Composites E-book by Spear Education

CO M POS ITE S

EBOOK By Spear Faculty

CONTENTS

COMPOS

SPEAR EDUCATION - THE PURSUIT OF GREAT DENTISTRY

ITES 4

Dentin Adhesives for Direct Posterior Composite

Four Guidelines for Direct Resin

Gold, Ceramic and Composite: A Restorative Dental Material Discussion

The Evolution of Composites and Light-Curing

Do You Pre-wedge For Your Posterior Composites?

The Impact From the Hygiene Operatory on Composite Restorations: Part I

The Impact From the Hygiene Operatory on Composite Restorations: Part II

The ‘Customized’ Posterior Composite Matrix

Composite for Managing Wear and Altering VDO

Dental Composite Comparison: Venus Diamond vs. Sonicfill 2

Dental Composite Comparison: Sonicfill 2 vs. Estelite Omega

Four Products to Immediately Improve Your Composite Restorations

Protect the Integrity of Your Restorations

Anterior Resin Restorations: A Technique For Predictable Class IV Restorations

Pink Ceramic Vs. Pink Composite for Soft Tissue Simulation

8 Steps for the Esthetic ‘Emergency’ Anterior Composite

Easy Tip for Removing Resin

DENTIN ADHESIVES FOR DIRECT POSTERIOR COMPOSITE By Frank Spear, D.D.S., M.S.D.

Direct composites represent an ever-increasing percentage of procedures in the 21st century dental office. In fact, they represent a procedure that restorative dentists do in their practice on a daily basis.

In spite of the frequency with which they are performed,

but two approaches I have used that have been very

they can occasionally be problematic because of tooth

effective have involved either a self-etching two-step

sensitivity following treatment. This sensitivity can be

system, such as Clearfil SE bond, or a total etch

caused by pulpal inflammation, but in most instances,

two-step system, such as 3M single bond.

I believe it is from inadequate sealing of the dentin. Here are the steps I follow to eliminate sensitivity and Martin Brannstrom taught us years ago that open

obtain an adequate bond to enamel and dentin, while

dentinal tubules lie at the heart of sensitivity and

recognizing that others may use different products

eliminating sensitivity requires the tubules be sealed.

and techniques and get excellent results as well.

There are many products that are capable of this, 4

Etch enamel

Whenever I use a self-etch 2-step in the posterior, I

Verify adequate coverage

After light curing the bonding agent, it’s essential to

etch the enamel first to ensure a good bond. I know

verify adequate coverage. A tooth that is adequately

several friends who don’t pre-etch the enamel with

covered will have a shiny surface all over the dentin. If

self-etching systems and have great success, but I still

you don’t see any shine, apply another layer of adhesive

prefer a 15-second enamel pre etch. If some acid gets

on top and repeat the process of drying and light curing

on the dentin, which it will, I am not overly concerned

until it yields the results you want. Remember, we have

about it. With the total etch 2-step systems I etch the

to seal the tubules to prevent post-op sensitivity.

enamel and dentin for 15 seconds. For either system the acid is then rinsed off and the tooth lightly dried.

Apply desensitizer

Since 1987 I have used Gluma desensitizer following my

Place first increment of composite

There is ample evidence that bulk filling techniques

etching prior to then applying the dentin adhesive, the

are successful and with the newer low shrink materials

Gluma contains 5% Glutaraldehyde and 35% HEMA. It has

likely even better than ever, but I personally like to

been shown to disinfect the preparation and coagulate

use incremental placement. I start off by placing the

proteins in the dentinal tubules, this slows down the flow

composite along the buccal and lingual walls of the

of fluid in the tubules reducing sensitivity. Bottom line for

proximal box and extend up and along the buccal and

me is that it has been incredibly successful at eliminating

lingual walls of the occlusal as well. Essentially leaving

most post-operative sensitivity. There is some question

the middle of the prep unfilled. This layer is cured

whether it is necessary with self-etching dentin adhesives,

completely prior to the second increment.

but I still choose to use it because of the results I get. I lightly dry the Gluma prior to applying the dentin adhesive, others leave it wet with success as well.

Apply dentin adhesive

I then apply the dentin adhesive according the

Place second increment of composite and cure:

The second increment fills up the center,

manufacturer’s instructions. It’s important to make sure the

but I don’t place the composite all the way to the top.

adhesive dries properly and all the solvent is thoroughly

If desired, I’ll add a little colorant to the top of this

vaporized. In my experience, the typical water/air syringe

layer to give the composite a more natural appearance.

does not produce clean, dry air. I like using an ADEC

Again, curing completely prior to the final increment. At

air-drying unit that attaches to a four-hole handpiece

this point, I place the final increment of composite and

hose to ensure the area is dried without contamination.

build it up to the correct contour for proper shaping.

must be applied with different protocols, and often

I recognize that there are more products and

dentists don’t read the instructions as to how to apply the

techniques available for placing direct posterior

adhesive, whether to agitate it or not, number of layers,

restorations than we have ever had in dentistry, many

etc. Whatever product you use, definitely follow the

which are very successful, but hopefully the recipes I

manufacturer’s instructions for application. After drying,

presented may help you if you are having sensitivity

the dentin adhesive is the light cured.

problems with your direct composites.

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The one thing I am very aware of is that different adhesives

FOUR GUIDELINES FOR DIRECT RESIN By Frank Spear, D.D.S., M.S.D.

There can be confusion for clinicians when deciding if direct composite is the adequate solution to treat patients, or if doing an indirect restoration will ensure the best chances of a predictable result. Especially in higher risk posterior areas, when we think about direct versus indirect restorations we want to pay very close attention to what the literature suggests will be a predictable result. There are four guidelines that I will evaluate 6

in order to determine if a direct restoration will yield the most successful results.

This is not to say that direct composite can’t be done if these criteria aren’t met. However, if these criteria were met there would be very little reason to not use a direct restoration.

Gingival margins in enamel

When the gingival margins of the proximal box are in the enamel, we get less recurrent caries in direct resin restorations as opposed to when the proximal box is all dentin. One of the problems with direct resin is shrinkage; when we cure it the composite shrinks and

Ability to isolate and visualize placement

If you can’t isolate, bond and visualize your

risks micro leakage. However, if there is enamel to etch

placement, there is no way to do a predictable

and bond to the risk of leakage is significantly reduced.

direct composite restoration. When you can’t visualize and isolate, you should opt for a more forgiving

Ithmus is less than half the intercuspal width

material, such as amalgam or consider an indirect restoration that doesn’t require perfect isolation such as a cemented restoration.

The smaller the composite, the more tooth structure remains to resist functional forces and flexure. When means the cusps retain a signifi cant resistance to flexure, which reduces the fatigue placed on the bond

Occlusion supported by enamel

Another factor that can add to the predictability

to the restoration. The wider the composite gets, the

of direct composites is if the occlusal contacts

weaker the cusps become, meaning cuspal flexure

are on the actual tooth structure itself. This minimizes

becomes an increasing problem, this flexure can result

the risk of overloading the composite, reducing the risk

in bond failure and the introduction of leakage.

of fracture and wear.

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the isthmus is less than half the intercuspal width, it

GOLD, CERAMIC AND COMPOSITE: A RESTORATIVE DENTAL MATERIAL DISCUSSION By Gary DeWood D.D.S., M.S.

G O LD RESTORATIONS In selecting an appropriate restorative material, the â&#x20AC;&#x153;gold standardâ&#x20AC;? was, and perhaps still is, gold. Gold restorations

Of course, it depends on the parameters within

This preference for gold does not extend to the public

which one is making the selection. Today one of those

served by the dental profession. The general public,

parameters is usually the similarity in appearance of the

having no such history of experience to draw on as they

restorative material to a natural tooth. That being said,

make choices, do the natural thing and ask for materials

a high percentage of dental professionals have gold

that look like teeth. The dental industry has worked

restorations in their mouths despite its failure to match

diligently over the past century to meet their demand.

the color of natural teeth. They have witnessed the long service life and tremendous adaptability of gold in the mouths of the patients they see, and they are drawn to gold for their own posterior restorations.

Amalgam restorations

A M A LG A M R ESTORATIONS In 1976, when I began having these conversations with

its use causes an increase in mercury in waste water,

patients, there were not a lot of options for restorative

and for these reasons alone, its use should be limited

materials period, let alone ones that mimicked the color

or eliminated. I have yet to be convinced that it caused

of a natural tooth. By far the most utilized restorative

or causes patients without an allergy to the material

material was amalgam. Amalgam is silver at placement

substantial risks.

and frequently black after a time of service due to the oxidation of the silver present in it. It is hardly an

For the purposes of our discussion, however, amalgam

esthetic restoration.

has already been de-selected as a preference due to its non-similarity to tooth appearance, so we are left

Amalgamâ&#x20AC;&#x2122;s history is a long one, with the earliest

to ponder whether or not its risks could be acceptably

documentation of it in a medical text published in 659,

managed since few patients on the planet would

and documented use of it as a dental restorative in

request it given alternatives.

