A History of the Pankey-Mann-Schuyler Method 

By Bill Davis 

During his three-month summer course at Northwestern University in 1931, L.D. Pankey was introduced to the principles of occlusion. This was a new term for him and many of his dentist colleagues. The students were assigned an article by Clyde Schuyler and published in the 1926 New York Dental Journal. Dr. Schuyler was a promenade prosthodontist from New York City. The article talked about the basic principles of occlusal function, its dysfunction (malocclusion), and the basic requirements for restoring occlusal harmony. 

1931: Dr. Clyde Schuyler Prompts Considerable Thinking 

At first, L.D. did not understand what Dr. Schuyler had written. He was not alone because most of his classmates had the same problem. L.D. eventually made personal contact with Dr. Schuyler and, after a series of conversations, understood Schuyler’s work.  

Schuyler told L.D., “Those in the field of dental reconstruction must have and cultivate the creative mind of the artist and the accuracy of the engineer.”  

That was easy for Schuyler to say, but he did not explain to L.D. how to approach and visualize a dental reconstruction. Before L.D. met Dr. Schuyler, he had restored posterior occlusion using a Munson articulator and a chew-in technique. The Schuyler article pointed out the importance of anterior teeth guidance. This made L.D. start thinking about approaching occlusion in a more logical step-by-step manner. 

1947: Dr. Arvin Mann Looks Up Dr. L.D. Pankey 

In 1947, Arvin W. Mann moved to Ft. Lauderdale from Birmingham, Alabama. Dr. Mann had graduated from Western Reserve and moved to Alabama to do nutritional research at the University of Alabama before he moved to Florida. L.D. also had an interest in nutrition. His first published article in the Florida State Dental Journal was related to the connection between carbohydrates and dental decay. 

While in Alabama, Arvin became interested in occlusal rehabilitation and the relationship between periodontal disease and restorative dentistry. A periodontal faculty member told Arvin, “When you get to Florida and want to do a restorative work where you won’t have to do all this grinding to correct occlusal restorations, look up Dr. L. D. Pankey in Coral Gables.” 

As soon as Arvin got to Florida, he went to Coral Gables to meet L.D. They became fast friends because they realized they had the same goal of helping their patients keep their teeth for their lifetime. Over the next ten years, they worked together to develop a predictable diagnostic and treatment method for restoring patients’ teeth to health, comfort, function, and esthetics that would fit into the Philosophy of doing their best to help patients keep their teeth. 

1947: Drs. Mann and Pankey Begin Collaborating on Cases 

Arvin began bringing a set of mounted diagnostic casts and an intraoral series of radiographs to L.D.’s office. Arvin and L.D. would review the case together and develop an optimum treatment plan. L.D. would then present the case to Arvin using Arvin as the patient. This was a way to demonstrate to Arvin how to use the Philosophy, get to know the patient, explain what needed to be done, and educate patients to accept the treatment plan.  

Arvin would practice the presentation on L.D. He would then return to his office and explain the treatment plan to his patient. When the dentistry was finished, Arvin would have another appointment to “resell” the case to the patient and make them a missionary for his practice. Within a short time, Arvin had a busy and successful practice. Arvin eventually helped four young dentists from outside his office like L.D. had helped him.  

Mann and Pankey Replace the Munson Articulator with the P-M Articulator 

They used L.D.’s Munson articulators when they started working together on their new restorative method. But soon, they found Munson articulators had limitations for their 3-dimensional approach, including a functionally generated path. Along with an engineer from the Ney Gold company, they designed their own — the P-M instrument and face-bow.  

Arvin became excited about their restorative technique and wanted to share this information with the profession at a Chicago Mid-Winter Dental Meeting. L.D. felt that it would be best to work with a small select group of dentists interested in occlusion and comprehensive restorative dentistry. By now, L.D. had been teaching the Philosophy for a few years.  

L.D. and Arvin selected eleven dentists from various geographical locations around the country who had taken the Philosophy course at least three times and were already using a conventional method to do restorative dentistry. They asked them to try the new P-M technique and articulator for a year. At the end of the year, the group got together in Dallas. The reports from the eleven dentists at the meeting were positive and gratifying. L.D. and Arvin then started the Occlusal Rehabilitation Seminars to teach other dentists the P-M technique and how to use their articulator and face bow.  

