TOWNIE REVIEW: Esthetic Material can be used in anterior and posterior restorations By: Daniel T. Quevedo, DDS

Today’s cosmetically inclined dentist is faced with many choices when it comes to composites. Some clinicians favor the versatility of a hybrid resin that “does it all” and use it both for anterior and posterior cases. Others use resins designed specifically for the area in which they are working. One thing hybrid composites all have in common is a particle size that varies from sub-micron to greater than one micron. This might be beneficial when it comes to sufficient compressive strength to endure the forces of mastication on posterior teeth, but doesn’t always work too well for the polishability and overall esthetics desired for anterior restorations. This is especially true for facial direct bonding in the esthetic zone (the twelve anterior teeth). So in effect, the hybrids are really best suited for posterior restorations, although you can use them up front if you like.

J. Morita has addressed this in almost a reverse approach with Palfique Estelite (Tokuyama Dental Corp.), a spherically filled esthetic restorative composite that is primarily meant for anterior restorations, but you can use it in select cases in the posterior. According to the manufacturer, it’s spherical filler that exhibits a uniform particle size of 0.2 microns. Palfique Estelite is highly filled at 71% by volume and 82% by weight. Its compressive strength is 380 MPa. The manufacturer’s official recommendation is that Palfique Estelite is best suited for anterior restorations, but due to its strength, can also be used in small Class Is, Class IIs if it’s just a small buccal/lingual groove, and also Class Vs. Proper case selection would be necessary for posterior use, i.e. you would not want to use it on a second molar in a patient who is a bruxer or a clencher.

Posterior Example
Palfique Estelite polishes better than anything I’ve ever used! When it was introduced in the U.S., Raymond Bertolotti, DDS, PhD, said Palfique is “the ultimate anterior composite. My best kept secret (is) now available in America.” This composite also has a chameleon effect that makes shade matching a breeze. In fact, a relatively small number of shades are all that are really needed. For example, shade A1 works for matching the following shades: B1, A1, B2, D2, and A2. Figure 1 demonstrates this chameleon effect in clinical settings. The first molar is markedly lighter than the second molar. Figure 2 shows the result using the identical shade of Palfique Estelite (A2) on both teeth. It seemed to darken itself to blend in with the second molar, and remained light enough to provide a pleasing result on the first molar just the same. The benefit to the doctor is that you can match a great number of colors using a fewer number of shades. Other benefits include high resistance to abrasion, and radiopacity. It is available in both pre-loaded tips and syringes.

Fig. 1 Before: First molar decidedly darker than the second molar

Fig. 2 After: Color match using Palfique Estelite

Anterior Example Using Special Shades on Progressing Cases
When restoring a large direct anterior case, handling characteristics are almost as important as its esthetics. Palfique Estelite is not as stiff as many composites I’ve used before, but still able to hold its shape without slumping. It’s very easy to smooth and contour it the way you want it to be. Opaque, cervical, and incisal shades are available for those situations where you need them.

The patient presented with a badly broken down dentition due to years of neglect. Even though this is a case “in progress” and is not near completion, I’d like to show you some pictures showing what you can do in a drastic case. Figure 3 shows the pre-op picture of old resins with recurrent decay combined with interproximal caries due to poor dietary habits and equally poor plaque control. During the primary prevention phase, I focus on getting control of the factors causing disease and destruction.

During phase II, I focus on stopping the advancement of disease/destruction already present. No crown and/or bridgework will be suggested until phase I and II are completed. In the meantime, while my patients are trying to “clean up their act”, I give them something to make them happy with their smile. Figure 4 shows an occlusal view in which both of the lateral incisors had carious pulp exposures and endodontics had to be performed. Tooth #10 required a post and core build-up as well. I used the opaque shades to reproduce the palatal enamel walls. This is especially important in the interproximal areas to prevent that translucent effect on the mesial and distal.

Fig. 3 Pre-op view of old resins with recurrent decay

Fig. 4 Occlusal view after caries removed

Fig. 5 Post-op view of #s 7-10 on a case in progress

After establishing the palatal wall, I build it up in layers. For instance, with #10, I placed A3 beginning at the cervical about 2mm in thickness, and then tapered it getting thinner as I went towards the incisal until I reached the junction of the middle and incisal third of the tooth. Then I placed A2 in a similar fashion up to within 2mm of the incisal edge. The balance of the facial aspect was done with A1. No incisal shade was needed in this case since none of his other teeth have a translucent incisal edge. Even though I’ve only finished four of his front teeth so far, Figure 5 shows what a difference it makes! Simplicity self-etching adhesive (Apex Dental) was used for all of these restorations. The left lateral incisor (#10) was almost totally recreated with Palfique Estelite. The patient couldn’t believe it when he looked in the mirror. The ability to transform someone’s life for the better is one of the many satisfactions of doing cosmetic dentistry.

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Daniel T. Quevedo, DDS is a wet-gloved dentist in Longwood, FL. After 12 years of practice in the Nashville, TN area, he decided to move back home to Florida. He started his current practice “almost from scratch.” An avid participant at DentalTown.com, Dr. Quevedo focuses on cosmetic dentistry that is health-focused instead of “disease-treatment” focused. He is a member of the Florida Academy of Cosmetic Dentistry.

Dr. Quevedo welcomes all comments and can be reached at (407) 786-2552 or by email at DrDan@DQDDS.com