Germany in 1528. By 1850 it was the most widely used for filling teeth, it worked. It still works and there are still situations in which its merits outweigh the risks. As a long-time amalgam user and supporter, I nonetheless agree that there is no doubt that it increases the mercury exposed to and present in at least one population: dental personnel. Additionally,

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material to â&#x20AC;&#x153;restoreâ&#x20AC;? tooth structure. As a material

Ceramic restorations

C ERA MI C RESTORATIONS My best tool back then for a natural looking

We did have one material that permitted a

“tooth-colored” restorative was a porcelain-jacket

tooth-colored material to be “bonded” to enamel:

crown or a porcelain-fused-to-metal crown with

Nuva-Fil. Ultraviolet-light polymerized, it was the best

porcelain-shoulder margins all the way around. While I

we had, and although the colors available were very

did have two composite materials available for my use,

limited and quickly changed their color once placed in

truth was they would not qualify today as adequate.

the oral cavity, it was used for several years as the best

Although bonding had been pioneered, its use with

alternative to full coverage with a porcelain material.

composites and ceramics was in the very early stages

But a revolution was on the way.

and not part of regular use in practice, so it was not part of my dental school education.

CO MP OSI T E RESTORATIONS Dentin Bonding and Composite materials hit the dental

for posterior direct restorations despite the fact that

world like a tsunami. From the late 1970s through

in the dental schools, composite is taught as a better

today, they represent the majority of the change that

alternative. Given that new dentists are being taught

is fundamental to modern dentistry. When bonding

this, the trend away from amalgam will continue. In

became a viable and reliable technique, it became

the future it might cease to be an option and although

possible to build, mill, and eventually press composites

I have long championed its benefits, advances in

and ceramics into shapes that could readily replace

materials and techniques have convinced me its

amalgam or gold. Millions of these were and are placed

benefits are not worth the risks.

as anterior and posterior restorative solutions. Dental composite materials are composed of a Composites are by far the majority of direct dental

resin matrix based on BISGMA (bisphenol A-glycidyl

restorations placed today in the United States. A 2010

methacrylate), UDMA (urethane dimethacrylate) or

a study in the United Kingdom and Irish dental schools

PEX (semi-crystalline poly ceram). One of these has

showed that while posterior composite restorations

been cited as containing a component material that

were taught as the preferred choice, a majority of

may be of concern: BPA (bisphenol A), a component

practitioners at that time were still preferentially

of the BISGMA resin. As in all controversies, there is

placing amalgam in posterior teeth. Amalgam is still

data suggesting both sides of this discussion have

more widely used than composite in some countries

an argument.

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Composite restorations

and sealants) for one or both of two reasons. It can

THE FU TU R E OF D E N TA L R E STOR ATION S

be present as a by-product of other ingredients in the

We have come a long way in what we are able to offer

materials that have degraded and it can be present as a

our patients in the time that I have been involved in

trace material left-over from the manufacture of other

dentistry. As most of you know, my daughter,

ingredients used in the materials. BPA is not used as a

Dr. Kathryn DeWood (Katie), is a 2014 dental school

formula ingredient in any dental materials according

graduate. Her practice does not include amalgam and

to the manufacturers, a fact that American Dental

it has included the ability to create ceramic restorations

Association research has confirmed.

at time of preparation, two things that are so far

BPA can be present in dental materials (composites

outside of the 1976 box her mother and I lived in that I A 2008 report from the National Toxicology Program

could not have imagined them back then. I’m betting

at the department of Health and Human Services

the speed of change and innovation will only pick up,

states, “Dental sealant exposure to bisphenol A occurs

and that Katie’s daughter will undoubtedly wonder how

primarily following the use of dental sealants that

her mother could possibly practice with the stuff she

contain bisphenol A dimethacrylate. This exposure is

has available in 2019.

considered an acute and infrequent event with little relevance to general population exposures; food and beverage consumption accounts for the majority of human exposure to BPA.” While BPA has potential effects on the brain, behavior and prostate glands of fetuses, infants and children, the research into how those effects apply to exposure from dental materials does not seem to apply to the exposures from food and beverages. Sealant placement is a transient event, and the BPA from such exposure is not detectable following placement. Data also suggests that regardless of the exposure source, BPA is excreted and not detectable after a short period of time. One recent study looked for BPA in urine at one day, 14 days and six months after placement of a dental composite and recorded an initial increase at one day, but no detectable presence of BPA at 14 days and no detectable presence at six months.

This is why dentistry is so much fun. Everything I know gets re-written and the excitement of the ride doesn’t end! Ain’t it a great time to be alive!

INTERESTING READING Esthetic, conservative, cast gold restorations for posterior teeth. Solow RA. Gen Dent. 2016 Sep-Oct;64(5):14-19. The enduring merits of gold. Heymann HO. J Esthet Restor Dent. 2009;21(6):357-8. Long-term survivals of â&#x20AC;&#x2DC;direct-waxâ&#x20AC;&#x2122; cast gold onlays: a retrospective study in a general dental practice. Bandlish LK1, Mariatos G. Br Dent J. 2009 Aug 8;207(3):111-5. The history of dental amalgam. Borklund G. (1989). 109 (34-35): 3582-3585 Published in Norwegian Re-dating the Chinese amalgam filling of teeth in Europe. Czarnetzki A, Ehrhardt S. (1990) International Journal of Anthropology, 5 (4): 325-332 Quantification of Hg excretion and distribution in biological samples of mercurydental-amalgam users and its correlation with biological variables. Gul N, Khan S, Khan A, Nawab J, Shamshad I, Yu X. Environ Sci Pollut Res Int. 2016 Jul 27. [Epub ahead of print] Use of Mercury in Dental Silver Amalgam: An Occupational and Environmental Assessment. Jamil N, Baqar M, Ilyas S, Qadir A, Arslan M, Salman M, Ahsan N, Zahid H. Biomed Res Int. 2016; Epub 2016 Jun 30 Use of the ultrviolet light polymerized adhesive (Nuva-Seal and Nuva-Fil) in clinical dentistry (I). Sheykholeslam Z, Houpt MI. Quintessence Int Dent Dig. 1979 May;10(5):19-6. Use of the ultraviolet light polymerized adhesive (Nuva-Seal and Nuva-Fil) in clinical dentistry (II). Sheykholeslam Z, Houpt MI. Quintessence Int Dent Dig. 1979 Jun;10(6):17-21. Clinical performance of all-ceramic inlay and onlay restorations in posterior teeth. Beier US1, Kapferer I, Burtscher D, Giesinger JM, Dumfahrt H. Int J Prosthodont. 2012 Jul-Aug;25(4):395-402. State-of-the-art techniques in operative dentistry: contemporary teaching of posterior composites in UK and Irish dental schools. Lynch CD, Frazier KB, McConnell RJ, Blum IR, Wilson NH. Br Dent J. 2010 Aug 14;209(3):129-36. Bisphenol A is released from polycarbonate drinking bottles and mimics the neurotoxic actions of estrogen in developing cerebellar neurons. Le HH, Carlson EM, Chua JP, Belcher SM. Toxicol Lett. 2008 Jan 30;176(2):149-56. Bisphenol A (BPA) in China: a review of sources, environmental levels, and potential human health impacts. Huang YQ, Wong CK, Zheng JS, Bouwman H, Barra R, Wahlstrom B, Neretin L, Wong MH. Environ Int. 2012 Jul;42:91-9.

National Toxicology Program. Center for the Evaluation of Risks to Human Reproduction. Monograph on the Potential Human Reproductive and Developmental Effects of Bisphenol A. NIH Publication No. 08- 5994, September 2008. Changes in urinary bisphenol A concentrations associated with placement of dental composite restorations in children and adolescents. Maserejian NN, Trachtenberg FL, Wheaton OB, Calafat AM, Ranganathan G, Kim HY, Hauser R. J Am Dent Assoc. 2016 Aug;147(8):620-30.

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Endocrine disrupting chemical, bisphenol-A, induces breast cancer associated gene HOXB9 expression in vitro and in vivo. Deb P, Bhan A, Hussain I, Ansari KI, Bobzean SA, Pandita TK, Perrotti LI, Mandal SS. Gene. 2016 Sep 30;590(2):234-43.

THE EVOLUTION OF COMPOSITES AND LIGHT-CURING By Gary DeWood, D.D.S., M.S.

I wrote a Spear Digest article in 2011 about light-cured composites, light curing, and curing lights. Let’s look at the evolution of materials and lights since then.

