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Raymond L. Bertolotti received his D.D.S. degree from the University of California, San Francisco, after working as a Ph.D. metallurgical and ceramic engineer at Sandia National Laboratories. He is currently Clinical Professor in Biomaterials Science at the University of California and conducts a large private practice in San Leandro. Much of his private practice is involved with conservative crown and bridge techniques and adhesion dentistry.

Dr. Bertolotti has published extensively in journals such as the American Dental Association, International Journal of Prosthodontics, and Quintessence International, as well as authoring four dental textbook chapters.

His "firsts" include introducing "total etch" to North America in 1984, Panavia in 1985, and intraoral tin plating in 1989. Intraoral sand blasting is also his innovation. He is a Fellow of the American Academy of Dental Materials, a Fellow of the American College of Dentists, a Fellow of the Pierre Fauchard Academy, and an Accredited member of the Academy of Cosmetic Dentistry. A frequent speaker at major international meetings, he has been ranked as one of the top three speakers in "Dentistry Today".

This is a very long newsletter. You will not be able to read it all in one sitting. Remember the RED numbers on the left of each topic to help you return to the place you left off previously. Think of them as Chapter #'s

Most Current Newsletter Editions

(1) - Posterior Composites
Issue 18, First half 1999 (preview edition)

I was planning on a new issue each quarter but I have been so busy with other things that time has flown by. Therefore my new plan is to be more realistic and post two issues a year with possibly a special brief issue or two in between. I think you can count on January and July for each new issue. I will keep at least two regular issues on the web site, the most current and the previous one in case you missed it.

This year we plan on two special Yosemite programs, in keeping with our tradition of sponsoring the very best guest speakers at this special location.

In March it will be Tom Hughes, the marketing genius who many of you know from High Impact Marketing. He will be speaking on marketing ideas for a fee-for-service, cosmetic oriented general practice. Tom will also be presenting the "Fab 40", 40 great clinical tips in around 40 minutes. He is one of the greatest dentists I know and full of great ideas. Additionally Dr. Gary Unterbrink, the Ivoclar/Vivadent guru, will be presenting on the topic of "Technique Sensitivity" in regard to composites and bonding. Gary is the world expert on kinetics of polymerization and a very revolutionary thinker. Bring your questions on laser and fast cure. This is a rare opportunity to hear one of the greatest Bondodontists in the world.

In November, it's Van Thompson, the East Coast guru of dental materials that many of you know. In both of these Yosemite seminars, I do a part of the program, usually discussing some very new topics.

In this issue I quote some special friends who have important messages and also post some often requested procedures from the current seminars.

For the Millennium, keep a watch on our web site. We have some major plans in the works for a Millenium blowout.

(2) - Posterior composites - matrix update

As many of you now, Danville's Contact Matrix ring and matrix system has been out of stock for some months. I am pleased to report that they are now available in quantity. They are available through Pollard and through this Web Site.

The new rings, matrix and the metallurgy used is my design. (I do have a financial interest in this one and I want to be "up front" with you on this point. I have no hidden agenda. If you don't like the Contact Matrix system, I will take the blame but please be sure to let me know what's wrong with it. Contact Matrix 2 is on the way so keep your input coming.)

The new rings are made of a stainless steel alloy that seems nearly indestructible, in normal and "reverse" models which Danville confusingly named inward and outward. Danville also offers both a normal sectional matrix and a reduced height matrix, both sizes in regular flexible and the new "stiff" types. The stiff are useful when the flexible one would get stuck and bend during placement in a not entirely broken contact. All 4 types are in the introductory kit. The rings themselves are also sold as a 2 pack if you don't need the sectional matrix. (These 4 matrix types cover my needs quite well but some of you will want the very long GDS matrix too. It has a gingival extension on the regular type.)

For the Contact rings, I wanted fatigue durability and deformation resistance, also enhanced chloride corrosion resistance. The new custom stainless steel proved to be very difficult to fabricate and heat treat. It is a custom alloy which is unfamiliar to most machine shops. However the wait seems worth it. I am quite pleased with what accomplished in improving the rings.

I agree with the commentary of Bob Davis, author of the Tools newsletter, who posted the following on the Internet Dental Forum a few months ago. Bob was evaluating only the Contact rings before the four matrix types were introduced.

There are now four distinct types of contact/ring matrix systems out on the market. I have all four, and have used all four. You cannot get everything from one system, unfortunately. Here is a rundown.

2-1. BI-TINE® Rings (From Darway®): Only one size and type of ring. Metal is rectangular in cross section. Tines are parallel to each other, and at 90 degrees to the ring portion. Comes with one size of kidney shaped matrix section.

PRO'S: Very strong and the result is a very tight contact. You will need Wynman Pliers, Hu-Friedy #104 serrated pliers, or Howe Pliers to remove the matrix portion. Not sure of cost, but not as expensive as the Garrison/ Compositite system.

CON'S: Not as retentive as the Danville rings due to lack of convergence of the tines. Cannot "stack" the rings because they do not come in different tine lengths like the Garrison (Compositite) rings do, and they are not 'angled' tine to ring as the Danville rings are.

