

dentistry is in part 

a byproduct of 

clinicians’ greater 

understanding of 

the cavitation process and the therapeutic 

benefits of adhesive dentistry. 

The ultimate objective of minimally 

invasive dentistry is the preservation 

of tooth structure for strength and 

long-term function. Innovative diagnostic 

devices such as Midwest Caries 

I.D. (DENTSPLY Professional, 

York, PA) and other means of caries 

detection have supported the transition 

to minimally invasive dentistry, 

thus better enabling the practitioner 

to conservatively respond to the oral 

health needs of today’s patient. Management 

of patients with dental caries 

involves careful treatment planning 

as well as the selection of appropriate 

instrumentation during restorative 

care (Figure 1). Proper maintenance 

and home care are also important in 

managing the caries-prone patient. 

If an area is suspected to have caries 

involvement, detection—either 

through conventional methods (eg, 

radiographs, explorers) or technological 

means such as with Midwest 

Caries I.D.—is important as the 

clinician attempts to prevent the 

caries process from progressing. Any 

such exploration should be as conservative 

as possible and confined to 

tooth enamel. 

When preparing for exploration 

or direct restoration of initial caries, 

access should be performed using 

Figure 1. Tapered, round-end burs (ie, Midwest ® Esthetic Finishing 

Bur, DENTSPLY Professional, York, PA) are well suited for conservative 

preparation along the buccal grooves of the tooth. 

Figure 2. Use of a 1/4 small round carbide (Esthetic Finishing Burs, 

DENTSPLY Professional, York, PA) allows conservative access to caries. 

Preservation of tooth structure is the key to conservative dentistry. 

25

› “Midwest carbides have helped me conservatively 

prepare teeth for direct restorations and rapidly remove 

compromised tooth structure in the process.” 



Figure 3. Divergent walls of the preparation can be created using a 

tapered round-end bur, which improves overall retention of the direct 

resin restoration. 

Figure 4. Note the resulting groove along the occlusal anatomy of the 

tooth as it is prepared for minimally invasive therapy consisting of fl owable 

resin placement. 

a ¼ small round bur (Midwest® Operative Bur, DENTSPLY 

Professional, York, PA) for minimal intervention that is 

limited to the carious area (Figure 2). Throughout this procedure, 

the goal is to preserve sound tooth structure as a 

means of retaining the residual strength of the tooth and to 

serve as a substrate for the adhesion of composite resin. 

Once initial access has been achieved with the ¼ round 

bur, the clinician can use it or the ½ round shape to conservatively 

remove the existing caries. A direct “preventive” 

restoration with a flowable resin such as TPH®3 flow Restorative 

(DENTSPLY Caulk, Milford, DE) can then be accomplished. 

This aesthetic, flowable composite can be efficiently 

delivered to posterior regions through a Compula® tip, and 

the resin has radiopacity that enables effective monitoring 

by the clinician during subsequent maintenance visits. 

In the event that the caries progression extends beyond 

the dentoenamel junction, a Class I or II cavity preparation 

should be performed. The Midwest® tapered, round-end 

carbide (DENTSPLY Professional, York, PA) may be useful 

in such a preparation design (Figures 3 and 4); the clinician 

should keep the width of the preparation as narrow as 

possible and ensure all internal line angles are rounded and 

cavity walls are smoothed in order to enable optimal resin 

adaptation upon placement. Carious dentin not removed 

during the initial access, and preparation can be accomplished 

using the ¼ small round bur (Midwest® Operative 

Bur, DENTSPLY Professional, York, PA). Once the dentin 

demonstrates a firm tactile response when an explorer is 

applied, removal of the tooth structure should cease. A horizontal 

layering of composite resin (eg, TPH®3 Micro Matrix 

Restorative, DENTSPLY Caulk, Milford, DE) can then be 

conducted to reduce volumetric polymerization shrinkage 

and cuspal flexure. The restoration can then be finished 

using 12-, 18-, and 30-fluted carbides (eg, Esthetic Finishing 

Burs, DENTSPLY Professional, York, PA) that accomplish 

successive trimming, smoothing, and cleaning of the direct 

buildup. Finishing and polishing with Enhance® and PoGo® 

systems (DENTSPLY Caulk, Milford, DE) can then be utilized 

to render the final appearance of the restored tooth 

with a smooth, natural-looking luster for optimal aesthetics 

and function. 