1959: The P-M Method Is Presented to the AARD 

In 1959, they presented the P-M therapeutic method to the American Academy of Restorative Dentistry at the Chicago Mid-Winter. They were then asked to write up two articles describing their new process showing the use of the P-M articulator for publication in the 1960 Journal of Prosthodontic Dentistry.  

1960: The Occlusal Rehabilitation Seminars Begin 

Arvin and L.D. wrote the Pankey-Mann Manual for the Occlusal Rehabilitation Seminars and started teaching the restorative technique to other interested dentists. The seminar schedule was coordinated by L.D.’s long-time secretary, Rose Quick.  

One of the most significant difficulties in teaching the P-M technique was the inability of dentists to understand occlusion. At that time, no dental school in the United States taught occlusion. L.D. and Arvin realized it was essential to have Dr. Clyde Schuyler present his work on occlusion at their seminars. Also, they did not want Clyde to go to his grave without the profession appreciating his contribution to dentistry.  

L.D. asked Clyde if he would help them teach occlusion. Clyde was reluctant because he anticipated much opposition to this new method and articulator. Also, he didn’t want to upset his friends and colleagues who had authored books or conducted clinics with him about occlusion. 

Eventually, Clyde agreed, and from that point forward, the P-M technique became the Pankey-Mann-Schuyler Technique for Oral Rehabilitation. 

Restorative Notes on Bonding to Sclerotic Dentin and Removing All-Ceramic Crowns 

By Lee Ann Brady, DMD 

Bonding to Sclerotic Dentin 

Bonding to sclerotic dentin is difficult, if not close to impossible. If the lion’s share of the tooth’s surface is sclerotic, you may not have the longevity that you’re hoping for. I’m specifically thinking of some lower anterior restorative cases I’ve seen over the years, where the veneers just haven’t held up and we’ve had to go to full coverage. 

I don’t trust some of the self-etching adhesives to result in a strong bond on sclerotic dentin, even the newer ones in the eighth generation. Fortunately, one thing we don’t need to worry about is sensitivity because the dental tubules are closed. Since I’m not worried about sensitivity, I can apply the same techniques I would with enamel with the intent of improving the probability of a strong bond. I can do a light prep, get rid of the sclerotic surface, and etch it with phosphoric acid for 25 or 30 seconds. Alternatively, I can use 30- to 50-micron aluminum oxide in an abrasion unit.  

Removing All-Ceramic Crowns 

Removing dental crowns can be a delicate and time-consuming procedure. In a world of so many different materials, it’s helpful to have an idea of which bur to use and how long removing the crown could take. One of the biggest challenges is determining whether a crown is a lithium disilicate or zirconia restoration. The radiograph and visual inspection will give us clues but afterwards, we must go through a process to understand what may be involved. 

Our First Clue: Zirconia looks like metal on a radiograph, and lithium disilicate looks radiolucent like natural tooth structure.   

Our Second Clue: If the crown is partial coverage, it’s much more likely to be bonded and I plan to prep down the entire restoration.  

Lithium disilicate restorations are often easier to cut through or section but they could be bonded and impossible to remove in pieces. Even if we can cut four pieces, we may have extensive prepping to do.  

On the other hand, zirconia can be harder to cut through, especially the 3y or 4y variety. But at least once you get to the cement layer, you can normally break it into pieces and remove them instead of having to extensively prep the entire tooth.  

If the restoration is full coverage, I can easily remove it in sections. In this case, I attempt to make my cuts all the way from buccal to lingual across the occlusal surface without bothering to stop. At this stage, I can pick up a crown remover and apply some general pressure to crack it off. If the crown is not budging at all, I assume it is bonded to the tooth, and the next thing I do is pick up a big flat-top diamond to do my occlusal reduction as if I were prepping a natural tooth. Once all the occlusal is off the glass, the pieces on the buccal, lingual, and interproximal fall off. 

Dr. L.D. Pankey, Sr. (“L.D.”) was born on July 31, 1901. He received his Doctorate in Dental Surgery degree from the College of Dentistry at the University of Louisville, practiced in New Castle, Kentucky, for one year, and then relocated his practice to Coral Gables, Florida, in 1926.