2-2. SON OF BI-TINE®: New. Still rectangular in cross section. Ring section has parallel sides and is longer. Tines still come in only one length, and are still 90 degrees in relation to the ring. Have a 'detent' on each side near the tine for the RD forceps.

COMMENT: I can see no reason to switch over to these. They do not incorporate any design advantages over the original Bi-Tine®, IMHO. They are not more retentive on the tooth, do not offer any improvement in final shape, contour or tightness of the contact, and still cannot be stacked for multiple preps or MOD's.

2-3. GARRISON COMPOSITITE: Round in cross section. Each tine has an enlarged portion on the tip to aid in ring retention. Come in two tine lengths, which allows the use of one long and one short ring in situations where 'stacking' the rings is needed. System comes with three different sizes of matrix sections: Small, regular, and deep gingival.

PRO'S: The long and short tines enable 'stacking', which is the big innovation here. The enlarged tip on the tines does help to retain the rings. I like the small matrix section, which is just as long bucco-lingually, but of decreased occluso-gingival height. I use this matrix over 50% of the time with all of these systems.

CON'S: I do not find that this system generates the rock solid contacts of the original Bi-Tine® or the Danville System (see below). The rings do not seem to be as strong due to their round cross section. The contacts are 'adequate', but not as tight. And this system is more expensive than the others.

2-4. DANVILLE CONTACT MATRIX: Designed by Ray Bertolotti, this system takes a novel approach to solving the deficiencies of the other systems. The rings are rectangular in cross section. The tines are angled 75 degrees to the ring so the ring portions are not parallel to the occlusal surface of the tooth, allowing 'stacking'. There are two different tine configurations, normal and 'reversed'. Matrix shape is oval, eliminating confusion about which side goes to the gingival.

PRO'S: Strong rectangular metal rings compare favorably with Original Bi-Tine®'s for tightness of contacts. Tine angle with respect to ring portion enables 'stacking' like Compositite rings. Tines angled in toward each other makes this the tightest (best retention on tooth) of all the rings on the market. Reversed tine configuration is helpful for those situations where the box form is so wide that most other rings impinge on the matrix, crushing it inward and impinging on desired restoration contour in the axial areas. Kits are very inexpensive compared to others.

CON'S: None noted. If I had to buy just one contact matrix system, this would be it. I might still purchase some of the small matrix sections from Garrison, as I really like that matrix size, shape, and thickness, however.

Bob Davis may be reached at drtooth@dentools.com. He teaches hands on air abrasion courses in Watsonville, CA, near Monterey. I have taken and very highly recommend this course. Since Bob Davis published his evaluation of the rings and matrix, Danville has introduced the four matrix types that I discussed at the beginning of this section. There is also an update on the matrix and rings among my clinical illustrations under "How To Get Perfect Contacts".

While we are on the subject of posterior composites, here is my latest "bite-form" technique, now in day 2 seminars:.
Ordering & Contact info.

(3) - POSTERIOR COMPOSITES

1. Cut conservative prep, using Caries Finder, CariesDetector, or Caries Finder G as a guide. (If you anticipate a pulp exposure, the green Caries Finder G is the preferred one to use.)

2. Place a short Danville or short GDS matrix and wedge. Check for centric occlusion and adjust matrix height if necessary to allow for a closed bite into the composite. Add the Palodent® Bitine® ring or the Danville Contact ring. (If using a rubber dam, be sure matrix does not extend above the marginal ridge.)

3. Apply LB2V Prime to dry or damp enamel and dentin for 30 seconds (minimum time, longer OK, agitation improves it).

4. Dry only (no wash), starting from about 2 inches away with the dry air syringe and get close to the prep in a few seconds. Fully dry the primer. (Composite does not bond to alcohol, water, or both the solvents used in the Prime!)

5a. Apply LB2V Bond (bottle A only), air thin (to avoid radiolucency), light cure.

6a. Apply light cure flowable composite (Starflow recommended) with needle tip to cervical margin and all dentin, and on the matrix up to the near contact. Light cure.

5b. Apply LB2V Bond (bottle A mixed with catalyst bottle B),air thin (to avoid radiolucency), light cure.

6b. Mix self cure (Bisfil 2B) or dual cure (StarFill 2B) flowable composite and load into a Centrix needle tip. Apply to cervical margin and all dentin, and on the matrix up to near the contact. Let it self cure, catalyzed by the bonding agent, to "direct" the initial shrinkage toward the tooth. The self cure will take around 2 minutes after placement. (Starfill 2B may be stabilized by a very brief light cure, approximately 1 sec., to avoid slumping.)

7. Place light cure composite (such as Heliomolar, Charisma, Herculite, etc.) slightly overfilling, taking care to insure all margins are covered. (One increment will suffice after the first increment of cured Starflow or either 2B, except in very deep preps.)

11. Light cure from occlusal. (Sometimes a buccal cure while in CO is prudent, especially when the composite is placed next to thin enamel.)

