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Composite Materials for Optimal Restorative Results by Lee Ann Brady, DMD

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by Lee Ann Brady, DMD

Composite technology has changed over the years, constantly improving the quality of care we can provide for our patients. Dental material development is subject to a unique set of stresses that other materials do not face. As an aesthetic material we hold restorative composites to a high standard of replicating the natural tooth structure in form, color and wear. As a direct restorative material we hold composites to the longevity standards of materials like gold and amalgam. As an alternative restorative replacement for amalgam, composite has also been held to the same economic pressures as amalgam, despite it being a much more challenging and technique-sensitive material to work with. Through it all, composite has continued to develop and evolve and represents the bulk of the direct restorations placed today.

In the early years we struggled with macrofill materials and hoped for composites with better physical and aesthetic properties. As filler, monomer and photoinitiator science improved, newer composites have offered us better handling properties along with improved physical properties, resulting in greater predictability of composite restorations.

Polymerizations shrinkage is a factor within the shrinkage stress concept. This change is the result of advances in filler content technology and the process of polymerization. The total shrinkage of the material as it polymerizes is a less critical factor than understanding the amount of stress that accumulates at the bonded interface during polymerization. It is this stress that compromises the bond and results in premature failure at the restorative margins or post-operative sequelae.

Placing composite incrementally in layers was a technique developed to overcome physical properties of composite materials. Factors like depth of cure, condensation voids and shrinkage stress led to the development of multiple placement and curing techniques that may or may not be needed with our modern materials. Some newer composites have increased depth of cure and reduced shrinkage stress, allowing layers of up to 4mm with equal success. In addition, lower viscosity materials with high enough filler content to have durable physical properties overcome the challenges of condensation.

Each of these developments leaves dentists with new and improved options to offer high quality care to patients. The challenge is deciding which is the optimal material to use in a given clinical situation. Each patient and each tooth has a different balance of aesthetic, biologic and functional concerns that should be considered when selecting an appropriate restorative material. Techniques should be matched to the requirements of an individual material to optimize success.

Case report

A 16 -year-old patient presents with multiple areas of interproximal decay ranging from incipient to large in size. On this particular appointment, we were scheduled to restore the upper left-hand quadrant, where decay was present on the distal of the upper first premolar and the mesial of the upper second premolar. After reviewing the radiographs and reconfirming the diagnosis the patient was anesthetiz ed. The mucosa was dried to allow surface contact of the topical anesthetic. Topical was applied over the mucosa above the premolars, covered with a two by two and allowed to work for a full minute. Using The Wand from Milestone Scientific, a computerized anesthetic delivery system, a quarter carpule carbocaine plain was infiltrated over the premolars with a 30 gauge short needle on the slowest delivery setting. The carbocaine was allowed to anesthetize the soft tissue for a full minute, then a carpule of septicaine was infiltrated into the same location to achieve maximum anesthesia of the two teeth.

Once the patient was adequately numb, Vaseline was applied to her lips and a regular size Isolite placed for isolation, retraction of her cheek and tongue, and illumination. An orange plastic wedge was placed between the two premolars prior to commencing with tooth preparation. This concept of pre-wedging allows the periodontal ligaments to accommodate tooth movement equal to or greater than the thickness of the matrix that will be used during restoration, ensuring a tight interproximal contact. Pre-wedging also protects the papilla from being damaged as the interproximal box is prepared, and in cases where you do not have adjacent lesions reduces the risk of nicking the adjacent tooth during preparation. The wedge is placed so that equal amounts of the wedge are visible on the buccal and lingual of the tooth requiring adequate pressure. If you can place a wedge more than half way to the other side of the embrasure, a larger wedge is indicated. If the reverse is true and you cannot place the wedge fully into the embrasure, move down to a smaller size.

Using a Brasseler 245 carbide bur the upper left first premolar was prepared for disto-occlusal restoration. I made the decision to start with the first premolar as the decay on the second premolar looked very incipient on the radiograph. This approach would allow me the opportunity to evaluate the mesial of the first premolar clinically prior to preparation. With the box and occlusal outline complete, the buccal and lingual walls of the interproximal box were beveled with a diamond to align the enamel rods for maximum adhesion of the composite.