The motivation for his decision to leave New Castle came when he received a letter from his mother. She wrote,” I am happy you are doing so well in your practice, but I hope you are not doing to your patients what has been done to me. I have had all my teeth out and now have dentures. This has been the unhappiest experience of my life.”

L.D. had examined his parents while in dental school and was sure they did not need dentures. After reading his mother’s letter, he made a commitment to practice dentistry in a new way, focused on saving teeth. This was a difficult decision because at that time he did not know how to achieve his commitment. In 1926 the typical dental practice provided examinations, cleanings, extractions, silver and silicate fillings, and complete and partial dentures.

His decision to leave New Castle, Kentucky was driven by the desire to have a new, fresh start and to find his own way to practice dentistry without removing teeth. Over his lifetime, he often said, “When I left New Castle, I vowed that I would never take out another tooth as long as I lived.”

Shortly after arriving in Coral Gables, he was lucky to be invited to join a unique dental study club in Miami headed by an oral surgeon. The purpose of the study club was to study ways to prevent tooth loss. He couldn’t have moved to a better place to learn with and from other like-minded professionals.

What made this club unique was they did not pay an honorarium to speakers., Instead, they paid their travel expenses, and they personally entertained the speakers in their homes for the week. The speakers were happy to have a mini vacation with their families in Miami. This gave L.D. the opportunity to meet and befriend them.

Among the visiting speakers were notables such as Winston Price who talked about nutrition as it related to caries, C.C. Bass MD who talked about flossing and home care (the Bass tooth brushing technique and unwaxed floss), Harry Morton who talked about restorative dentistry and showed them how to use of the Munson articulator to create the curve of Spee and Wilson, and Clyde Schuyler who came down from New York City to discuss his ideas on occlusion.

The letter from his mother launched his unique career and influence on dentistry which has been indelible for the last 90 years. Reflecting on L.D., the person who inspired me most to take the career journey I have been on for over 50 years, I realize his philosophy of dentistry and his friendship still inspire and shape me. His mother’s letter is always on my mind as I continue to teach prosthodontics and chair the Department of Dentistry at the University of Toledo. I can’t imagine a more meaningful life than providing others with optimal health, function, and the happiness of having a beautiful smile.

One day an elderly woman came into the office without an appointment. Mrs. Blanchard was a tall woman wearing a large, flowered hat and a black ribbon around her neck. She had the airs of an aristocrat. She had been referred to the office by her next-door neighbor who told her Dr. Pankey was the dentist who did not believe in pulling teeth. When she came in, she refused to sit down and asked to talk to the dentist immediately. When asked why Mrs. Blanchard was there she told the receptionist it was both professional and personal.

L.D. escorted her to his private office. She immediately said, “Dr. Pankey I understand you do not extract teeth.”

L.D. Said, “I do not extract teeth; however, if you need extractions, I will send you to a good oral surgeon in Miami.”

She interrupted, “That is the reason I am here. I do not want to lose my teeth.” She had ready been seen by two dentists and both said she needed dentures. Her plan was to have only Individual teeth extracted when she was in pain. She asked if he would be willing to try to save her teeth. Because she was a walk-in they made another appointment for a proper examination, x-rays, and time for a consultation.

When she came back, he told her he thought she could keep most of her teeth; however, he couldn’t promise all of them. He also told her he had been studying with some of the best dentists in the country and would do his best. Although she did not ask him, he quoted her a fee large enough to allow him to redo work if necessary. She showed no concern about the fee, so they got started.

She needed a couple of extractions and endodontic procedures. During the healing time, he did simple restorative dentistry. Her treatment took three and a half months. L.D. told her everything he was doing and why. She became extremely interested in the process. He used the Munson articulator and followed Taggart’s 1912 “chewing in” technique. All the crowns were done directly in the mouth using compound impressions, amalgam dies, and denture card wax to create a functionally generated path. When everything was completed, he put her on a three-month cleaning regime. Happily, the dentistry lasted until Mrs. Blanchard was 81.

Being a little eccentric, Mrs. Blanchard never wanted to sit in the reception room. When she did come in for her cleanings, she preferred sitting in L.D.’s private office. One day, during the midst of the Great Depression, she was in his office paging through an American Dental Association journal that she had found on his desk. An article about the upcoming International Dental Congress meeting in Paris, France caught her interest.