12. Finish and polish. Very useful diamonds to define grooves are "Top Spin" diamonds that resembles an acorn amalgam burnisher. For polish, I use cups and points.

Note: Reality gives advice on finishing many brands of composite. Reality is a necessary subscription! Trust me on this one!(michaelmiller@realityesthetics.com) or order it from the bottom of this page.

Ordering & Contact info.

(4) - DIAGNODENT

There is a new laser system for detecting caries. It is expected to hit the USA market (Kavo USA) by early 1999. Basically what it does is emit a laser beam at the tooth and it measures the intensity of the fluorescence out of caries. It gives as an objective measure of caries amount and activity. Now we have a good way to determine "watch" or intervene. Successive examinations with an increase in caries is a good reason to stop watching.

Kavo USA is the domestic contact, Scican in Canada and Vivadent in Australia. It is not terribly expensive, mine cost well under US$2000. X-ray is not nearly so effective. This gadget even detects caries under crown margins. Revolutionary!

Here is some commentary posted by another friend, Geoff Knight who also does international lectures. You can click on his web site from my links. From: "Geoff Knight"

I have been using a DIAGNOdent since late April. It has taken much stress out of occlusal caries diagnosis. Similar to flying by instruments. In some cases I was sure there wasn't caries and have been proved wrong and visa versa. It is actually a laser beam surrounded by a glass rod that picks up reflected light. Laser emits at 655 nm, penetrating to a depth of 2mm and caries fluoresce at 550nm. Instrument gives a digital readout and audio signal depending upon the reading. The deep growl it makes above 50 certainly tells patients that there is something seriously wrong in their mouths. 0-25 indicates initial decalcification that may be treated by remineralization. 25-50 initial caries that may be treated by fissure sealing or minimally invasive techniques. above 50 frank caries. Debris must be removed from fissures, the instrument doesn't like composite resin (there is a school of thought that caries are always found under composites) The instrument has applications for diagnosing caries at crown and restorative margins, some use for proximal caries and importantly it can monitor caries activity over time. Finally when doing minimally invasive dentistry the preparation simply has to be scanned to determine caries has been removed, much faster than caries detector solution. Cost me AUS$2.5K but may have changed due to dollar dive. For the money, the instrument saves heaps of time and reduces stress.

Geoff Knight, Brighton.
Ordering & Contact info.

(5) - CROWN/INLAY/ONLAY TEMPS at TURBO SPEED

Turbotemp (Danville) and Luxatemp (Zenith/DMG) are microhybrid composite materials for temporary restorations. These have very low shrinkage compared to traditional temporary resins and super esthetics. The cartridge fits most impression material guns after changing only the "slide". Turbotemp and Luxatemp, when used in conjunction with a good polysiloxane such as Star VPS Monophase,makes imcomparably fast and accurate temporaries, rarely requiring occlusal adjustment.

There are several brands of similar temporary materials. I like Luxatemp and TurboTemp the best. Luxatemp wins for ease of handling, TurboTemp wins for color and strength. I don't like the dual cure products (wastes time, in my opinion) and don't need them since undercuts are not a problem if you follow my advice and use VPS impression material.

Before the prep
While the patient is getting numb, place some flexible polysiloxane on a posterior bite tray (Tin Man has a great buy on generic closed bite trays) and have the patient close into it while still not fully numb. A very rapid setting, flexible material such as Star VPS Monophase is ideal. Stiff (bite) materials should be avoided since once removed, the impression will not go back into undercuts easily. Putty misses the proximal areas, resulting in a lot of trimming of the temporary. The thermal buttons do not flex into the undercuts so I think they are dreadful for this technique.

After the prep
After you have the prep and impression completed, you are ready to make the temporary. Inject Turbotemp or Luxatemp into the prep areas of the preliminary impression, avoiding bubble trapping (a needle tip helps). Have that patient close into the tray.

You have a choice to make: cement or no cement. If you plan to cement, have the patient open 1.5 minutes after the mix was injected. The temporary will be flexible and retained in the impression. Break off the excess Turbotemp around the temps while they are in the impression. Since the excess is just a thin film and flexible, it cuts off very easily with an amalgam carver. Immediately reseat in the mouth, wait one minute, remove again. Pop the temp out of the impression, trim margins with a diamond (since it is now rigid). A wipe with an alcohol swab will polish it (Schein catalog # 100-0882). Cement it. There is normally no need for occlusal adjustments if you used polysiloxane properly. The no cement technique: Leave the Turbotemp in the mouth on the initial insertion for about 3 minutes. It will shrink fit. You will need to cut it off so keep the preliminary impression in case you need to make another temporary.

For inlay/onlay, place a non-eugenol cement into the prep with a brush (Kerr's TempBond NE is ideal) before forming the TurboTemp. It will be "pre-cemented". Blue TurboTemp is ideal for this use. It can be easily seen, preventing residual material left in the prep at the cementation appointment. Both the blue color and the pre-cement technique came from Tom Hughes, our Yosemite guest speaker.

1. When starting with a new cartridge, waste the first "pea size" amount dispensed through the mixing tip to even the dispenser.