A LO N G , LONG TIME AGO ... 201 1 T HE CO MP OS ITES :

Most of us were using composite materials (Figure 1)

most commonly used initiator in all applications.

for which the recommended depth of cure was 2 mm

You will note that the color of the initiators is quite

maximum, a depth that was decreased to 1 mm with

different. While CQ worked very well with the lights

darker shades. This guideline meant that the placement

available, the color was an issue for manufacturers.

of several increments in succession cured between

Although the intense yellow was mitigated by the

each increment was a necessity to ensure adequate

polymerization, it represented a problem with color

polymerization. The three light sensitive initiators (Figure

matching composites to teeth prior to the cure. TPO is

2), camphorquinone (CQ), phenyl-propanedione (PPD),

the least “colored” of the initiators and made possible

and trimethylbenzoyl-diphenyl-phosphine oxide (TPO)

clear flowable resins that could be used to seal things.

acted as the triggers that set off polymerization in all the

Clear sealants use TPO as an initiator.

available products when light was applied. CQ was the

Figure 1

Figure 2

PPD

TPO

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The spectrum of absorption by these initiators was not a problem when quartz-halogen was the only available source. However, with the introduction of the LED light the initiator became a factor in the cure as single wave LED lights, most of which emitted in the 430 to 500 nanometer range, did not interact well with TPO, which absorbs in the 350 to 430 nanometer range (Figures 3-6).

Absorption Spectrum CQ

Figure 3

Absorption Spectrum PPD

Figure 4

Absorption Spectrum TPO

Figure 5

Absorption spectrum of the three initiators:

Absorption Spectrum CQ PPD TPO

Figure 6 SPEAR | COMPOSITES EBOOK

LI G HT CU RING AND TH E LIGH TS Quartz-halogen lights were the standard in most

Plasma lights (PAC lights), a very bright type of

practices. The quartz-halogen bulb (Figure 7) seen

fluorescent, provided incredibly high power and depth

here is an example of the source that provided the

of cure. They also generated significant heat at the

light, usually in a gun-shaped instrument with an

point of application. The one I had experience with was

internal cooling fan. If you have ever used these lights

the Sapphire light (Figure 9). I thought these worked

in your home, you know why there had to be a fan â&#x20AC;&#x201C;

well when managed appropriately. Cost was a barrier

these babies get hot. They also lose their power as they

for many dentists as these lights were generally much

age and need to be tested to insure adequate depth of

more expensive than the quartz-halogen lights or the

cure (Figure 8).

LED lights that were available (Figure 10).

Emission Spectrum Figure 7

QTH

Figure 8

Emission Spectrum PAC

Figure 9

Figure 10

LED as a possible source for curing composite was first mentioned in 1995 (Figure 11). They began to slowly replace the quartz-halogen and plasma lights because of their lighter weight and better ability to function on battery power. The replacement was relatively slow because quartz-halogen lights were dependable and long lasting. Most of us are slow to replace something that works well unless the differences are life altering. Thatâ&#x20AC;&#x2122;s why in 2011, the most found light in the country was quartz-halogen (Figure 12).

Figure 11

LED emission spectrum:

Emission Spectrum LED

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Figure 12

Emission spectrum of the three most used light sources in 2011:

Emission Spectrum QTH PAC LED

Figure 13

Emission and absorption spectrums of sources and initiators:

Emission Spectrum QTH PAC LED POLYWAVE LED Figure 14

The problem with the LED1 light and TPO:

Emission Spectrum LED

Figure 15

How the LED2 (polywave) light covers the frequencies that initiate TPO:

Emission Spectrum POLYWAVE LED

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Figure 16

I N TO T HE FUTURE … 2019 CO MP OSI T ES : We’re using way more bulk fill composite than we did in 2011. This has made placement more efficient but has also caused concerns. Some authors have raised questions about that increased use1,2 noting failure rates due to under polymerization, inadequate contact development, and lower hardness, stiffness and strength relative to incrementally placed composites. Most of the questions I encountered were related to technique, and thankfully that is something we as clinicians can control. Like many advances in technology, the protocol around its use becomes the most important factor in determining its success. There is consistent evidence that bulk fill materials can be a viable alternative to incrementally applied materials when the protocols required are observed. In this, as

Figure 17

it becomes increasingly important to carefully read

IVOCE R IN - A N E W IN ITIATOR FR OM IVOCL A R V IVOD E N T:

and follow the manufacturer’s instructions. There are

In the quest to improve the performance of bulk fill

enough differences in the techniques that a small

composites, one manufacturer, Ivoclar Vivodent,

difference can dramatically change the outcome.

introduced a new initiator, Ivocerin. According to the

in most things involving polymerization and bonding,

scientific report from the company, it is highly reactive These materials tend to lower value. The qualities that

to light in the visible range and imparts a bleaching

permit polymerization of a large volume in which light

behavior to composite resins. It does not need to be

spreads easily also create a “darker” look to the final

used with other initiators and is more efficient than CQ.

restoration since light goes in rather than bounces off. This is not usually an issue in posterior applications

If you are interested in reading the report, I’m including

according to most of the authors I read.

a link here. It’s a real nail-biter.

Figure 18

The Bluephase G2 Poly-Wave LED

L IGHTS LED lights have moved into the number one position. Both single and poly-wave LED lights are less bulky than their quartz-halogen counterparts and easier to make cordless â&#x20AC;&#x201C; attractive qualities in the dental operatory and, in my opinion, two of the primary reasons for their ascension to the leading positions. According to The Dental Advisor, the dental curing lights most commonly found in the operatory are the Bluephase G2 (Ivoclar Vivadent, Figure 19), the Elipar S10 LED Curing Light (3M ESPE, Figure 20), and - in a tie for third - the Demi Plus (Kerr Corporation, Figure

Figure 19

Figure 20

21) and the CURE (Spring Health, Figure 22).

The Elipar S10

The Cure

Single Wave LED

Poly-Wave LED

Figure 21

#3 (Tied)

Single Wave LED

Figure 22

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Demi-Plus

Poly-wave LED lights can cure any material since they

Ascent PX

400-490

wave light is rarely an issue since the only initiator not

M ESPE Elipar Deep Cure-S 3 LED

430-480

sensitive to the single wave LED is TPO, and it is rarely

3M ESPE Elipar S10 LED

430-480

used alone. The exceptions to this are most clear sealants

Allegro LED

452

and clear resins such as Palaseal. Knowing your light and

BEYOND Cordless LED

400-420

Bluephase 20i

380-515

Bluephase G2

380-515

Bluephase Style

385-515

Celalux 2

420-490

One of the things that has been learned about LED

Coltolux LED

465

lights is that all of them, single-wave or poly-wave, have

DEMI

450-470

a spread of light from the tip that is not homogenous.

Demi Plus LED Light

480

This fact affects the cure pattern of the material. We have

FlashMax

450-470

always known that the distance from the light source

FlashMax P3

450-470

impacted the cure speed and cure depth, but the LED

Fusion

385-490

spread is a relatively new understanding. This diagram

LED Blast

463

Mini LED

420-480

Mini LED Auto Focus2

420-480

Paradigm DeepCure LED

430-480

Paradigm LED Curing Light

430-480

Q-Lite Cordless LED

455

S PEC 3Ä&#x192;, ĐĄ LED Curing Light

455-465

Slimax-C Plus

430-480

Smartlite iQ2

460

trigger all initiators. Having said that, the use of a single

knowing your materials will ensure that polymerization occurs. In the graph to the right, you can find the wavelength emission of selected curing lights. The boxes marked in blue denote a poly-wave light (Figure 23).

(Figure 24), from an ADA laboratory evaluation of light-emitting diode curing lights3, shows a 3D representation of the curing pattern from four LED sources. This understanding has led to the recommendation that LED lights be moved as the light is applied. This movement often results in greater distances between the light source and the materials slowing the cure. After my reading, asking and doing, there are three things that separate 2011 from 2016 for me. Number one, I use bulk fill composite in more applications. Since

The CURE, TC-01

they tend to be lower in value than incrementally placed

The CURE2, TC-CL II

composites, I rarely apply them without an increment

Translux Power Blue

448

over the surface of a non-bulk fill material.

Valo

395-480

i-Light

380-490

Second, I use an LED light exclusively in the operatory.

radii plus

460

I am still using quartz-halogen in the lab curing units,

starlight pro

440-480

the CURE

458

so when Paloseal is appropriate I cure it in the Pro-Cure lab unit.

Figure 23

Finally, I continuously move my light throughout the cure. Because this creates greater distance from the material, I add time to my polymerization. Material cannot be over cured, but an under-cured material 24

is a recipe for failure. I wonder what 2020 will bring?

