31.08.2015
The tunnel restorationD K Ratledge1, E A M Kidd2 & E T Treasure3A description of tunnel restoration. Universally indicated for all indirect applications, NX3 is a permanent resin cement system with an innovative chemistry for unmatched aesthetics, adhesion and great versatility. Click Dental Supplies is operated under licence as a trading division of HM Logistics Limited, whose registered office is: EUROPA HOUSE EUROPA TRADING ESTATE, STONECLOUGH ROAD, KEARSLEY, MANCHESTER, ENGLAND, M26 1GGRegistered in England No. A few months ago I introduced resin-modified glass ionomer (RMGI) into my practice after reading this article by Dr. A 77 year old male presented with multiple carious lesions on root surfaces throughout his dentition.  Due to his higher caries risk and the subgingival location of the lesions, he was treatment planned for RMGI restorations. Please note that I can no longer answer questions from the public regarding their personal dental care. Inlays and onlays are used by dentists to restore teeth that have been damaged due to decay or trauma.
If you want to have a brighter, whiter and more radiant smile don’t waste your money with cheap whitening methods. If you smoke, drink wine, coffee, tea or cola chances are your teeth are going to develop a brownish or yellowish tint. Zoom Whitening is performed by our professional dentists on both offices located in Glendale, CA. There are two types of veneers our dentist use: one is made out of porcelain and the other is made out of acrylic resin. Bonding is a dental procedure in which composite resin is adhered to the tooth in order to improve the appearance of your smile.
When patients have gaps on their teeth, the bonding procedure can be used to fill in the space between them. The first step for the bonding procedure is the dentist choosing a composite resin that matches the natural color of your teeth. This procedure has many advantages such as: it is inexpensive, fast, relatively painless, long lasting and effective! A dental restoration is a procedure to restore missing tooth structure due to accidents or infections. Direct restorations are those made directly on the tooth, while indirect restorations are those made externally and then placed on the tooth, such as crowns, bridges and veneers. Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. Delivery system choices include an automix syringe for dual-cure indications and a light-cure cement for multiple units where unlimited work time is needed. In many instances, inlays and onlays are a more conservative approach to repairing a tooth without getting a full dental crown. Inlays are placed inside of the tooth, similar to a filling and onlays are placed on the surface or outside of the tooth. This thin shell can create a fantastic and bright smile; and with proper care, can last up to 15 years. Bonding is used in cosmetic dentistry because it gives a natural look by rebuilding your teeth and improving your smile.
Our dentist in Glendale, CA prepares the tooth and applies the composite resin that is dried and hardened with a curing light. Dental restorations can be made of different materials: metals, dental composites, glass ionomer cements and porcelain. The automixing dual-cure cement can be used for all indirect applications, including veneers.With Kerr’s proprietary aminefree initiator system and optimized resin matrix, NX3 is the first truly colour-stable adhesive resin cement.
They help with uneven tooth alignment, spaces between teeth, chips, cracks, worn and discolored enamel or stained teeth. They preserve more of the natural tooth structure and last much longer than traditional dentures. Inlays and onlays are additionally beneficial because they are made to match the color of your teeth.
The tunnel preparation is one of these, first described in 19631 for the restoration of distal approximal surfaces of deciduous second molars. In this preparation approximal carious lesions were accessed and prepared by approaching the lesion from the occlusal aspect, instrumenting beneath the marginal ridge, but leaving it intact. The teeth were restored with a fluoride-leachable silicate cement and it was suggested that this might prevent caries developing in the mesial surface of the first permanent molar. Here the approximal enamel is retained because there is no macroscopically observable cavitation. A partial tunnel preparation extends onto the approximal surface into a macroscopically observable cavitation or into an area where the enamel has disintegrated during cavity preparation. The enamel is carefully smoothed around the opening leaving some demineralised enamel adjacent to the filling. The demineralised dentine in non-cavitated lesions is minimally infected.21Top of page Clinical trialsTable 1 lists the clinical studies of the tunnel restoration that have been carried out on permanent teeth.