2. Do not remove the mixing tip after each use. Wait until ready to use it again and load new tip (to prevent catalyst contamination with a resulting plug).

3. Mount the mixing tip in proper alignment. Note that the tips are notched to indicate the proper alignment on the cartridge. By forcing the tip, it can be mounted backwards, resulting in non-setting mixes. (The two sides of the mixing tip have different size bores.)
Ordering & Contact info.

(6) - VENEER TEMPS AT TURBO SPEED

TurboTemp is especially attractive for anterior veneers temporaries due to its accurate Vita color and slight opacity.

Before the preps
While the patient is getting numb, place some flexible vinyl polysiloxane (VPS) on a anterior closed bite tray (Triple Tray, Premier; Pollard). Have the patient close into it before making the preps. You may "recontour" the teeth with non-bonded composite prior to taking this impression if you wish to build contour changes into your temporaries). A rapid setting, flexible material such as Star VPS monophase is ideal. Alginate should be avoided since it will not match the accuracy of the temporary material and can not be retained to replace a broken temporary. Stiff (bite) VPS materials should be avoided since once removed, the impression will not go back into undercuts easily. Putty misses the proximal areas, resulting in a lot of trimming of the TurboTemp.

After the preps
After you have the prep and final impression completed, you are ready to make the temporary. You have a choice to make: bonded or non-bonded temps. I prefer the non-bonded temps for most cases of 4 to 6 upper veneers. Less than 4 are usually best bonded unless preps have undercuts to help retain them without bonding.

Non-bonded temps
Inject Turbotemp into the prep areas of the preliminary impression, avoiding bubble trapping (a needle tip helps). Have that patient close into the tray. Wait 3 minutes and then have the patient open. The TurboTemp will be on the teeth. Remove the gingival flash with a #2 or #2B scalpel blade or preferably with a Kincheloe instrument (Hu Freidy or generic, Pollard). Repair any bubbles with StarFlow. Margin add-ons usually require a bonding agent such as Photo Bond before adding the StarFlow. Polish the facial surface with an alcohol swab (Schein catalog #100-0882). You are finished.Since these temps are not bonded, they can be easily removed by prying with a metal instrument. Instruct the patient on how to maintain the area since they can't floss due to the temporaries being all bonded together. Retention is not a problem since the veneers shrink fit around the arch.

Bonded temps
Bonded temps require spot etching and bonding before inserting the impression material loaded with the with the TurboTemp. I generally etch a spot (on each tooth) about 3mm in diameter on the facial (incisal half) away from the incisal edge. After washing and drying, I apply a fairly thick, solvent free bonding agent such as 3M Enamel Bond, or Danville's BondStar E to the etched area. It is optional to cure at this time. Then proceed to place the TurboTemp as above. You need to cure the bonded spots (through the temps) immediately after removing the impression material and before finishing.
Caution for bonded temps:
Do not use Photo Bond for spot bonding the temps. It is a sort of self etching primer that makes the removal of the temps unusually difficult. (That same property makes Photo Bond a great choice for final veneer bonding.)

This is the first issue that will not be sent by snail mail. It is on the web site only. As you can imagine, sending out thousands of newsletters runs up a big printing and postage bill. Snail mail limits how many issues I can send gratis. This way I can post a new newsletter quarterly and not even worry if I have enough room.

This issue will focus mainly on Liner Bond 2V and the new "condensable" composites as well as fast composite curing. They seem to be hot topics these days.

The best way to contact me for questions is by Email: rbertolott@aol.com (please note no i in bertolott, AOL does not allow enough space). You can also reach me easily from my web site: www.adhesion.com While FAX also works, I find returning the FAX is often a problem. Many dental offices do not have a reliable incoming FAX, often necessitating second calls ("call after I turn it on" or "next time I won't answer") or even third calls to resolve the problem.

We intend to continue sponsoring the very best speakers at some exciting locations. Walter Hailey and Steve Anderson probably need no introduction for their Planned Marketing presentation. They are scheduled for Hawaii on July 31 following my program on July 30 this year. And a bonus: Shigehisa Inokoshi, the Japanese guru of bonding, will be presenting a bonding update at Hawaii.

Our Yosemite seminar in November, featuring Dr. Buddy Mopper is sold out (and has been for months). However the March 4-6, 1999 date is still available.

There is also a South Africa series in August. The South Africa series is in partnership with Geoff Knight of Australia (who some of you will remember from last year at Hawaii).

We had a very successful cruise seminar to Alaska in May. We have no cruise plans for next year but we are getting high demand for another Cabo San Lucas seminar so we will try for September 1999.

(8) - Liner Bond "3"

What I have been calling Liner Bond "3", the successor to Liner Bond 2, was actually named Liner Bond 2V, V as in Versatile, to end any possible confusion!

It is indeed versatile, usable as a replacement for ED Primer in the Panavia 21 kit as well as being either a dual cure or light cure bonding agent. It's no surprise that it bonds well to metal but here is the kicker: it even bonds porcelain when you add Activator! "Versatile" does seem totally appropriate as the trade name.