Bluephase Style

Coltolux

Demi Ultra

Elipar S10

FlashLite Magna 4.0

SmartLite Max

VALO

Optilux 501

2mm

9mm

2mm

9mm

500

1000

2000

3000

4000

Irradiance (mW/cm2) Figure 24

REFERENCES composites-a-good-idea

2. Are bulk fill composite restorations working? http://www.dentaleconomics.com/articles/print/ volume-102/issue-9/practice/ask-dr-christensen.html

3. LED lights should be moved while using due to the irradiance beam â&#x20AC;&#x153;hot-spotsâ&#x20AC;? they have. http://www.ada.org/en/publications/ada-professional-product-review-ppr/archives/2014/november/anada-laboratory-evaluation-of-light-emitting-diode-curing-lights

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1. Are bulk filled composites a good idea? https://www.dentalaegis.com/id/2014/10/are-bulk-fill-

DO YOU PRE-WEDGE FOR YOUR POSTERIOR COMPOSITES? By Greggory Kinzer, D.D.S., M.S.D.

Direct posterior resin is a mainstay in clinical practice. However, it is not uncommon for clinicians to struggle creating consistently tight interproximal contacts.

Due to the contraction shrinkage of the composite

• It helps protect the interproximal tissue and

from photo polymerization, tooth separation greater

rubber dam

than the width of the matrix is necessary to create an

• It helps protect the proximal surface of the

intact proximal contact. One advancement that has

adjacent tooth

made achieving a solid interproximal contact more predictable is the use of a sectional matrix and a

As the tooth preparation proceeds, the wedge

separating ring.1 Another recommendation that can

should be continually advanced into the embrasure

be beneficial is to “pre-wedge” the embrasure prior to

to accommodate for any softening or movement of

treatment (but after the administration of anesthetic).

the wedge. A new wedge should be used at the time

of matrix placement. Although pre-wedging has been around a long time, it is

something that is still valid today. The concept involves

This approach allows ample time to attain the needed

placing a wooden wedge (following the administration

orthodontic movement of the involved teeth in order

of anesthetic) into the proximal area to be restored prior

to compensate for the thickness of the matrix band

to beginning tooth preparation. Aside from causing

and composite shrinkage.

separation of the teeth, the pre-placement of a wedge has other advantages as well:

1. Loomans BAC, Opdam NJM, Roeters FJM, Brokhorst EM, Burgersdijk RCW. Comparison of Proximal contacts of Class II Resin Composite Restorations in Vitro. Operative Dentistry 2006; 31-6: 688-693 2. Eli I, Weiss E, Kozlovsky A, Levi N. Wedges in restorative dentistry: principles and application. J of Oral Rehab 1991;18(3):257-264

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REFERENCES

THE IMPACT FROM THE HYGIENE OPERATORY ON COMPOSITE RESTORATIONS:

PA R T 1

By Greggory Kinzer, D.D.S., M.S.D.

As clinicians, we spend a considerable amount of time placing composite restorations that strive to re-create a natural surface texture and polish (Figure 1). We know from the literature that numerous factors have the potential to degrade the composite surface over time, but have you ever stopped to think about how the things we do in our own practices affect the composite surface â&#x20AC;&#x201C; specifically in the hygiene operatory? 1

Figure 1: Before and after a composite restoration

H YG I EN E A ND COMPOS ITE R E STO RATIONS Ideally, we would like the hygienist to remove plaque, calculus, stain and biofilm while not harming the surface of restorative materials or tooth structure. However, the negative impact that prophy paste can have on different dental surfaces can be quite remarkable. This is especially true when it comes to composite restorations. It has been shown that all products with the ability to remove stain cause some surface roughness of the restoration. With 70 to 80 percent of the prophy paste sold being coarse or extra coarse, the negative impact can be significant. However, it is not just the coarseness of the prophy paste that is damaging. The effect of a prophy on the tooth/ restoration is multi-factorial and depends on: • The weight/pressure of the handpiece • The duration of the polish • The speed of the handpiece • The shape particle size of the abrasive agent

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In order for a surface to be polished, the abrasive agent must be harder than the surface it is polishing. For an idea on the interaction of prophy pastes and dental materials it is helpful to observe the Mohs hardness values of dental tissues and dental materials in comparison to the values of some of the abrasive agents in prophy paste (Figures 2-3).

DENTAL TISSUES

MOHA HARDNESS VALUES

Enamel

5.0

Acrylic

2.0 - 3.0

Dentin

3.0 - 4.0

Gold

2.5 - 3.0

Cementum

2.5 - 3.0

Amalgam

4.0 - 5.0

Composite

5.0

Porcelain

6.0 - 7.0

Figure 2: Mohs hardness values for dental tissues and dental materials.

DENTAL MATERIALS

ABRASIVE AGENTS IN PROPHY PASTE

MOHA HARDNESS VALUES

Boron

9.3

Silicon Carbide

9.0

Garnet

8.0

Emery

7.0 - 9.0

Perlite

5.5

Zirconium Silcate

7.5 - 8.0

Aluminum Oxide

3.4

Zirconium Oxide

7.0

Calcium Carbonate

3.0

Silicon Dioxide

7.0

Sodium

0.5

Pumice

6.0 - 7.0

Potassium

0.4

Figure 3: Mohs hardness values for abrasive agents in prophy paste.

1. Polishing and toothbrushing alters the surface roughness and gloss of composite resins. Kamonkhantikul K. Dental Materials Journal 2014; 33(5): 599â&#x20AC;&#x201C;606

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REFERENCES:

THE IMPACT FROM THE HYGIENE OPERATORY ON COMPOSITE RESTORATIONS:

PA R T 2

By Greggory Kinzer, D.D.S., M.S.D.

In my previous article, the multi-factorial impact that a coarse or extra-coarse prophy paste can have on the surface of composite restorations was discussed. How is it then that the hygienist can remove plaque, calculus, stain and

Figure 1 : Tubes of Proxyt - Fine, Medium, Coarse

biofilm while not harming the surface of restorative materials or tooth structure?

In discussing this with my hygienist, Jodi Demming, RDH, she informed me that the key is to use what she calls selective polishing. Typically, one paste is not appropriate for the entire dentition of most patients given the variety of materials and clinical situations. The use of a fine polishing paste or a cleaning paste with no abrasives is safe, however, it doesnâ&#x20AC;&#x2122;t remove stain. 32 Figure 2 : Proxyt polishing paste placed on the back of a gloved hand.

P OLI SHI N G PASTE AND CO MP OSI T E RESTORATIONS In areas requiring stain removal, selective use of a more

By following this simple polishing protocol in our office,

abrasive paste â&#x20AC;&#x201C; medium or coarse â&#x20AC;&#x201C; is recommended.

we have been able to prolong the surface shine, polish

These more abrasive pastes must be followed by the

and overall esthetics of the composite restorations for

use of a fine paste to help improve the surface following

our patients (Figures 3 and 4).

the more coarse paste. Although this sounds like it would create a lot more work for the hygienist and increase the necessary appointment time, it actually can be done quite easily and efficiently. In our office, we use Proxyt polishing paste (Figure 1) from Ivoclar. It is conveniently supplied in tubes and can be dispensed as needed to minimize waste. A medium or coarse paste is used when removal of stain on tooth structure and restorative materials is necessary. This is then followed by the use of a fine paste to re-polish the surface. To make this an efficient

Figure 3: Before the composite restoration.

process, Jodi observes the dental condition of the patient and then places the different materials on the back of her non-working hand for easy accessibility (Figure 2). It must be noted that in some situations, it may not always be possible to restore surface polish of the restoration with paste. In these situations, it may be necessary to use restorative composite polishers to re-activate the surface of the restoration.

Figure 4: After the composite restoration.

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THE ‘CUSTOMIZED’ POSTERIOR COMPOSITE MATRIX By Greggory Kinzer, D.D.S., M.S.D.

I must admit that I don’t know a lot of dentists who “look forward” to a day filled with posterior Class II resins. These restorations are often technically difficult, time consuming and overall challenging to do well. Figure 1

The sectional matrix systems have done wonders

Unfortunately, every tooth has slightly different

in helping make it easier to create restorations with

contours so, although the new rings are helpful, they

better contours and proximal contacts. These systems

are often far from ideal. One thing that can be done to

continued to evolve from the generic BiTine or G-Rings

help make posterior composites a little easier and more

to rings with more proximal contour/anatomy to help

enjoyable is to use a “customized” posterior matrix.

better adapt the sectional matrix to the tooth

The good news is that making the customized matrix is

(Figure 1).

rather quick and you most likely already have what you need to do it.

This technique was developed by Dr. Jordi Manauta, a talented clinician from the group Style Italiano.

T HE 6-ST EP C USTOMIZED P OST ERI O R MATRIX TEC HNIQU E

STEP

Prior to preparing the tooth, pre-wedge and place a small amount of Opal Dam or similar product (e.g. Kool-Dam, Ena-Dam) in the buccal and palatal proximal embrasures and cure (Figure 2).

Figure 2

STEP

Using the original BiTine or G-Ring design, place the ring engaging the first increment of Opal Dam (the ring should not bite through the first increment or touch the tooth). Once the ring is in place, completely surround the working end of the ring with more Opal Dam and cure (Figure 3).