When L.D. came into the room she asked, “Are you going to this meeting in Paris?” He said, no I am very busy here with my practice and keeping my staff working.”

Two weeks later she returned and asked to see L.D. As usual, she was sitting in his private office when he came in. She said, “I still think you should go to the International Congress in Paris because you have great potential. I want you to go, and I want you to travel first class. I would like to pay all your travel expenses, all your office expenses including your staff, and compensate you for the time lost in your practice. When you go, I want you to travel all over Western Europe because that is where our civilization came from. You need to see London, Florence, Rome, Vienna, Heidelberg, and of course, Paris. Now, are you willing to go?”

L.D. was totally taken aback. Mrs. Blanchard had a great deal of gratitude for the time L.D. had spent learning how to treat her problem and for the care and understanding he gave her during and after her treatment. The enormity of her gratitude and appreciation was whelming.

After talking to his wife and his staff, he did go to Europe, and he did go to the Congress in Paris. Little did he know what a profound impact this gift would have on his life. Mrs. Blanchard had given him the opportunity to expand his knowledge of dentistry and the potential to become a leader in dentistry.

Complex dental cases often need support from multiple specialties for a final successful outcome. The approach to work out these cases can be a “multidisciplinary approach” or an “interdisciplinary approach.”

In the case of “multidisciplinary treatment planning,” each of the dental professionals makes their own plan for the treatment they will provide and they seek the help of other disciplines as the need arises. A fairly common example is when a patient finishes orthodontic alignment and then sees a dentist for esthetic restorations.

“Interdisciplinary treatment planning” takes another approach. Treatment is preplanned among the restorative dentist, specialists, and the laboratory team prior to commencement. What is notable in this approach is that you communicate, you collaborate, and you create the plan together as a team. As a restorative dentist, my role is to sit at the center of the specialist, the lab technician, and the patient. In my experience, involving the lab technician from the beginning produces best results and a more efficient process of treatment.

Avishai Sadan — my colleague and the dean at USC, says interdisciplinary treatment planning results in “being able to formulate a custom-tailored treatment plan that addresses patient present and future needs and to execute it to the highest clinical level possible, using state-of-the-art techniques and technologies.” This statement defines for me the best way to do dentistry.

The Benefits of Interdisciplinary Treatment Planning

The foremost benefit is to our restorative patient, whose well-planned dentistry optimally solves current and future needs. Not only are restorative results at the highest clinical level, but we can practice what we enjoy doing most at our highest skill level, while enjoying collaboration with others who are working at their highest skill level. Liability is lower, and we learn from each other.

As a team, we have developed a smooth process of communicating, contributing knowledge, and deciding what will be an optimal course of treatment. We document with photos the procedures each of us performs so we each have complete documentation of the cases we do together.

The others who are on my interdisciplinary team refer patients to me because they are comfortable with the process we have developed and value the quality of the restorative dentistry I do. My practice is distinguishable from dental practices that do not do interdisciplinary treatment planning. Patients who are referred are commonly told about this interdisciplinary planning approach before they arrive. They anticipate a high level of personal attention and a course of treatment that all doctors agree upon. Case acceptance is high when all doctors and the lab team agree on what is best for the patient. Communication and agreement among the providers is so complete, the patient can be optimally informed about what to expect at each stage of treatment.

More dental leaders are blogging on the subject of leading dental patients to improved health by learning what is important to them. Often, the next words we read are “We need to meet patients where they are.” What exactly does that mean???

To me, this doesn’t mean we meet expectations of low cost, faster care, with immediate results. This doesn’t mean we make promises that all their dental needs are met for the next six to twelve months. It doesn’t me the therapy we provide will solve an incipient or chronic problem for life. It doesn’t mean their insurance coverage dictates the value of the care we deliver. It doesn’t mean we are going to open our office after hours or on the weekend because that’s what someone wants. It doesn’t mean we guarantee a crown or veneers will last and never need to be replaced.

To me, this means understanding the individual patient, not patients (plural) as a population with trending, new expectations in 2022. It means focusing on the things each person thinks are important and relevant to their lives…where their priorities lie. Then, we can attempt to strategically tie what they value to their dental health to help them make a connection to a preferred future self. Most people, it seems, are unable to make these connections on their own.