Minimally invasive dental procedures are gaining increased 

popularity for the treatment and the restoration 

of initial carious lesion defects. The ability of the adhesive 

restoration to reinforce residual sound tooth structure 

should be coupled with the selection and appropriate use 

of instrumentation in order to deliver the best outcome to 

the patient. ■ 

26


Direct Resin Procedures 

for Aesthetics in 

Anterior Restorations 

› Abstract: 

The aesthetic expectations of 

today’s dental patients require 

the practitioner to have an 

innate understanding and 

the clinical skills necessary 

to perform smile repair or 

enhancement. Composite 

resins such as Esthet•X ® 

Micro Matrix Restorative 

(DENTSPLY Caulk, Milford, 

DE) possess physical and 

aesthetic properties that 

facilitate the clinician’s ability 

to provide direct treatment 

with success and predictability. 

This presentation reviews 

guidelines that influence 

composite material selection 

as well as placement protocols 

used in their direct application. 

The increasing aesthetic expectations 

of dental patients 

dictate the use of state-of-theart, 

imperceptible anterior 

restorations for smile repair 

or enhancement. When treating a fractured 

tooth or repairing an existing restoration 

(Figure 1), it is necessary to mimic the aesthetics 

of the surrounding dentition and 

to build up the resin restoration in a manner 

that matches the contours, length, and 

width of the adjacent teeth. In selecting an 

appropriate shade, it is important to do so 

prior to the placement of a rubber dam to 

prevent improper shade matching due to 

dehydration or the tooth reflecting the color 

of the dam. For a Class IV fracture or repair 

of a porcelain veneer, a chamfer preparation 

is placed around the entire margin to increase 

the adhesive surface area, and a scalloped 

bevel should be used to break up the 

chamfer line. Once the preparation is complete, 

the tooth may be etched and a dental 

adhesive may be applied. 

The dentin layer may then be built up 

with a composite resin material using slow, 

steady pressure. For anterior procedures, a 

material that provides high strength and 

polishability (eg, Esthet•X® Micro Matrix 

Restorative, DENTSPLY Caulk, Milford, 

DE) should be selected. The range of shades 

available in Esthet•X® ensures a successful 

treatment outcome, whether performed in 

a single-shade approach or an advanced 

technique involving multiple shades and 

opacities. It has also demonstrated high 

fracture toughness in areas (eg, margins, 

incisal regions) that must withstand considerable 

intraoral forces. 

First, a thin layer of opaque dentin is applied 

(Figure 2). The regular body layer is 

then built up over the opacious layer (Figures 

3 and 4), followed by a translucent 

enamel layer to mimic the natural dentition 

(Figure 5). Care is taken to leave space 

for the successive increments of composite 

resin that will render the final appearance 

of the restoration. The contour and shape 

are adapted using the appropriate instruments, 

and then light cured. For the aesthetic 

blending of shades, additional body 

and enamel layers may be individually 

Figure 1. A Class IV anterior fracture, porcelain repair, or diastema 

closure present similar aesthetic challenges. 

Figure 2. Following preparation and surface conditioning, a thin layer of 

Esthet•X ® is placed against the lingual matrix to form the palatal shelf. 

27

“The aesthetic capabilities of the 

Esthet•X composite—such as its 

color matching and polishability—will 

allow the patient to show his or her 

smile with confi dence.” 

Mitch Conditt, DDS 

Private practice, Fort Worth, TX. 

Figure 3. A1-shaded composite resin (Esthet•X ® , DENTSPLY Caulk, 

Milford, DE) is used to replicate the mamelons of the natural tooth. 

Figure 4. Full contour is created using an additional increment of A1- 

shaded composite resin. 

Figure 5. A CE-shaded layer of Esthet•X ® is applied and contoured to 

match the adjacent central incisor. 

Figure 6. Predictable aesthetic results may be achieved in this operative 

dental procedure through the layering of composite resin materials with 

physical and optical qualities similar to those of the natural dentition. 

added to create a natural, aesthetic restoration. The final luster 

and appearance may then be achieved with appropriate 

finishing and polishing techniques (Figure 6). Differentiating 

the performance of Esthet•X® following such treatment 

is the material’s innate polish, which improves over 

time as the resin functions intraorally. This ensures lasting 

smoothness and a natural luster for the completed resin 

restoration. Esthet•X® also possesses radiopacity that enables 

simple review of its performance during subsequent 

evaluation by clinician and auxiliary staff. DENTSPLY 

Caulk has recently launched Esthet•X® HD (High Definition 

Micro Matrix Restorative), an upgrade to Esthet•X®. 