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Figure 3

STEP

The customized matrix is now complete and can be removed from the mouth. The Opal Dam should be one with the ring (Figure 4).

Figure 4

STEP

Prepare the tooth and finalize the preparation. Place your sectional matrix/wedge and assure a good seal at the gingival margin. Once complete, place the customized matrix (Figure 5). Since the matrix was fabricated with a wedge in place, it should fit intimately against the tooth. However, if the wedge is in a slightly different position and doesnâ&#x20AC;&#x2122;t allow the matrix to be seated completely, the apical portion of the custom matrix can be adjusted with a bur outside of the mouth. Note how well the sectional matrix conforms to the contours of the tooth. This will help ensure ideal contours and help minimize the time required for finishing.

Figure 5

STEP

The tooth is now ready to be selectively etched, bonded and layered with composite (Figure 6).

Figure 6

STEP

Once the final contour is built and cured, the matrix can be removed to allow for proper finishing and polishing. The image on the left below in Figure 7 was taken immediately after removal of the matrix. Note how well the proximal contours blend with the natural tooth, thereby minimizing the amount of finishing required. The image on the right below in Figure 7 is after finishing.

Figure 7

As you can see, this technique is not difficult to perform, but it can have a dramatic impact on the final outcome. In addition, it can be used in a variety of clinical situations where the traditional matrices fall short. However, given that the custom matrix adapts and recreates the contour of the existing tooth, the technique is generally not recommended when you do not desire to reproduce the existing anatomy.

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COMPOSITE FOR MANAGING WEAR AND ALTERING VDO By Greggory Kinzer, D.D.S., M.S.D.

In general, the use of composite is significantly more common in Europe than the United States. Let me clarify that by saying that although composite is a

Figure 1

primary restorative material for posterior fillings, Class V restorations and anterior cosmetic dentistry in both Europe and the USA â&#x20AC;&#x201C; I believe that we in the States underutilize composite for managing the more advanced full mouth wear patients in lieu of ceramic restorations. It has been well documented in the literature that composite can be used successfully to manage these

Figure 2

types of patients.1,2

Figure 3

There are many advantages of using composite: • It’s conservative • It can restore both function and esthetics • The reduction of overall financial cost to the patient • It’s more easily repairable if fracture occurs For the most predictable restorative success, case selection can be important. Given the strength differences between ceramic and composite, using composite on patients with an erosive or abrasive loss

Figure 4

of tooth structure may be more predictable than using it on attrition patients where force management is more of an issue. This patient presented at the office holding a treatment plan from her current dentist for a full mouth reconstruction with crowns and veneers utilizing implants in all four posterior sextants (Figures 1-3). Her treatment goal was to improve both the esthetics and function, as she didn’t feel she could eat normally without breaking the thin edges of her anterior teeth. The treatment plan that I presented utilized composite

Figure 5

resin to help restore the esthetics and function. Given that she had been without molars for many years, she was fine with not having these teeth replaced. The treatment plan was developed using the facially generated treatment planning process beginning with the determination of the maxillary incisal edge position (Figures 4-5).

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The entire occlusal thought process and design was worked out on mounted models utilizing a diagnostic wax-up (Figures 6-8).

Figure 6

Figure 7

Figure 8

The placement of the direct composite was performed in a single visit and was well tolerated by the patient (Figures 9-11). It not only accomplished the treatment goals, but it did so in a very conservative manner.

Figure 9

Figure 10

Figure 11

REFERENCES:

2. Tooth wear treated with direct composite restorations at an increased vertical dimension: results at 30 months. Hemmings KW, Darbar UR, Vaughan S. J Prosthet Dent 2000 Mar;83(3):287-93

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1. A comprehensive and conservative approach for the restoration of abrasion and erosion. Part 1: concepts and clinical rationale for early intervention using adhesive techniques. Dietschi D, Argente A. Eur J Esthet Dent 2011;6(1):20-33

DENTAL COMPOSITE COMPARISON: VENUS DIAMOND VS. SONICFILL 2 By Courtney Lavigne, D.M.D., and John Carson, D.D.S., P.C.

Figures 1-3: Venus Diamond with amalgam staining

Dr. John Carson and I will look at a

In the first of this series, I looked at Venus Diamond

few key factors in evaluating different

by Heraeus Kulzer versus Sonicfill 2 by Kerr. I looked

composites. John will be giving the second opinion in this article.

at the compressive strength, adaptation and handling, translucency, flowability, shrinkage, polishability and overall ease of use.

Venus diamond is a nanohybrid composite available in

Sonicfill 2 has a steeper learning curve because it

23 shades. Sonicfill 2 is a bulk-fill composite activated

handles unlike any other composite I’ve worked with.

by the vibratory action of a handpiece and is available

That being said, once I was able to adapt to the timing

in four shades. These two composite materials were

of the transition from a very malleable composite to a

evaluated for Class II composite placement.

more rigid state prior to final curing, it was easy to work with. The adaptation is exceptional and feels more like a

Compressive strength: The compressive strength

flowable composite at the very early stages of placement.

is important when placing posterior composites in

I did not find it sticking to my instruments, and it was very

high-function areas that must be able to withstand

carvable in the later stages of placement, which allowed

heavy occlusal forces. The compressive strength of

for minimal finishing. Because it is a highly translucent

Venus Diamond is listed on their website and is 332

material, it can be cured reliably up to 5 mm deep, so only

MPa. Although no information on the compressive

one layer was placed.

strength was directly listed on Kerr’s website, studies have shown it to be between 254 MPa (Sonicfill 1) and

Translucency: Venus Diamond was a fairly opaque

316.596 ± 22.23 MPa. Both are adequate for posterior

material, but because there is a plethora of shades, I

composite strength and durability, but Venus Diamond

found there to be adequate options to select one that

has a higher compressive strength.

blends nicely with the surrounding tooth structure. Because the material is less translucent than Sonicfill,

Adaptation and handling: This is based solely on use

it had improved esthetics over Sonicfill when the

in my hand. The Venus Diamond is a thick composite

remaining tooth structure presented with amalgam

that doesn’t easily adapt to the walls of a deeper

staining. It was able to adequately block out stains so

preparation. I use titanium-coated instruments by

that the margins blended fairly well into the surrounding

Hu-Friedy and found the material to be sticky and

tooth structure.

difficult to place. I found the difficulty of placement increased with darker shades, which is to be expected, but the increase was more noticeable than other composites I’ve worked with. I found that placing the box, a second layer and a thin final layer for carving anatomy was easiest. Final anatomy necessitated finishing and polishing. Radiographically, I was more likely to have a small void at the outermost portion comfortable with adaptability when a thin flowable layer was placed on the pulpal floor prior to placing Venus Diamond.

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of the box due to inadequate condensing. I felt more

Sonicfill is a highly translucent material, which is one of the best and worst properties in my opinion. Because it is so translucent, you can use very few shades and have them blend seamlessly into many different teeth. I used A3 on almost every restoration placed, and they all blended extremely well. Because of the translucency, you can cure a deeper amount of material reliably as well. The translucency can be difficult when you are replacing an amalgam restoration. Even when the stain is a few millimeters below the surface of the prep, it is very apparent at the final cure. I overcame this difficulty by using a flowable opaquer on the pulpal floor when indicated and the results were excellent (Figure 6-8). This does, however, add an additional step to the process and minimizes the benefit of one-layer placement.

Figures 6-8: Sonicfill 2 with opaquer over amalgam staining

44 Figures 4-5: Sonicfill 2 with no opaquer over amalgam staining

I would choose to have Sonicfill 2 in my armamentarium for Class II composites based on its ease of use. It can be placed in one layer, it is easy to manipulate and one or two shades will match most teeth exceptionally well. There aren’t many products that you can limit to that few shades and be happy with the result routinely. It’s nice to have a nanohybrid when you do need a unique shade (and Venus Diamond has 23 options). While I Figures 9-10: Sonicfill 2 in shade A3

wouldn’t choose Sonicfill for anterior placement, Venus Diamond can be used for both.

Flowability: Venus Diamond is not a flowable material to work with. You have to adequately condense the material to feel confident you have achieved the necessary adaptation. Sonicfill is very flowable in the beginning stages upon placement and becomes less flowable as you work with it. Shrinkage: Venus Diamond has 1.5% shrinkage versus Sonicfill’s 1.88%. Both are very low shrinkage percentages. Polishability: Both materials were highly polishable. On initial polish, Sonicfill 2 had a glossier, smoother appearance. On patient recall, I found that Venus Diamond looked the same as when placed, whereas the Sonicfill 2 looked similar to Venus Diamond and had lost the additional glossy finish it had on the

Figures 11-12: Venus Diamond in a class III case

day of placement. Overall Ease of Use: Overall, Sonicfill 2 was easier to use after you overcame the learning curve. I can see first-time users getting frustrated with Sonicfill 2 during the first few placements, but after mastering the timing, a nanohybrid, and adaptability is a real concern. It is not as user friendly, but the learning curve is not as steep if you’ve placed other nanohybrids.