(9) - Liner Bond 2V: (V as in Versatile)

The new LB2V Prime and LB2V Bond are both dual cure, unlike Liner Bond 2 which was light cure only. Therefore LB2V is compatible with any composite, light cure, self cure, or dual cure. The LB2V Prime is always mixed (A + B). The LB2V Bond may be used as a one component light cure (bottle A only) or mixed with the catalyst (bottle B) when dual cure is desired.

The LB2V Bond catalyst (bottle B) is sold separately so that LB2V can be purchased and used exactly the same as LB 2 by those not interested in dual cure.

(10) - Using Liner Bond 2V:

Light cure composites:
The LB2V Prime is used exactly the same way as LB 2 Prime for light cure composites. (LB2V Prime A+B 30 sec, dry, LB2V Bond A, air thin, light cure.)

Dual cure composites:
Dual cure composites and luting composites (such as StarFill 2B and Variolink 2) as well as self cure composites (such as Bisfil 2B and DenMat Core Paste) are fully compatible with LB2V if the dual cure LB2V Bond (A+B) is used after the LB2V Prime.

Panavia 21 luting:
The LB2V Prime can take the place of ED Prime when using Panavia 21. The only noticeable changes are the Panavia 21 sets faster than usual, in around 45 seconds (rather than the 60 seconds with ED Prime), and the Prime minimum application time is only 30 seconds whereas ED is 60 seconds. (Note that Photo Bond/Panavia 21 sets in about 3 minutes.)

Porcelain bonds:
The LB2V Prime may be mixed with Activator (the same Activator as now mixed with Photo Bond or New Bond to make Clearfil Porcelain Bond) to make a "new porcelain bond". (I do not have data yet to compare its strength to the prevoius Porcelain Bond.) However, when bonding to dentin, the Activator should not be added to the LB2V Prime, unlike Photo Bond where Activator may be in the dentin bonding mix. Presumably Activator dilutes the acidity required for a self-etching primer. If a stiff rather than flowable composite is being bonded, an unfilled resin (such as BondStar-E, 3M Enamel Bond or Photo Bond) must be applied and cured before the stiff composite.

Using Clearfil "Activator" for porcelain bonding:
a. With Liner Bond 2V ..........
     Activator + LB2V Prime (A+B), low viscosity composite
      (ex: StarFlow, Panavia 21, Dual Cure Cement)
     Activator + LB2V Prime (A+B), unfilled resin, high viscosity
     composite (ex: Herculite, Charisma)
b. With Photo Bond ............
     Activator + Photo Bond (A+B), any composite

Desensitizer for cervical areas:
Apply LB2V prime for 30 sec, dry, apply LB2V Bond, cure. If contour needs change, apply Danville's StarFlow composite (if shallow) or Parkell's EPIC-TMPT (if deep), light cure.

Ordering & Contact info.

(11) - Pulp caps

There is a great paper from the Dr. Charlie Cox group at Alabama. (Some of you will know Charlie from Yosemite.) They used Liner Bond 2 and APX composite and reported results in Quintessence Inter 1998;29;177-188. Basically they found that hemostasis created by 1:1 Chlorox and then capping with Liner Bond 2 and APX composite made excellent pulp caps.

(12) - Sealant/desensitizer for indirect restorations at "prep":

Gluma/ED Primer at prep appointment. Apply Gluma Desensitizer for 30 sec, dry, then apply ED Prime for 60 sec, dry. Place temporary with non-eugenol cement. When ready to final bond, use total etch and Photo Bond. (It is not yet known how well LB2V Prime will work in the place of ED Prime.)

(13) - "Slow set" Panavia 21:

Etch, wash, dry, Gluma Desensitizer or Microprime, dry, Photo Bond, dry, Panavia 21 in restoration, seat, remove excess, Oxyguard 2. (set time 3 to 4 min.)

(14) - Photo Bond - is it currently recommended?

One question I frequently get is "now that we have Liner Bond 2V, do we still need Photo Bond?" The answer is yes. Photo Bond is the world's best enamel bond by far (ease of use, high bond strength, thin, no color, cheap, dual cure). I prefer to use Photo Bond with Activator for porcelain bonds. The Photo Bond, rather than the LB2V Prime, allows any composite to be placed without an intermediate unfilled resin layer. With the LB2V and Activator mix, you will need to place an unfilled layer (such as Enamel Bond, Photo Bond or BondStar-E) if you plan to place a high viscosity composite rather than a flowable or Panavia 21.

Photo Bond is my preferred veneer bonding agent. Etching and applying Photo Bond makes a stronger enamel bond than the self-etch enamel bond of Liner Bond 2V. In any enamel-bond-critical situation, for example class IV, I recommend etch and Photo Bond. For those class IV composites, use a very stiff composite. 3M's Z-100 is the stiffest and therefore probably the best for that use. Z-100 works beautifully with Photo Bond. Avoid flexible composites such as microfills on those incisal edges.