Esthet•X® HD offers excellent shading, handling, and 

physical properties. With a newly optimized glass filler 

package, it now provides a faster, easier-to-achieve polish. 

Aesthetic repair or enhancement of anterior teeth is both 

feasible and predictable using contemporary composite 

resins. To achieve an optimal outcome, the aesthetic dentist 

needs only keen observational skills, patience, and 

meticulous application of clinical technique. ■ 

28


Direct Resin Restorations: 

Considerations for 

Adhesive Bonding 

› Abstract: 

It is the obligation of the 

practitioner to provide the 

dental patient with the most 

aesthetic restoration using 

clinical techniques that 

ensure proper function, 

biocompatibility, and 

preservation of sound tooth 

structures. Composite resin 

materials and adhesive bonding 

techniques are well suited for 

such concepts of conservative 

dentistry. Consequently, a 

thorough understanding of 

adhesive bonding procedures 

and knowledge of adhesive 

material options are 

prerequisites in contemporary 

dental practice. 

During tooth preparation for 

a direct resin restoration, 

residual organic and inorganic 

components form a 

“smear layer” of debris on 

the tooth surface. This barrier decreases the 

permeability of dentin and must be removed 

or made permeable so that resin monomers 

or adhesives can contact and interact with 

the dentin surface. Two fundamental strategies 

are used to overcome the smear layer: 

■ Total-etch: Adhesive systems with an 

acid gel to condition dentin and enamel 

surfaces, dissolving the smear layer 

and 1 µm to 6 µm of hydroxyapatite. 

■ Self-etch: Adhesives that treat the 

dentin and enamel surfaces with a 

non-rinsed solution of acidic monomers 

in water. These bonding systems 

make the smear layer permeable to 

subsequently applied monomers. 

Etch-and-rinse adhesives used in the totaletch 

technique involve separate etching and 

rinsing steps, followed by the application of 

a hydrophilic primer and/or bonding resin 

to produce a “hybrid layer” or resin-dentin 

interdiffusion zone. With an etch-and-rinse 

adhesive, the prepared tooth surface must 

remain slightly moist after the etching gel is 

rinsed away. Overdried dentin must be rewet 

in order to raise the collapsed collagen to 

a level suitable for bonding. 

One-bottle, etch-and-rinse adhesives 

such as Prime & Bond® NT (DENTSPLY 

Caulk, Milford, DE) combine the primer 

and adhesive resin into a single step that 

achieves micromechanical interlocking of 

monomers with the collagen-rich etched 

dentin. The nanofiller technology of this 

material reinforces the hybrid and adhesion 

layer, protecting against microleakage and 

postoperative sensitivity while establishing 

a proper marginal seal. Its combination of 

nanofillers and PENTA chemistry results 

in a material that eliminates postoperative 

sensitivity and ensures patient comfort. 

The chemistry of XP BOND Adhesive 

(DENTSPLY Caulk, Milford, DE), a universal 

self-priming adhesive, provides an 

extended working time and has a wider wetto-dry 

preparation tolerance than previous 

etch-and-rinse adhesives. Its ability to penetrate 

into the conditioned collagen network 

ensures the formation of an optimal bond. 

Figure 1. Preoperative view of defective fi lling that requires replacement 

with a direct composite resin restoration. 

Figure 2. Conservative cavity preparation is facilitated by adhesive-based 

approach that preserves sound tooth structures. 

29

“I use Xeno IV for my patients 

because of its simplicity and its 

ability to eliminate postoperative 

sensitivity in my patients.” 

Ronald A. Feinman, DDS 

Private practice, Atlanta, GA 

Figure 3. After conditioning of the enamel and dentin, an adhesive agent 

is applied with a fl ocked applicator to moisten the tooth surfaces. 

Figure 4. Finishing of the direct resin restoration is conducted using 

Enhance ® Finishers, followed by PoGo ® One-Step Diamond MicroPolishers 

for the fi nal polish. 