Clinically the mesial of the upper left second premolar was cavitated and soft, necessitating restoration. However, the dimension of the carious lesion was small enough to allow direct preparation interproximally through the box prep on the first premolar. The preparation on the second premolar was completed with a Brasseler 330 carbide bur and the walls beveled with a fine diamond. The wedge was removed to allow placement of Garrison sectional matrix bands. Two sectional matrix bands were placed, one facing each proximal box. The wedge was returned to the gingival embrasure and a separator ring placed. When filling two adjacent proximal boxes, I have tried multiple techniques over the years. To date, placing two adjacent bands back-to-back and then filling them separately has granted me the greatest success in creating a tight contact. With the two bands in place, the first premolar was selectively etched using phosphoric acid gel only on the enamel margins. The etchant was rinsed and dried and then Gluma Desensitizer, made by Heraeus Kulzer, was placed over the dentin with a micro-brush. The excess Gluma was dried with a cotton pellet and then a self-etching dentin adhesive was scrubbed over the preparation for 20 seconds. The solvent was evaporated with clean dry air and then the dentin adhesive was light cured for 20 seconds. The preparation was filled in multiple layers of GC America’s G -ænial Universal Flo composite, and each layer was cured for 20 seconds. The separating ring, wedge and bands were removed and the restoration light cured again from buccal and lingual for 10 seconds each.


The proximal box of the second premolar restoration was finished to create smooth margins and a nicely formed interproximal wall. Following trimming and polishing of the first tooth, a sectional matrix was placed to fill the first pre-molar preparation along with a wedge and the separating ring. The first premolar was prepared prior to placement of the composite in a similar manner as the second premolar. An initial layer of G-ænial Universal Flo was placed at the depth of the box and cured for 20 seconds. The remainder of the preparation was filled using two layers of Kalore. Kalore was placed with a gold-tipped condenser, and the final occlusal layer shaped with a gold-tipped acorn burnisher to reduce excess and shape the composite prior to curing.

Following curing of the occlusal layer, the matrix, wedge and separating ring were removed. The composite was finished using a fine football diamond to remove gross excess. An Arkansas stone was then used to refine the occlusal surface and add anatomy. The interproximal box margins were finished using a fine mosquito diamond and then the margins were all fine-finished with a brownie silicone point. The brownie finishes down the composite very efficiently without cutting the tooth surface, resulting in an infinity margin. I do my entire composite trimming and finishing on slow speed to minimize the ditching of the composite. When finishing margins, I try to always have the bur running on both the tooth structure and composite simultaneously. When moving from tooth to composite or composite to tooth during finishing, it is easy to ditch the restorative material. Once both restorations were finished, the Isolite was removed and the interproximal contact flossed to verify tightness and dimension of the contact. The occlusal contacts were checked and refined to leave an ICP contact on the mesial marginal ridge of the second premolar. The composites were finished with two silicone finishing points of varying surface texture, and then lastly with Ultradent diamond polishing paste on a slow-speed brush.

Conclusion

G-ænial Universal Flo gives the advantage of a flowable material with high adaptation to the marginal interfaces and walls of the preparation, increasing marginal integrity. It creates a solid fill without voids, without the issue of material condensation, and has equal physical properties to a conventional composite material. Kalore offers the durability and occlusal wear resistance of a conventional nano-composite. Combining the two grants optimal results.

Dr. Lee Ann Brady is a privately practicing dentist and nationally recognized educator, lecturer and author. With an extensive history in leadership, previously as Executive VP of Clinical Education for Spear Education and Clinical Director of the Pankey Institute; Dr. Brady is currently the Director of Education for Clinical Mastery, providing hands on and live patient programs across the country. Dr. Brady has also developed a vast library of online instruction at www.leeannbrady.com. She practices in Glendale, Arizona, is the clinical editor of the SSC Journal, and a member of the editorial board for the JCD and Dentaltown Magazine.

Dentaltown Magazine
April 2024
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