Alternatively, you may etch the enamel, then use LB2V Prime and LB2V Bond. That procedure is more difficult but is about equal in bond strength to the Photo Bond to etched enamel. However you should avoid etching the dentin if you plan to use the LB2V.
Ordering & Contact info.

(15) - Alloy Primer or tin plate?

Another hot "Clearfil topic" is Alloy Primer. For Panavia 21, tin plating produces a stronger bond than does Alloy Primer. However tin plate may be overkill. For now, I will continue to tin plate and watch what happens with the Alloy Primer.

(16) - CR Inlay Cement and DC Cement

As many of you know, my favorite dual curing CR Inlay Cement is discontinued. I did stock up. For those of you who didn't, I have good news: Panavia dual cure is on the way for later this year. This should be an ideal replacement for the CR. The recently introduced Clearfill DC Cement lacks the metal adhesive properties of Panavia so it does not excite me very much. It's OK but it lacks shade selection. For that type of non-adhesive composite, I prefer Cosmedent's Insure Light DC which is available in many good shades.

Some hot topics:

(17) - Condensable composites

I am sure you have seen the big promotions for the new condensable (packable??) composites. I have used Solitaire (Heraeus Kulzer) and like the product. It makes exceptionally fine margins. The apparent reason is that its polymerization "soft starts", that is cures slowly in the initial stages of light curing. (Research that showed the built-in soft start of Solitaire came from the UK, soon to be published.) In terms of wear relative to my benchmark composite, HelioMolar (Ivoclar/Vivadent), we need more time to evaluate. So far, so good. In terms of the other condensables, it is too early to tell.

Quite frankly, I think the concept of packable composite is preposterous. What's the point? Making contacts? Using familiar instruments? Bitine® rings get us contacts, no problem. If you use a packable rather than a flowable composite against the matrix, the packing displaces the matrix at the gingival margin unless it is stabilized. How about the packing "defects" that these packable composites definitely tend to develop? Do we need to be able to use our amalgam instruments to place a composite? If yes, I recommend that the manufacturers increase the comfort zone of the consumer dentist by making an amalgam shade, perhaps one that gets blacker with age. Call it "Virtual Amalgam"! If you do use a packable, be sure to use a flowable as the first increment, especially at the gingival margin. In terms of being light curable to a great depth, look out for high stresses due to bulk polymerization. These stresses can lead to margin defects and even cracking of the tooth, especially cusps.
Ordering & Contact info.

(18) - Fast impressions.

You may have noted a product line, Half Time (Discus), advertised to be "the world's fastest vinyl polysiloxaine impression materials line". That is a fine product and may be the fastest "line". However if you are interested in a faster material or two, Danville's Star VPS Monophase is faster. Perhaps Danville should rename it "Quarter Time". I use it in the mouth for 1 min, 15 sec. That makes it ideal for preliminary impressions (closed bite) and simple impressions like high and dry onlays or perhaps one or two veneers, again closed bite. Danville will soon introduce a matching fast set "Light body Super Flow".

In terms of impression material, Danville may well have the lowest viscosity vinyl polysiloxaine too. It is the new Star VPS "Ultralight" which is matched to use with Ultra heavy. I use these in the impression technique I learned from Dr. John Kois. (See the link to his web site. He runs some of the best "hands on" courses around.)

(19) - Fast cure lights

I want to go on record as opposing fast cure no matter how the light is generated. I have been watching the literature that concerns rate of cure, never mind the "geographic" studies reproducible only near the various manufacturers locations. So far, I have not seen a shred of independent evidence that fast cure gives enhanced results. I have seen multiple studies that show fast cure is a bad plan. It tends to maximize the overall shrinkage or stress or both. The first study I saw was published back in 1991: Uno and Asmussen, "Marginal adaption of composites polymerized at reduced rate", Scand J Dent Res 1991;99:440-444. Many recent papers support their conclusions.

Now if your high intensity light source can "soft start", that is cure slowly initially, then I have no opposition. The high intensity (after the soft start) could enhance the overall cure. Kreativ appears to have such a light and I would definitely look at that one if you are in the market. As I understand it, they have a programmable chip that can be changed as new curing data emerges. Very clever.

(20) - Some problems

There are three no-no's for self etching primers. They are eugenol, calcium hydroxide, and strong acids. Use of these materials seems to adversely affect the action of self-etching ED Prime and LB2V Prime.

The eugenol residual (such as from IRM, Ward's, Temp Bond) seems to adversely affect the polymerization of the primer. This effect appears to be negated when a separate phosphoric acid etch step is part of the procedure. Presumably the residual eugenol in the tooth affects polymerization of the self etch primer while the separate etching is thought to rid the tooth of the eugenol.

Calcium hydroxide has a pH around 12.5. Any residual appears to neutralize the acidic primer, preventing its etching action.

Strong acid is a more complex problem. We know that strong acids used first often prevent subsequent etching by a weaker acid. An excellent example is PREMA (contains hydrochloric acid) followed by phosphoric. The phosphoric does not etch. (You must disk thru the layer affected by the PREMA, then no problem etching.) Astringident, Ultradent's excellent hemostatic agent, is far more acidic than the self etching primers. Likewise, it appears to adversely affect the etching action of the primers.