Table. Recommended Adhesive According to Clinician Profile 

User Consideration 

Prime & 

Bond ® NT XP Bond Xeno ® IV 

My preparation is confined to enamel ■ ■ 

My preparation extends into the dentin layer 

■ 

I occasionally have difficulty judging moisture levels on my conditioned cavity ■ ■ 

Long-term clinical performance is more important to me than ease-of-use 

■ 

Reducing my patients’ postoperative sensitivity is paramount 

■ 

Marginal fit is imperative ■ ■ ■ 

I generally prefer the total-etch technique ■ ■ 

I usually employ the self-etch technique 

■ 

I prefer the ease of application and simplified handling of a one-bottle solution ■ ■ ■ 

When used as an adhesive agent for an indirect restoration, XP 

BOND does not need additional curing. The material will 

completely “dark cure” on its own even if parts of the bonding 

interface are not light cured. 

Self-etch, non-rinsing adhesives are also available to condition 

and prime enamel and dentin simultaneously without separate 

acid etching. Self-etching adhesives penetrate the smear layer 

and partially dissolve hydroxyapatite to generate the hybrid layer. 

One-bottle, self-etch adhesives such as Xeno® IV (DENTSPLY 

Caulk, Milford, DE) are often regarded as more convenient and 

less technique sensitive (Figures 1 through 4), as their application 

time is reduced compared to etch-and-rinse adhesives or 

two-bottle, self-etching systems. These adhesives do not require 

a moist dentin substrate because of the water inherent in their 

composition, and no etching is involved. 

The availability of adhesive systems that coincide with 

a clinician’s preferred bonding technique (Table) has thus 

simplified the delivery of direct resin restorations. Once the 

tooth surfaces are properly conditioned and the adhesive 

agent has been applied and cured, incremental layers of a 

universal composite such as Esthet•X® or TPH®3 (DENTSPLY 

Caulk, Milford, DE) can be placed to achieve an aesthetic 

restoration with excellent physical properties and longevity. 

Consequently, concepts such as adhesive dentistry, aesthetics, 

and simplicity—once distant goals—can now be conducted 

in daily practice. ■ 

30


Finishing and Polishing Composite 

Resin Restorations 

Clinical Parameters 

› Abstract: 

The use of composite resin 

restorations continues to 

increase as clinicians gain 

proficiency with state-ofthe-art 

dental materials 

and contemporary adhesive 

bonding techniques. In order 

to ensure optimal aesthetics 

in direct resin restoration, 

proper finishing and polishing 

procedures must be conducted. 

These clinical steps predispose 

the restoration for longterm 

performance and the 

patient for optimal oral health. 

Accordingly, selection of the 

appropriate instrumentation 

and use of sound operative 

principles as highlighted herein 

are imperative. 

Finishing and polishing composite 

resin requires a systematic 

approach to ensure an 

aesthetic outcome. Effective 

finishing and polishing of direct 

restorations is necessary not only for 

aesthetic purposes, but also to ensure optimum 

oral health. The accumulation and 

retention of bacteria and plaque around 

composite restorations can be affected 

by the marginal finish, surface texture, 

and the integrity of the final restoration. 

If a smooth, well-polished surface is not 

achieved, this plaque accumulation can 

lead to chronic gingival inflammation, 

recurrent marginal decay, staining, and 

restoration failure. The finishing and polishing 

of composite restorations also aids 

the clinician in establishing functional occlusion 

and contour. Devices for finishing 

and polishing include both cutting instruments 

(eg, multi-fluted carbide finishing 

burs) as well as abrasive finishing and polishing 

systems that will be used to successively 

refine restoration surfaces. 

Carbide burs are available in various 

sizes and utilized by the clinician to 

achieve natural tooth contours as well as 

to smooth restorative surfaces in advance 

of the polishing sequence: 

■ 12-fluted carbides—trimming and 

contouring. 

■ 18-fluted carbides—successive finishing 

of surfaces. 

■ 30-fluted carbides—final finishing 

prior to polishing. 

Selection of the appropriate bur for a 

given clinical situation is dictated primarily 

by the required anatomy of the 

restoration. Embrasures, lingual regions, 

occlusal surfaces, and the various tooth 

shapes have differing contours that must 

be achieved during a finishing procedure. 