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it is extremely user-friendly. Venus Diamond is typical of

THE SECOND OPINION BY DR. JOHN CARSON While Courtney offered excellent points and I agree with her on much of what she said, there are few items in which I will offer a different opinion. But let’s start with the points we agree on. For sure I agree that Sonicfill 2 is way more flowable and easy to adapt. Additionally, I agree that Sonicfill 2 is way more translucent, which is great for blending in teeth that are not discolored; however, when you do have discolored teeth, Venus Diamond does a better job at masking the dark colors, particularly if you are not going to use an opaquer with Sonicfill 2. I also agree on the polishability of the two materials. Where I do disagree is on the point made about the learning curve. For me, there was nearly zero learning curve. I will also add that at times I find both materials wanting to stick, but I use stainless instruments; that being said, I see this way more with Venus Diamond. When sticking does occur, I find a small amount of flowable composite or bonding resin on my instrument really helps if sticking is an issue. I tend to use flowable when using Venus Diamond as I already have it out to place a thin base coat as Courtney described. When I am using Sonicfill 2, which is most of the time in the posterior, I tend to use a bonding agent since I don’t already have flowable out. In closing, for me Sonicfill 2 is my go-to composite in the posterior, but there are times when I want or need a more conventional composite, so I choose to have both available. Yes, I could get by with just a conventional composite like Venus Diamond, but I like working with Sonicfill 2 in the posterior way more – for me it is much more efficient. While I choose to have both on hand, if you only want to stock one composite for everything, Venus Diamond could fit the bill while 46

Sonicfill 2 would not.

Didem A, Gozde Y, Nurhan Ã&#x2013;. Comparative Mechanical Properties of Bulk-Fill Resins. Open Journal of Composite Materials OJCM. 2014;04(02):117-121. http://www.dentalcompare.com/4479-Hybrid-Composites/35522-Venus-Diamond/ http://www.agd.org/media/271984/GenDent_MJ15_Vandewalle.pdf

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REFERENCES:

DENTAL COMPOSITE COMPARISON: SONICFILL 2 VS. ESTELITE OMEGA By Courtney Lavigne, D.M.D. and John Carson, D.D.S., P.C.

Dr. John Carson and I have presented a comparison of Venus Diamond and Sonicfill 2. Now we’re left with a comparison between Sonicfill 2 and Estelite Omega.

I will share with you that I use both products in my

I primarily use Sonicfill for Class I and II composites

office, but for very different applications. While

in the posterior. Estelite Omega, on the other hand, is

Sonicfill 2 is a great bulk-fill composite for posterior

a fantastic esthetic composite for Class III, IV and V

restorations when indicated, I wouldn’t use it in the

composites as well as direct resin veneers.

anterior. While Estelite Omega has fantastic esthetics and handling for anterior composites, I wouldn’t use

What are the differences between these two materials?

it in the posterior for a number of reasons. We aren’t

Estelite Omega is a polychromatic supra-nanofilled

comparing apples to apples here. Perhaps elucidating

composite, whereas Sonicfill 2 is a nanohybrid

the differences rather than holding one to the other’s

activated by sonic energy.

standards will help you determine how each could best serve you in your practice. 48

Compressive strength: The compressive strength

system that allows more or less translucency depending

is important when placing posterior composites in

on how much tooth structure you are replacing, the

high-function areas that must be able to withstand

desired translucency, and the translucency of the

heavy occlusal forces. Though no information on the

surrounding teeth. When using a matrix to place it

compressive strength was directly listed on Kerr’s

in the anterior, the milky-white and trans composite

website, studies have shown it to be between 254 MPa

shades in Estelite Omega can increase the incisal

(Sonicfill 1) and 316.596 ± 22.23 MPa. The compressive

edge translucency. The dentin shades can control how

strength for Estelite Omega was listed at approximately

opaque the restoration is if you want to decrease your

400MPa by Tokuyama. Sonicfill is better able to handle

translucency. There is much more control with a

the compressive stresses in the posterior.

layering composite like Estelite Omega than a bulk fill like Sonicfill.

Adaptation and handling: These are two of my favorite materials to work with in practice; both are extremely

Flowability: Sonicfill and Estelite Omega are moderately

user friendly and fun to place. The adaptation of

flowable; they feel creamy on placement and are

Sonicfill is exceptional and feels more like a flowable

flowable enough to adapt well, but not so flowable that

composite at the very early stages of placement. It

you can’t shape your restorations. The flowability really

doesn’t stick to my instruments and it is very carvable

is a huge benefit for both of these materials.

in the later stages of placement, allowing for minimal finishing. Because it is a highly translucent material, it

Shrinkage: Sonicfill’s shrinkage is 1.88 percent, while

can be cured reliably up to 5 mm deep so only one

Estelite Omega’s is 1.3 percent.

layer was placed. Polishability: On initial polish, Sonicfill 2 has a glossy, smooth appearance. On post-op, the glossy finish is not

and adapt. As Dr. Carson pointed out in the previous

quite as impressive as on the day of placement. Estelle

article, it feels almost creamy, like it melts into the tooth.

Omega is extremely polishable and looks equally as

Estelite also tends to avoid sticking to my instruments.

good both at placement and on recall.

Translucency: Sonicfill’s translucency is high, which can

Overall ease of use: Sonicfill 2 is fairly easy to use

be a disadvantage when the remaining tooth structure

once you determine the use of the handpiece speed

is discolored. This can necessitate stains and opaquers

for placement. Estelite Omega can yield phenomenal

to get a more esthetic result. Estelite Omega has a

esthetic results in the anterior, but I would argue it takes

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Estelite Omega is extremely user-friendly to place

a hands-on workshop to really garner the benefits of

Omega is the material that brings me the most fun

the material. I don’t know how I use to practice without

in my workday. Sonicfill 2 gives me asymptomatic,

Estelite Omega in my armamentarium (or an anterior

functional and esthetic posterior composite restorations

layering composite for that matter), but I don’t know

while Estelite Omega gives predictable, beautiful

that I would have been able to implement the system

anterior restorations. If I were to choose one over the

successfully without significant training first.

other, it would be choosing whether I like esthetic anterior composite placement more (which I do!)

While this series focused on composite comparisons,

or posterior composites. It would be comparing

I don’t think that I can give you a true comparison on

procedures, not materials.

Sonicfill 2 vs. Estelite Omega. They aren’t meant for the same applications and you won’t reap the benefits of their best properties on the same procedure. In my practice, I wouldn’t want to give up either. Sonicfill is a workhorse for posterior composites, while Estelite

Sonicfill 2

Figure 1

Figure 2

Figure 3

Figure 5

Figure 6

Sonicfill 2

50 Figure 4

Estelite Omega

Figure 7

Figure 8

Estelite Omega

Figure 9

Figure 10

Estelite Omega

Figure 11

bulk placement without compromising the function or esthetics. Estelite Omega takes your anterior composites to the next level. Both are phenomenal, each in their own right.

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Sonicfill 2 gives you a technology that allows easy,

Figure 12

THE SECOND OPINION BY DR. JOHN CARSON As always, Dr. Lavigne has given us some great insight!

classifies Estelite Omega as a universal composite and

Just like our first article together, I agree with much of

includes posterior restorations, including Class 1 and

what she said here in this article. However, there are few

2 restorations, in their list of indicated restorations. I

points on which our opinions differ.

get we have other choices we might prefer to use in posterior in many cases, but the fact of the matter is

For sure I agree both Sonicfill and Estelite Omega are

you can use Estelite Omega in the posterior if you want.

great products. Additionally, I will also agree they are very different from each other and marketed toward

So in closing, and just to be clear, in most cases I would

very different applications. Because of this, they have

personally prefer to use Sonicfill on my posterior cases,

way more differences than similarities. Therefore, while

but I could use Estelite Omega in posterior cases

you could say comparing them is not fair, I think it is

understanding it will require much more work and, in

still worthwhile to compare them. Of course, Sonicfill 2

most cases, will not be worth the extra effort and time.

is much faster, and you would not want to use Sonicfill

On the other hand, if esthetics are in play, Sonicfill is

in the anterior when esthetics are in play. This is where

not an option in the anterior.

Estelite Omega shines. Thus, if I had to pick just one, it would be Estelite However, I will respectfully disagree with Dr. Lavigne

Omega as I could use it in the posterior. The bottom

in that, while I would often prefer to use Sonicfill over

line for me is being able to have â&#x20AC;&#x201C; and indeed, I do

Estelite Omega in the posterior, you could use Estelite

have â&#x20AC;&#x201C; both in my practice.

Omega in the posterior if you wanted. In fact, Tokuyama

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FOUR PRODUCTS TO IMMEDIATELY IMPROVE YOUR COMPOSITE RESTORATIONS By Courtney Lavigne, D.M.D.