Now a new problem. There appears to be a definite correlation in the use of various chlorhexidine disinfectants and post-op sensitivity with ED Prime/Panavia 21. I don't know why and have no mechanism to postulate. For now, I recommend you cease and desist using chlorhexidine products prior to any self-etch primer.
Ordering & Contact info.

(21) - Stop sensitivity!

I am constantly amazed at how many dentists continue to ask about the source of post-op sensitivity resulting from direct composites. There are many causes, most relating to insufficiently thick or insufficiently adhesive bonding agents. The easy solution: Liner Bond 2V. Here is the latest technique, sensitivity free, straight out of the current seminar:

2. Place trimmed Palodent® matrix or short Garrison (GDS) matrix or new Danville short matrix and stabilize the matrix with a wedge. Check for centric occlusion and adjust matrix height if necessary. Add Spring Retainer ring. (If using a rubber dam, be sure matrix does not extend above the marginal ridge.)

3. Apply LB2V Prime to dry or damp enamel and dentin for 30 seconds (minimum time, longer OK, agitation improves it).

5. Bonding:
option a. LIGHT CURE TECHNIQUE:
     1. Apply LB2V Bond (bottle A only), air thin (to avoid radiolucency),
          light cure.
     2. Apply light cure flowable composite (Starflow recommended)
          with needle tip to cervical margin and all dentin, and on the
          matrix up to near the contact. Light cure.
option b. DIRECTED SHRINKAGE TECHNIQUE
     1. Apply LB2V Bond (bottle A mixed with bottle B), air thin
          (to avoid radiolucency), light cure.
     2. Mix self cure (Bisfil 2B) or dual cure (StarFill 2B) flowable
          composite and load into a Centrix needle tip. Apply to cervical
          margin and all dentin, and on the matrix up to near the contact.
          Let it self cure, catalyzed by the bonding agent, to "direct" the
          initial shrinkage toward the tooth. The self cure will take around
          2 minutes after placement. (Starfill 2B may be stabilized by a
          very brief light cure, approximately 1 sec., to avoid slumping.)

11. Light cure from occlusal. (Sometimes a buccal cure while in CO is prudent, especially when the composite is placed next to thin enamel.)

12. Finish and polish. Very useful diamonds to define grooves are "Top Spin" diamonds that resembles an acorn amalgam burnisher. For polish, I use cups and points (D-Fine).

(22) - "Directed shrinkage" vs. light cure composites in 1998

Danville's introduction of dual-curing StarFill 2B to compete with self-curing Bisfil 2B has raised several questions about how "directed shrinkage" is used currently.

Directed shrinkage (Bertolotti, PP&A Aesthetic Chronicle 1991) was proposed in the days when dentin bonding strengths were about half of what they are today. The concept was to direct the polymerization shrinkage toward the bonding agent rather than toward the light, thereby placing less stress on the weak bonding agent. The recommended bonding agents to accomplish this objective were All Bond or MicroPrime/Photo Bond. Both of these dual cure bonding agents are very effective accelerators for self cure composite. Bisfil 2B (a self cure flowable) was specifically developed for the first increment in this procedure. Numerous clinicians and publications have reported success.

A few years later, dentin bonding agents got a lot stronger so the directed shrinkage technique became less necessary. High immediate bond strengths were sufficient to overcome the shrinkage stresses in the curing composite, resulting in "gap free" restorations. While several current bonding agents are strong enough, I personally use and recommend Clearfil Liner Bond 2V. I recommend a flowable composite as the first increment, my favorite being Danville's StarFlow. Once again, this technique has been a winner in the hands of thousands of clinicians.

Now in 1998 we have a decision to make: to use light cure (Liner Bond 2V, StarFlow, LC composite) or "directed shrinkage" (Liner Bond 2V mixed for dual cure or etch, All Bond 2 or etch, MicroPrime, Photo Bond; then StarFill 2B or Bisfil 2B, LC composite). I recommend the directed shrinkage any time you have concern for incomplete light curing (deep, large, difficult access, poor light output, etc.). Practically speaking, the advantages of StarFill 2B, with assurance of complete cure and stress reduction, outweigh the disadvantage of having to mix the StarFill 2B base and catalyst (as compared to no mix with light cures).

On the other hand, average to small fillings are more quickly and easily completed by light cure composites, using a StarFlow as the first increment. Directed shrinkage does not appear to be necessary.

Danville's StarFill 2B is dual curing for several reasons. Theoretically, dual cures are more complete curing than self cures. Dual cure allows more flexibility in cure mode. With StarFill 2B, you can even direct the shrinkage toward the enamel with light. You trans-enamel cure with light while the bulk self-cures. Remember that it is important to allow the StarFill 2B to self cure in the bulk when you want the directed shrinkage toward the bonding agent. Therefore you would avoid direct occlusal light curing prior to the bulk self curing (takes around 2.5 minutes).