Two Big Questions We Ask Ourselves

What do our oral health findings–ideally uncovered during a co-discovery exam, mean to a particular person? If our findings don’t have meaning to the patient, how can we possibly motivate the patient to take action? All of us struggle with these types of questions because we can’t force our values, our philosophy of oral health on others.

We can, however, create opportunities to reveal a pre-existing, unrealized value of health the patient has. If we find the patient is not health-centered, we can triage that person appropriately so we spend most of our time with patients who are health-centered.

“Revealing” Unrecognized Value Takes Time

Early in my career, I thought I could educate my patients to see the value of oral health the way I saw it. I found I was often knocking my head against the wall. Some people just didn’t value it. They wanted help when they were in pain, but preventing dental deterioration wasn’t something they felt needed immediate action. Moving forward with treatment was not on their personal agenda.

Gradually, as I read Bob Barkley, L.D. Pankey, Nate Kohn, Jr., and others, I realized they had gone through a discovery process of their own. The first task was to get to know the patient and understand the patient’s value for health and the patient’s oral health objectives. It was also to try to discover if their oral health circumstances were important to them so I could help them envision their preferred health future. But that takes time—time with each patient.

If your practice is primarily insurance dependent, you are underpaid most of the time. How do you compensate for this problem? You find ways to work faster. You find ways to see more people in a day. You delegate more. You look for a way to cut your lab technician’s salary out of your life. You buy in bulk and wake up in the middle of the night wondering why you got into dentistry in the first place.

It doesn’t have to be that way!

Many years ago, when I began spending time with new patients to learn if they are health-centered, I was able to better manage my time with them. If they valued health…if I could connect them with their dental needs on a deeper level, then spending even more time with them was well worth it.

Those who value health are the patients we can easily help understand why we take our comprehensive approach to restoring and maintaining optimal oral health.

You can be more productive per hour than you can imagine, IF you take the time to connect with patients on a deeper level and you strategically find ways to spend most of your time with people who care about their health in the first place.

L.D. Pankey wisely said, “People change, but not very much.” And that’s a critically important life lesson, one that took me years to accept because I thought my philosophy would psychologically trump theirs, and I would therefore win the day. I was wrong – very wrong.

The more complex the dental treatment plan gets, the more challenging the process becomes. Adding in interdisciplinary care with multiple specialists adds another layer of complexity. We need to clearly plan our sections, and clearly communicate the outcomes we hope for from the other providers.

The Challenges

One of the challenges has been communicating to my orthodontist my visual for the results. The other challenge has been how to visualize tooth movement to optimize my restorative. What has helped me tremendously is doing an ortho setup as well as a restorative wax-up.

My Process

This is a process I use when planning complex cases involving orthodontic and restorative that has helped create clear expectations for everyone.

1. I start my aesthetic treatment planning by drawing white shapes and lines on photographs of the teeth to determine the desired tooth proportions and gingival aesthetics. I’ve blogged about this before in these two articles: Tooth Proportion Aesthetic Ratio and Where the Pink Should Be. I also draw lines on photographs to determine the Anterior Segment Aesthetic Ratio.
2. When a complex restorative case involves orthodontics, I want a clear sense from my white lines of where I want the teeth moved so I can optimize my restorative. I will send a set of preoperative models to the laboratory and ask them to do an ortho setup. Multiple copies of the ortho setup allow us to move the teeth and do a restorative wax-up on the moved teeth. Once I examine the wax-up I decide if the teeth look the way I visualized they would. Do they have the right length to width ratios? Do they have all gingival margins in the right positions? If I were to just do a carved restorative wax-up, I wouldn’t understand if the tooth movement is helpful. If you are not familiar with ortho setups, I recommend reading this article from 2012.
3. Once I have the teeth positioned in an ortho model the way I think will be best for my restorative, I send my orthodontist the model to communicate exactly where I want the teeth moved. The orthodontist provides feedback on what will be involved to get those movements. Based on that, I can balance the risks and benefits of alternative treatment plans and discuss with the orthodontist whether restorative treatment should occur at the very end of orthodontics or be done in phases during orthodontic treatment.

Ferrule is a critical factor in being able to plan the prosthodontic phase of treatment for an anterior tooth that has had endodontic therapy. It is also an ingredient in predicting the longevity of the tooth and restoration. Yet, given this level of importance, it is often misunderstood and overlooked.