Composite can be one of the most difficult materials we work with in dentistry depending on where we are in the mouth, how cooperative our patient is and how easily we can isolate the area.

Figure 1

After trials and tribulations with a number of different products and techniques, here are four of my must-have products to help you with composite excellence.

BRUSH AND SCULPT I use Brush and Sculpt (Figure 1), a product by Cosmedent, to smooth my final layer of composite when Iâ&#x20AC;&#x2122;m blending along a bevel, either in the anterior or with a Class V restoration. While I used to use some adhesive on my instrument to prevent composite pull-back, most adhesives contain HEMA, which will discolor your restorations.

A class V composite after using Brush and Sculpt to blend the composite, after cord removal.

ENAMELIZE COMPOSITE POLISHING PASTE Tooth #9 has a MIFL composite; the hypocalcification was added using brushes and the polish was completed with Enamelize (Figures 4-5). What is Enamelize? It’s an aluminum oxide polishing paste that can give a final polish to composites, porcelain, metal and natural tooth. It consists of water, glycerin, vegetable oil, emulsifier and aluminum oxide (Figure 6).

Figure 3

Figure 2

What is Brush and Sculpt? It’s a light-cured, low-viscosity modeling resin. Its approximately 36 percent filled. It’s fantastic for making your resins easy to manipulate at the final smoothing step during placement. I have my assistant put a small drop on the back side of her glove and rub my brush or dip my instrument in the small amount as needed. More is not better; just a touch is plenty.

Figure 4

Once you’ve finished and polished your restorations, and you’re happy with everything except the luster or final polish, this product is amazing at giving your restoration its final beauty. It’s my final step to composite placement for giving that glossy, smooth surface we all desire. You can use it with a rubber prophy cup or, my preference, a felt wheel (also available at Cosmedent) (Figures 2 and 3). Figure 5

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Figure 6

D EN TA L COMPOSITE BRUSHES I didn’t know these existed until a few years ago, but since I started using them, I’m not sure how I ever placed composite without them. They’re great for applying tints and opaques, and for smoothing out the final layer of composite before curing. I also use brushes with Brush and Sculpt for that final layer. What brushes should you get? Cosmedent has brushes in three sizes (Figure 7), or when you purchase the Tokuyama Estelite kit of composites, you’ll get brushes with that kit. I like to use the #1 fine brush

Figure 8

the incisal edge or adding hypocalcification details.

D IACOM P FE ATHE R L ITE IN TR A- OR A L COM POSITE POL I S H E R

I like using the #3 brush for the final layer of

These new composite polishers (Figure 8) are great in

composite with Brush and Sculpt.

the posterior for maintaining your composite anatomy

for fine detailing, like adding tint for translucency at

and giving a really beautiful luster. What are they? These are diamond impregnated medium (green) and fine (gray) composite polishers. They are sterilizable and reusable, and you use them with light pressure at 5-6,000 rpms with water. They’re the best posterior polishers I’ve used to date and the newest member of my composite “must haves.” Don’t set the rpm too high or apply too much pressure, or the arms will fly off and you won’t get many uses out of them. There is a DO composite placed on the premolar that was polished with the DiaComp Feather Lite polishers (Figure 9). I hope these pearls can help improve your composite placement and the fun you’re having in the process. Figure 7

56 Figure 9

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PROTECT THE INTEGRITY OF YOUR RESTORATIONS By John Carson, D.D.S., P.C.

As we all know, the resins we use in our practices all have one thing in common: They all have an outermost layer that when exposed to air does not set, which is known as the air-inhibited layer. While some materials have a thin air-inhibited layer, others have a thick layer. Whether thick or thin this layer can cause a real issue if itâ&#x20AC;&#x2122;s not managed properly when cementing or bonding our 58

indirect restorations.

This potential issue starts with the fact that no matter

One potential issue with this method is excess resin

how good our margins, there are small gaps between

cement, no matter how small the amount it can be

the margin of our restorations and the finish line of

tedious and time consuming to remove. Given this my

our preparations. If our materials contain any resin â&#x20AC;&#x201C;

recommendation is to reserve this method for cement

including resin reinforced glass ionomer cements â&#x20AC;&#x201C; and

where excess is easy to remove such as resin reinforced

the excess cement is removed right to margin prior to

glass ionomer cements, or in cases where the margins

being cured or set, then there will be an air-inhibited

are easy to access with rotary instruments.

layer present that will washout quickly. To prevent this there are two easy steps that can be taken.

The second method is to clean the excess cement back to the margin prior to it completely setting and then place a gel such as water-soluble glycerin gel over the

at the margin until the material is fully set. Once set

margin. This will block the air from the cement, which

you can then trim away the remaining small excess

will then prevent the air-inhibited layer from forming

(including the air-inhibited layer) which will leave

and nothing to clean up afterwards. While you can get

nothing but fully cured cement, which will not be

gels, such as Oxyguard from Kuraray for this purpose

prone to premature washout.

from your dental supplier, you can also find generic options at your local pharmacy.

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The first would be to leave a small bead or material

ANTERIOR RESIN RESTORATIONS: A TECHNIQUE FOR PREDICTABLE CLASS IV RESTORATIONS By Jeff Lineberry, D.D.S., F.A.G.D., F.I.C.O.I.

Figure 1

In this article weâ&#x20AC;&#x2122;re going to describe a technique that I have learned from leading clinicians for completing Class IV resin restorations (as well as for adding to incisal edges) that is predictable, straightforward and will blend in naturally to the surrounding tooth structure.

For this patient a shade was immediately taken to avoid the tooth from desiccation and having an impact on the final outcome of shade selection. Often, one of the struggles with developing your final restoration in cases like this is the ability to reproduce the anatomy of the loss tooth structure. You can either freehand it (which I find difficult to do, especially in the mouth) or you can make it easier by developing a guide to work off of (great for cases that you already have models and have had waxed up). In this instance, the patient was an emergency case (Figure 1) and was anesthetized; an alginate impression 60

was made by the assistant and poured in a fast setting stone (Snap-Stone from Whipmix).

Figure 2

Once the stone was set (usually in five minutes or less), the assistant can add wax or old composite in the area of the fracture and then develop a lingual putty stent (Figure 2). After it set hard, remove the stent and trim the facial aspect back to the facial incisal line angle (Figure 3, green line). Seat the putty stent in the mouth and check for a passive fit and scribe a line in the putty with an explorer (Figure 3, black line) along the area that is fractured.

Figure 5

Figure 4

Figure 6

You can isolate the tooth and complete an initial 45Â°

For this layer, I like to use an enamel shade in a

bevel (Figure 4, marked in blue) and then feather

microhybrid and of course, you can now use the

your finish line out in an irregular pattern to help

nanohybrid composites. The main reason for this

blend in your final restoration (Figure 4, marked

is for strength and support of the final restoration.

in yellow). Complete your bonding procedure

Now, place it in the mouth, align it with the

using your bonding system of choice and you are

tooth and apply pressure. This should allow nice

now ready for the next step. Place a thin layer of

adaption to the tooth and you can now cure it

composite in the matrix to the scribe line and pull

and remove the matrix (Figure 6). You now have a

the composite resin up onto the incisal edge

perfect place to layer composite and develop the

(facial-incisal line angle) as well as the mesial

restoration to blend it perfectly with the adjacent

and distal line angles (Figure 5).

teeth and only requires minor polishing to remove any flash and minimizes finishing.

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Figure 3

PINK CERAMIC VS. PINK COMPOSITE FOR SOFT TISSUE SIMULATION By Robert Winter, D.D.S.

There is the need, at times, to simulate soft tissue with artificial materials because of ridge or papillae deficiencies. One of the goals of the restorative clinician is to create a long-term outcome for patients that require minimal or no professional

The three restorative choices to simulate soft tissue

maintenance of the prosthesis.

with a fixed prosthesis are: • Pink ceramic • Pink composite - alone or laminated onto a ceramic base • Pink heated processed acrylics or injected acrylic/ composite. These are generally only used for removable prosthesis such as complete and partial dentures, or hybrid implant support prosthesis, which may be removable or screw retained, so they will not be further addressed.