(23) - Keller's new Meridian Center

Keller Lab of St. Louis has opened their "hands-on" educational center. It is state of the art. They offer courses by great educators such as Hornbrook, Chiche, and Turbyfill. For info: (800) 325-3056.

(24) - Hands-on in Colorado, at Colorado Springs

Dr. Tom Hughes is kicking off his new "hands-on" educational facility at High Impact Marketing on October 16 and 17. Dr. Buddy Mopper will be guest educator. Buddy is the master of direct resin. He will be the guest speaker at Yosemite in our sold-out November seminar. If you want hands on learning, I highly recommend this course. I thought I had a pretty good handle on direct composite until I took the course myself about 3 years ago. To contact High Impact Marketing: (719) 488-0808, or use our E-Mail forwarding service from the bottom of this Web Page. It will only take you a couple of seconds.

Contact info.

Our seminars are usually two days in duration with the second day (Advanced Concepts) building on the first day (Current Concepts). We recommend attendance at the second day only for those who have heard day 1 in the last year or two (or perhaps heard Dr. Bertolotti at a dental meeting within the same time frame). Our seminars are continually updated and we constantly hear how "new" the information is to those who attended some years ago.

We are a private provider of continuing education in dentistry. We are not beholden to any commercial sponsors. We are recognized by the AGD, the ADA, and many states which have continuing education requirements. We started business in 1983. Our primary speaker, Dr. Raymond Bertolotti, has been invited to speak at most of the major US dental meetings such as the ADA, the Chicago Midwinter, and the Hinman a well as major foreign meetings. We have occasional guest speakers who we consider to be among the best in the world. For example, Dr. Takao Fusayama of Japan and Dr. John Kanca of the USA. Guest speakers share the program with Dr. Bertolotti.

Dentists who are willing to make changes. The comments at the top of this page reflect the impact that our adhesion dentistry seminars have had on five clinicians. What we teach is how to practice "better, faster, and easier" dentistry. For those who implement the changes, the results can be dramatic. From Dr. Tom Hughes:

Dr. Hughes has said that the turning point in his very successful cosmetic oriented practice was attending Dr. Bertolotti's seminar in 1987. He was hampered by many of the same clinical problems which many clinicians currently describe.

Dr. Bertolotti believes that a successful practice needs to "give your patients more of what they want and less of what they don't want". They don't want amalgams! They don't want crowns that destroy teeth! They don't want bridges that need pencil sharpener preps! They do want dentistry that feels good, looks good, and lasts a long time. This seminar will give you a jump start on the knowledge necessary to practice state of the art dentistry, delivering more of what patients want and eliminating a lot of what they don't want. What we teach you can implement the next day in your practice. Although technology is our primary topic, we also teach a little about successful marketing. This knowledge will help you escape from the grip of insurance companies and have a practice that you and your patients both enjoy.

Most Current Newsletter Editions

(1) - Posterior Composites
Issue 18, First half 1999 (preview edition)

(2) - Posterior composites - matrix update

(3) - POSTERIOR COMPOSITES

(4) - DIAGNODENT

(5) - CROWN/INLAY/ONLAY TEMPS at TURBO SPEED

(6) - VENEER TEMPS AT TURBO SPEED

(8) - Liner Bond "3"

(9) - Liner Bond 2V: (V as in Versatile)

(10) - Using Liner Bond 2V:

(11) - Pulp caps

(12) - Sealant/desensitizer for indirect restorations at "prep":

(13) - "Slow set" Panavia 21:

(14) - Photo Bond - is it currently recommended?

(15) - Alloy Primer or tin plate?

(16) - CR Inlay Cement and DC Cement

Some hot topics:

(17) - Condensable composites

(18) - Fast impressions.

(19) - Fast cure lights

(20) - Some problems

(21) - Stop sensitivity!

(22) - "Directed shrinkage" vs. light cure composites in 1998

(23) - Keller's new Meridian Center

(24) - Hands-on in Colorado, at Colorado Springs

Most Current Newsletter Editions

(1) - Posterior Composites Issue 18, First half 1999 (preview edition)

(2) - Posterior composites - matrix update

(3) - POSTERIOR COMPOSITES

(4) - DIAGNODENT

(5) - CROWN/INLAY/ONLAY TEMPS at TURBO SPEED

(6) - VENEER TEMPS AT TURBO SPEED

(8) - Liner Bond "3"

(9) - Liner Bond 2V: (V as in Versatile)

(10) - Using Liner Bond 2V:

(11) - Pulp caps

(12) - Sealant/desensitizer for indirect restorations at "prep":

(13) - "Slow set" Panavia 21:

(14) - Photo Bond - is it currently recommended?

(15) - Alloy Primer or tin plate?

(16) - CR Inlay Cement and DC Cement

Some hot topics:

(17) - Condensable composites

(18) - Fast impressions.

(19) - Fast cure lights

(20) - Some problems

(21) - Stop sensitivity!

(22) - "Directed shrinkage" vs. light cure composites in 1998

(23) - Keller's new Meridian Center

(24) - Hands-on in Colorado, at Colorado Springs

(1) - Posterior Composites
Issue 18, First half 1999 (preview edition)