What is tooth ferrule?

Ferrule is the amount of natural tooth structure we have left on an anterior tooth on which we are going to do a post-core and crown. Knowing the amount is integral to knowing how we are going to seat the crown and it gives us ballpark information about the longevity of that restoration. We look at the natural tooth structure of the tooth on the buccal and the lingual.

The amounts of the natural tooth that are left on the mesial and distal don’t matter. We don’t measure them. They don’t help us at all with retention and longevity.

On the buccal and lingual, we look at the height of the natural tooth structure, measuring from the margin of the crown prep up to where the core starts. We also look at the thickness of that natural tooth structure, measuring from the outside surface of the crown prep to the inner surface where the post space begins. We measure the height and thickness, both buccal and lingual. We then use the smallest number. If we have less tooth structure on the lingual, then the ferrule is determined on the lingual. If we have less thickness than we have height, then the ferrule is determined by the thickness.

Wherever the place is where we have the least natural tooth structure, that now becomes the ferrule we use when we start to think about how we are going to treat this natural anterior tooth.

How does ferrule impact restorative decisions?

The amount of ferrule impacts restorative decisions such as:

• Bonding versus cementing the post
• Bonding versus cementing the crown
• Doing a post at all
• Predicting longevity after restoration

Guidance for these decisions has been formed from substantial research published by the University of Washington School of Dentistry in Seattle that looks at the longevity of the post-core based on the amount of ferrule and whether we bond or cement.

If we have minimum ferrule (1.0 to 2.0 mm) and we want to get the maximum longevity for the anterior restoration, we should bond the post-core and then bond the crown with a dual-cure resin bond system that adds strength to the restorative material, like NX3 Nexus™ Dual Cure from Kerr, Multilink® Automix from Ivoclar Vivadent, or G-CEM LinkForce® from GC America. There are lots of choices of systems you can use, but we need to etch, prime, and bond for high bond strength. We need to keep in mind that even though we are increasing the longevity of the restoration by bonding, the restoration on minimal ferrule will not last as long as a restoration on a greater amount of ferrule.

If we have 2.0 to 3.0 mm of ferrule, we can choose whether to bond the post-core and cement the crown or to cement the post-core and bond the crown to get the same longevity as the tooth with 1.0 to 2.0 mm of ferrule treated by bonding both the post-core and crown. When we have 2.0 to 3.0 mm of ferrule, we can increase the longevity of the restoration even more if we bond both the post-core and crown.

If we have greater than 3.0 mm ferrule, we can cement both pieces without affecting longevity.

If we have 4.0 mm or greater of ferrule, the question becomes whether we need to do a post-core on this tooth or do a fully bonded restoration.

Key Points to Remember

• The amount of ferrule we have has a strong impact on the longevity of the restoration.
• We can increase the longevity when we have less ferrule by bonding both pieces, the post-core, and the crown.
• When we have very little ferrule, we need to understand that we have a reduced longevity for the post-core restoration, even in the face of bonding.
• The amount of ferrule is one of the strongest indicators of how long an anterior crown will last, as well as whether we have bonded or cemented. How long a crown will last involves additional factors I will discuss in another blog, How Long Do Crowns Last?

SpeedCEM Plus is a dual-cure self-adhesive resin cement from Ivoclar that has been designed to be used with restorations that have inherent mechanical retention. It can be used for most materials – all-metal restorations, zirconia oxide ceramics, or something in the lithium disilicate category. The material will fully pull MRIs on its own, but it can also be light-cured. It has great esthetics, low technique sensitivity from the standpoint of using the material, and great bond strength. It is easily cleaned up. 

Prepping the Internal Surface of the Restoration 

Oxide-based ceramic restorations are etched with air abrasion. Your laboratory can do this, or you can use between 30 and 50-micron aluminum oxide to air abrade the intaglio of the restoration. Confirm with your lab if they are going to be doing this. 

The internal surface of lithium disilicate based restorations is etched using chemistry. You can use hydrochloric acid at 5% for no more than 20 seconds, or you can use an Ivoclar Vivadent product called Monobond Etch & Prime for 60 seconds.  