The search methods used to find these studies were a Medline search of English literature from the 1960s, to mid-2000 using the keywords, \'tunnel restoration\' and, \'tunnel cavity preparation\' followed by a careful check of all relevant references at the end of these papers.
Three of these3, 32, 33 were excluded because the number of restorations inserted at baseline was not clear. This information is fundamental if the success or failure of a technique is to be evaluated. One preliminary report34 of a study later described in further detail28 was also eliminated. The review will now comment on the design of the remaining 12 studies before attempting to summarize their findings.Randomised controlled clinical trialsOnly the first four studies,20, 23, 24, 25 are designed as clinical trials involving a control material. The inclusion of a control group is important in clinical trials that evaluate a new technique or material.
This design enables the researcher to comment on how the results of the new method compare to \'standard practice\' which in the case of the operative management of approximal caries, would access the lesion by removing the marginal ridge. In designing a clinical trial care should be taken to randomly assign subjects into experimental and control groups that differ only in terms of the intervention. It is therefore surprising that so few studies have been designed with controls since there appeared to be no shortage of patients. Ironically the first four studies in the table, which were controlled, have rather small numbers of patients.
It should also be noted that the ideal design of a clinical trial is double blind in that neither the dentist nor the patient are aware of whether the patient belongs to the experimental or the control group.
However, this design is not possible when comparing a tunnel restoration which preserves the marginal ridge with a standard Class II restoration which removes it.Top of page What constitutes failure? Two approaches were possible: the first was to accept that if a restoration was actually replaced it had failed.
The alternative approach is to accept that a restoration had failed when the decision to replace it was based on clearly defined criteria. However, this decision inevitably excluded all studies that examined the longevity of restorations placed in practice where the criteria for replacement were not given other than a dentist\'s decision to replace.All but one26 of the studies listed gave the criteria used to assess failure. This is particularly likely in these studies because the observer cannot be \'blind\' as to which group the restoration is in.
Thus the observer might wish the new technique to perform well and this is even more likely if the observer is evaluating his or her own work.
This may well have been relevant to some of the studies listed in Table 1 where dentists apparently assessed their own work.
The inclusion of multiple assessors is preferable although this introduces its own difficulties, as their assessments may not be reproducible with each other.
In a well planned trial a number (usually 10%) of observations are repeated and statistical tests used to check both intra- and inter-examiner reproducibility. None of the studies in Table 1 took this approach although several used multiple, calibrated examiners thus making a real attempt to standardize assessment. Furthermore, good studies ensure the data are clearly presented according to international standards. This ensures appropriate conclusions can be drawn but in the present work it was difficult to unravel the relevant data from the material presented.Top of page SettingMany of the studies listed in Table 1 were carried out in a community setting or in general practice. Thus the new restoration was placed and evaluated in the setting in which it will generally be used. Reference to Table 1 shows that in only seven studies was there more than one operator involved. Multiple operators is the clinically realistic situation but this introduces another variable.
In one study listed in Table 1 caries active patients were specifically selected23 and in two others the effect of caries rate on survival times was examined.22, 31Top of page Drop out rateThe number of patients completing a clinical trial is important information. Loss of subjects might reflect systematic differences between the groups because one of the treatments was ineffective or uncomfortable in comparison with the other. Thus loss of subjects may bias results (attrition bias) and this inevitably means that conclusions are reached on the basis of fewer assessments than was originally planned. Reference to Table 1 shows the drop out rates and the loss of subjects was often considerable ranging from 0 to 60%. This might not matter if the research could show the drop out was random but this has not been addressed in these studies.
It is equally possible that the high drop out reflects failure of the restorations.Top of page Results of the clinical trials presented in Table 1From the previous discussion it is obvious that many of the studies listed in Table 1 are methodologically flawed by a lack of controls and high drop out rates. The only studies considered acceptable by the systematic review36 on the longevity of restorations, were controlled or a prospective series of cases where specific criteria were given on why restorations were to be replaced.
Their paper concluded that the ideal study design to assess the longevity of restorations would be multicentre, multioperator studies for assessment periods greater than 10 years. While the logic of the approach is obvious, achieving it in a primary care, realistic setting seems almost unattainable! None of the studies in Table 1 fulfil these criteria.The length of the trial seems particularly important in the tunnel restoration.