In this manner, longer shapes (eg, 

tapered, interproximal) are indicated for 

facial surfaces of anterior teeth or interproximal 

regions of canine and posterior 

teeth. Flame-shaped carbides are used for 

primary anatomy and round-end burs for 

contouring, whereas egg-shaped burs are 

Figure 1. Carbide fi nishing burs (Midwest ® Esthetic Finishing Burs, 

DENTSPLY Professional, York, PA) are ideal for refi ning margins and 

obtaining optimal surface texture. 

Inset: The helical shape improves contact with the tooth surface. 

Figure 2. To provide a lasting surface luster with PoGo ® One Step 

Diamond Micro Polisher (DENTSPLY Caulk, Milford, DE), light pressure 

should be applied to the restoration surface. 

31

“Using PoGo saves me time and simplifies my 

polishing sequence. I find that PoGo can very 

efficiently and quickly render a great, glossy finish for 

my composite restorations.” 

Stephen Poss, DDS, 

Private practice, Brentwood, TN. 

A B A B 

Figure 3A. Preoperative view of fi lling that will be replaced with a direct 

resin restoration. 3B. After tooth preparation and adhesive bonding, 

TPH3 ® (DENTSPLY Caulk, Milford, DE) is layered. 

Figure 4A. Finishing is rendered using Enhance ® Finishers (DENTSPLY 

Caulk, Milford, DE) to enhance the appearance of the restoration. 4B. 

Final appearance of the direct resin restoration. 

geometrically well-suited to the lingual surfaces of anterior 

teeth (Figure 1). The helical blade geometry of the Esthetic 

Finishing Burs (DENTSPLY Professional, York, PA) aids in 

debris expulsion and diminishes chatter by maintaining 

broad contact with tooth surfaces. This produces a uniform 

finish conducive to efficient polishing. The wide assortment 

of designs, tapers, and blade lengths in the Midwest® 

Esthetic Finishing Bur portfolio ensures the clinician has a 

high-quality, efficient finishing instrument available for a 

given clinical need. 

The surfaces of a composite restoration can be further 

refined when finishing with carbide burs is followed by use 

of the Enhance® Finishing System and PoGo® One Step 

Diamond Micro Polishers (DENTSPLY Caulk, Milford, DE) 

(Figure 2). Aluminum oxide-impregnated finishing cups, 

discs, or points, as available in the Enhance® Finishing System, 

can deliver a finish that reduces the potential for biofilm 

formation and the risk of recurrent caries or staining (Figures 

3 and 4). To achieve an aesthetic, lustrous high polish, PoGo® 

One Step Diamond Micro Polishers can be applied with 

an increasingly light touch, resulting in a high-gloss shine, 

established line angles, and no alteration of form. Numerous 

in-vitro studies have confirmed that the one-step PoGo® 

system achieved the smoothest surfaces and highest gloss values 

in comparison to other polishing systems involving additional 

steps. 1-3 As a one-step polishing solution, PoGo® has 

also rendered resin restorations less susceptible to staining. 4 

Additional investigations establish the value of PoGo® for 

polishing microhybrid and nanoparticle resins to a highgloss, 

uniform appearance. 5 

As a properly finished composite restoration can influence 

its longevity, promoting greater wear resistance and marginal 

integrity, correctly instituting these procedures is essential. 

Using the DENTSPLY armamentarium as part of a cohesive 

finishing and polishing protocol stands to extend the life of a 

resin restoration and to improve the efficiency of the clinician 

delivering it. ■ 

References 

1. Yap AU, Yap SH, Teo CK, Ng JJ. Finishing/polishing of composite 

and compomer restoratives: Effectiveness of one-step systems. 

Oper Dent 2004;29(3):275-279. 

2. Da Costa J, Ferracane J, Paravina RD, et al. The effect of different 

polishing systems on surface roughness and gloss of various 

resin composites. J Esthet Restor Dent 2007;19(4):214-224. 

3. Ergücü Z, Türkün LS. Surface roughness of novel resin composites 

polished with one-step systems. Oper Dent 2007;32(2): 

185-192. 

4. Türkün LS, Leblebicioglu EA. Stain retention and surface characteristics 

of posterior composites polished by one-step systems. 

Am J Dent 2006;19(6):343-347. 

5. St-Georges AJ, Bolla M, Fortin D, et al. Surface finish produced 

on three resin composites by new polishing systems. Oper Dent 

2005;30(5):593-597. 

32

Indirect and Direct Restorative Protocols - Caulk

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