If you try in the restoration after it has been etched, as I like to do, then the restoration will need to be cleaned again before it is bonded. For this cleaning purpose, I use Ivoclar Vivadent’s Ivoclean. It’s a phosphate-free restorative cleaning material that can be used on metal, oxide-based ceramic materials, and on lithium disilicate materials. I simply vigorously shake the bottle and apply Ivoclean for 20 to 30 seconds, rinse the restoration and dry it. I recommend using a clean air source for drying such as an Adec airline on your unit. 

If you are going to use metal ceramics or lithium disilicate, you now need to condition the inside of the restorative material. I use the product Monobond Plus, which is appropriate for all kinds of materials.  

If you are working with zirconia or an oxide-based ceramic, one of the advantages of SpeedCEM Plus is you do not have to do anything to the inside of the restoration other than the air abrasion and cleaning because the chemistry in the SpeedCEM Plus will prime or condition the inside of the zirconia restoration.  

Prepping the Prepared Tooth 

With SpeedCEM Plus, we do not need to do anything to the tooth prior to cementation other than cleaning the tooth. I like to clean the prepared tooth with light air abrasion and apply a 2% chlorhexidine solution to the prep and clean the tooth with a bristle brush in a slow-speed handpiece. 

SpeedCEM Plus Application & Cure 

After cleaning the prep, you can load the restoration with SpeedCEM Plus and seat the restoration. SpeedCEM Plus comes with a mixing tip through which you express the adhesive.  

You now have two choices. You can hold the restoration in place with firm pressure and allow it to go to its self-cure mode which intraorally takes approximately 3 minutes. Alternatively, you can use your curing light to speed up the process.  

After I seat the restoration, I like to check the margins with an explore to make sure I have not had a mis-seat and then I pick up my curing light and, at a distance of 1 to 10 mm, I cure for one second at each line angle. We call this the quarter technique… mesial buccal one second, distal buccal one second, mesial lingual one second and distal lingual one second. I can now quickly go in and clean up all excess cement, making sure I get excess cement out of the interproximals. It’s important to cure on the line angles, not just buccal and lingual, or you will leave a lot of material that doesn’t reach the gel phase interproximally.     

Once all the excess material is cleaned off, I cover all of the margins with an oxygen barrier, and I do a 20-second cure on each of the four line angles using the quarter technique. The patient is good to go once you check the occlusion. 

Notes 

• SpeedCEM Plus comes in three shades 
• It is designed to be capped in the refrigerator. Never remove the used mixing tip and put a new empty tip on as this would leave the base and catalyst at the ends of the barrel exposed to air. You can either replace the used mixing tip with the original manufacturer’s cap or leave the used mixing tip on and disinfect it just like you wipe your light-curing unit. I recommend you do the latter, as it decreases the risk of contaminating the resin and initiating the self-cure process in the barrel. 
• Because the material is so versatile, you also can use it for placing your posts. 

All restorative materials have wear properties. We need to understand both how they wear and survive in the oral environment and how they impact opposing natural teeth.  

The wear of enamel is the basis for comparison.

Despite what we sometimes see clinically, enamel is highly resistant to wear (attrition and abrasion), with average annual wear rates of 30-40 microns. The range is from as low as 15 microns to as high as 100+ microns, and there is variability depending on the tooth position in the arch.  

Unlike enamel, which basically all has the same structure and properties, composites come in many different formulas. The chemical and physical properties of the material have a direct impact on its wear resistance and impact on other teeth. Some examples of this include: 

• Size, shape, and hardness of filler particles 
• Quality of the bond between filler particles and polymer matrix 
• Polymerization dynamics of the polymer 

These same properties affect the other physical and handling properties of the material and have to be balanced to create a composite that works clinically.  

Creating improvements in the physical properties of composites has eliminated the high degree of wear in non-contact areas we witnessed years ago. The loss of restorative material gave the appearance of fillings losing their shape and contour. Today our primary concern is in areas of direct occlusal contact.  

One approach might be to avoid using composite that has direct occlusal contact.

I would say this is not only not practical but not necessary. We have a variety of materials available today, with a range of handling and physical properties, and wear rates that are between 30-200 microns a year.  

We need to choose a composite based on things like wear versus polish–ability, anterior versus posterior, and the properties of the particular material we are using. In addition, we can manage the occlusion to maximize the success of the natural teeth as well as the composite.