Two papers25, 34 show reasonable results at 3 years but much higher failure rates at 5 years with respect to secondary caries. Since, secondary caries is primary caries at the margin of a restoration this is not surprising.
It would seem the tunnel restoration is contra-indicated in any patient with a high caries activity.An obvious question is how does the longevity of the tunnel restoration compare to that of amalgam and composite posterior restorations?
Since there is only one controlled study lasting longer than 5 years25 this information is not available from the literature.
However, a systematic review of the longevity of restorations36concluded that at 10 years less than 10% of amalgams had been replaced, and amalgam survived significantly better than composite.
Secondary caries is an important cause of failure and this becomes apparent in studies after 3 years.
The restoration seeks to restore the integrity of the tooth surface so that plaque control may be re-established. To be sure that the lesion is cavitated and to improve visual access for operative dentistry it is useful to separate teeth by placing an orthodontic elastic separator (American Orthodontics Corporation Wisconsin, USA). Figure 1 shows the separator in position and Figure 2 shows the small interproximal space created on removal of the separator 1 week later. The entry point of the bur is in the occlusal fossa about 2 mm away from the marginal ridge.
The bur is angled axially through the enamel to produce an ovoid access cavity but once dentine is reached the bur is angled towards the carious lesion (Fig. The cavity is considered to be caries-free when the dentine feels hard to a straight probe. The glass ionomer cement is mixed according to the manufacturer\'s instructions and carefully inserted into the cavity and condensed. Once the glass ionomer has set, the occlusal portion, approximately 1 mm in depth, is removed with slow round burs (Fig.
After washing and drying unfilled composite bonding resin is applied to the surface, gently air dried and light-cured for 10 seconds. The matrix band is removed and Softlex polishing strips (3M) are used to finish the glass ionomer at the approximal surface. The tooth is washed and dried and a further layer of unfilled resin is placed occlusally and approximally and light cured for 10 seconds.
After removing the rubber dam, the occlusal contacting surfaces are checked for interferences. Knight GM The use of adhesive materials in the conservative restoration of selected posterior teeth.
McLean JW Limitations of posterior composite resins and extending their use with glass ionomer cements.
Strand GV, Tveit AB Effectivenesss of caries removal by the partial tunnel preparation method.
Strand GV, Tveit AB, Espelid L Variations among operators in the performance of tunnel preparations in vitro.
Strand GV, Tveit AB, Eide GE Cavity design and dimensions of tunnel preparations versus composite resin class II preparations. Ratledge DK, Kidd EAM, Beighton D A clinical and microbiological study of approximal carious lesions.
H, Leirskar J, von der Fehr FR, Eide GE Tunnel restorations placed in routine practice and observed for 24 to 54 months. Svanberg M Class II amalgam restorations, glass-ionomer tunnel restorations, and caries development on adjacent tooth surfaces: A 3-year clinical study.
Wilkie R, Lidums A, Smales R Class II glass ionomer cermet tunnel, resin sandwich and amalgam restorations over 2 years. Lumley PJ, Fisher FJ Tunnel restorations: a long-term pilot study over a minimum of five years. Pilebro CE, Dijken JW, Stenberg R Durability of tunnel restorations in general dental practice – a 3-year multi-centre study. Nicolaisen S, von der Fehr FR, Lunder N, Thomsen I Performance of tunnel restorations at 3-6 years.
Knight GM The tunnel restoration – nine years of clinical experience using encapsulated glass ionomer cements. Moles DR, dos Santos Silva I Causes, associations and evaluating evidence; can we trust what we read? Chadwick B, Treasure E, Dummer P, Gilmour A, Jones R, Phillips C, Stevens J, Rees J, Richmond S Challenges with studies investigating longevity of dental restorations – a critique of a systematic review. Letzel H, van\'t Hof MA, Marshall GW, Marshall SJ The influence of the amalgam alloy on the survival of amalgam restorations: A secondary analysis of multiple controlled clinical trials.



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