The advantages of pink composite are: • T he color choices and match to natural tissue are

There are pros and cons for virtually every technique and material. The key is to assess which option is the most predictable in a given clinical situation.

generally better than ceramic • I t can be applied or layered intraorally to achieve the best color match The disadvantages of pink composite are: • I t is more porous than ceramic, and therefore will change color over time • T he surface appearance will change over time, typically losing its luster • I f the composite extends over the soft tissue in a

The advantages of pink ceramic are: • It is non-porous • It is biologically compatible to soft tissue • It can create a smooth, highly glazed or polished surface • It is a stable material - it does not change over time in color, surface, or overall integrity The disadvantages of pink ceramic are: • The color match to soft tissue can be challenging because of its tendency to be too violet or orange • The prosthesis is fabricated in a laboratory rather than directly in the patient’s mouth

thin layer to help hide the transition line between the prosthesis and the soft tissue, this composite overlay will need to be maintained periodically (possibly as often as yearly). Remember that using this technique compromises patient oral hygiene • I t may need to be removed and replaced to maintain its original appearance and integrity • T here is additional clinical time and expense for the initial procedure and for maintenance After weighing the risks and benefits, my general recommendation is to use pink ceramic as the restorative material. Unfortunately, at times this may result in slightly compromised esthetic outcome. If the clinician chooses to use pink composite alone or laminated onto a pink ceramic base, I recommend that the prosthesis be screw retained or removable in the case of an implant restoration. This allows for it to be removed from the mouth for maintenance, both for prophylaxis and SPEAR | COMPOSITES EBOOK

refinishing the composite.

8 STEPS FOR THE ESTHETIC ‘EMERGENCY’ ANTERIOR COMPOSITE By Kevin Kwiecien, D.M.D, M.S.

Big or small. Class III or IV. Incisal edge with or without the mesial or distal corner. A systematic approach that makes sense and is easy to reproduce and trust for every anterior composite will decrease anxiety, increase the fun and increase your Figure 1

confidence. But what if you and your patient actually see the value in taking a closer look at what caused the break (Figure 1)? What if you both want to avoid putting it back into the situation that caused it in the first place? What if you don’t have time because your patient has an important meeting coming up later that day? Sound familiar? Consistently incorporating these eight simple steps will allow you to actually look forward to these situations, as opposed to putting a kink in your day.

STEP

Putty Stent (or alternative?)

STE P

Dentin and Enamel Shade

Use whatever model you have in the office to create a putty stent. It might even be an old printed model from fabricating a “night guard” (that was originally made to at least protect the teeth at nighttime and during exercise - shocker, right?!) while waiting to do a comprehensive evaluation (Figure 2). Including the incisal edge will save time and increase the predictability (Figure 3). If you don’t have an old model hanging around, maybe your finger holding a piece of mylar when creating the lingual wall could be the “stent.” Regardless, identifying the source of a stent and knowing you are going to use it is the first step.

Figure 4

An old model and some putty can very quickly be used for the greatest predictability.

Figure 2

Before desiccating or even drying, identify the proper shade of the enamel using the tooth to be restored and the adjacent tooth, if you like it, of course (Figure 4). Use the broken or chipped tooth to identify the Figure 3

dentin shade (Figure 5).

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Figure 5

STEP

Create a Distinct Lingual Margin

Figure 6

Figure 7

Remember, there is no reason to blend the lingual margin for esthetics. You would rather see it clearly avoiding unsupported enamel and facilitating easy removal of excess composite and subsequent evaluation of the margin, as opposed to being the proud creator of an â&#x20AC;&#x153;invisible marginâ&#x20AC;? that you and your hygienist will see every six months (and very clearly when the flashing starts to stain) (Figures 6 and 7).

STEP

Figure 8

Create an Irregular and Long Bevel on the Facial

Figure 9

Figure 10

Begin the bevel from the deepest part of the broken

Intentionally create some irregularities of different

tooth/preparation (Figures 8 and 9). Imagine a

shapes and lengths on the superficial enamel beyond

swimming pool transitioning from the deep end to the

the edges of the original “long bevel” (Figure 10).

shallow end. It’s hard to see any distinct transitions,

Irregular patterns or scratches of different shallow

right? Compare that to the ocean where there is a quick

depths, combined with the long bevel, will hide the

and dramatic drop-off from shallow to deep. Which will

edges of any composite, even if the shade is not

be easier to hide and blend? It’s more than just a long

perfect. Try it. You’ll see! How do you think I know?

bevel in enamel. It’s a slowly transitioning bevel from deep to shallow.

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STEP

Create Lingual Wall

STE P

Replace Only What is Missing

Use the putty (or a mylar strip with your finger behind

Matching Dentin Layer

it) to replace the enamel lingual wall (Figure 11). By

The dentin layer should replace only where the dentin

using the putty matrix, you can predictably create

was. By leaving the lingual wall thin, there is space to

the incisal edge position, leaving room to place deep

create irregular depths of dentin and mamelons. Most

discoloration, translucency, hypo-calcification or halo.

importantly, the edges of the dentin shade composite

The wall should be thin, creating space to additively

should be almost imperceptible to differentiate from

build out the necessary layers of dentin and facial

the natural tooth, especially after curing (Figure 13).

enamel in the next step (Figure 12).

Remember, the enamel is translucent, so don’t expect it to mask any underlying irregularities. If you don’t like the look or color at this point, don’t place the enamel layer. Change the dentin shade or blend the “bottom of the transitioning pool” a little more before moving on. Enamel Layer The enamel layer should replace only the thickness of the missing or broken enamel. When applied intentionally and smoothed with a brush, you can confidently avoid bulking up the enamel just so you can remove half of it with a bur two minutes later. Feels a little counterproductive to me.

Figure 11

Figure 13

68 Figure 12

STEP

Identify Primary Anatomy

Even teeth with subtle shade differences look good at speaking distance, if they actually look like teeth. You can take 30 seconds to use the flat side of a sterile pencil to expose all heights of contour on the restored tooth and the adjacent tooth (Figure 15). By identifying the primary line angles, convexities, concavities and embrasure distances, you can quickly identify what changes are needed (Figure 16). Those changes are now made with intention, increasing efficiency and confidence. Figure 15

Figure 16 SPEAR | COMPOSITES EBOOK

Figure 14

STEP

Create Smooth and Broad

Since you havenâ&#x20AC;&#x2122;t yet comprehensively evaluated the esthetics or occlusion, or identified predictable steps to restore the situation that caused the broken tooth in the first place, what can be done to help the patient make it until that time? You donâ&#x20AC;&#x2122;t want to make any big changes at this point, right? But you can do some very slight re-contouring of enamel edges to create two very smooth surfaces and create a broad surface area so that when the patient does move to the position that we think was a contributing factor, the odds of a similar fate are dramatically decreased (Figure 18). At this point, you can do the final polishing of those edges, as well as the rest of the restoration, intentionally preserving the primary anatomy created and appreciating the depth of color and flow also intentionally created in the restoration (Figure 19). You also should not be surprised that the tooth fits right back into the stent that was used to create it all (Figure 20).

Figure 17

Figure 18

Figure 19

Many dentists think that fabricating and using a stent is just for “big cases.” Many of the same dentists think that there is no reason to layer the composite and routinely use one shade. However, these eights steps are taught in the Excellence in Composite Restorations workshop at Spear Education and we don’t teach them just for the big cases. Every case is a big case, right? And the more we create predictable systems in our offices for procedures like this, the more we trust it and enjoy it. That is my hope for you.

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Figure 20

EASY TIP FOR REMOVING RESIN By Mary Anne Salcetti, D.D.S., P.C.

We all occasionally have had resin cemented or bonded crowns come off the prepared tooth. Itâ&#x20AC;&#x2122;s easy to prepare the tooth for rebonding or cementation, but the problem is, how to get the resin out of the crown. Figure 1

Some of us may have tried to pick at it with a scaler

The technique I use to remove the resin is a Brownie

or lightly drill it out with a fine diamond. The inherent

Point. I only ever used them for polishing gold

risk is altering and weakening the intaglia surface of

restorations but have found them to function perfectly

the crown. We hardly ever worried about this when

well at slow speeds removing the cement without

removing cement on a PFM crown.

concern for scratching or marring the internal crown surface. Additionally, for those who spot etch and bond provisional laminate restorations, the Brownie is a great adjunct to removing that tiny bit of composite on the facial surface of your prep. Give it a try and see how it works for you.

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ABOUT SPEAR

Based in Scottsdale, Arizona, Spear Education is an innovative dental education company that includes the following practice-building, member-based services: Spear Campus Thousands of dentists visit Spear’s Scottsdale campus annually for continuing education courses. Members attend seminars in a state-of-the-art, 300-person lecture hall and receive hands-on training in the Spear laboratory. Spear Online Dentistry’s most innovative online growth platform has been proven to help increase case acceptance, create a united team and maximize patient care for thousands of dentists around the world. Spear Faculty Club This is designed as a prestigious community of doctors who share the journey to great dentistry with others committed to continued learning, professional growth and providing the best patient care. This group is at capacity and acceptance is on a wait-list basis. Spear Study Club Spear’s Study Club model involves small groups of peers that meet locally as many as eight times a year to collaborate on real-world cases, improve their clinical expertise and discuss growing practice profitability. Spear has the largest network of study clubs, with active clubs in more than 40 states and six countries. Spear Practice Solutions The fully integrated business and clinical solutions platform blends custom education, personalized coaching and real-time analytics to help your practice reach its full potential.