TOWNIE CLINICAL: The Fast Simple Amalgam Replacement By: Michael A. Esposito, DDS

The large MODB amalgam in #4 had definitely seen better days. The surface was pitted. There was substantial marginal ditching and discoloration. Though the tooth remained asymptomatic, the restoration itself was beginning to disintegrate.

Several years ago I strongly suggested to the patient he let me crown the tooth due to the extremely wide and failing restoration that was currently present. I’d been trying to persuade the patient to let me crown the tooth, but the 40-something-year-old-male steadfastly refused.

I’ll never know what finally possessed him, after all those appointments, to agree to replace the restoration. Perhaps he finally noticed the way the exposed amalgam reflected the light from a camera flash as he smiled for the camera. Whatever his motivation the timing couldn’t have been worse. He was leaving on vacation in two days and we were swamped, the best we could do was to squeeze him into a half-hour appointment—there was no time to waste. We had to strike while the iron was hot! The patient was still resistant to a full crown coverage. I informed him although that was the “ideal” treatment we have an option. I explained modern bonding techniques had progressed to the point we could now reliably place a resin and expect it to function extremely well. There was no guarantee it would last forever, but it was still a reasonable alternative. The direct restoration permitted me to restore the tooth and provide some cusp reinforcement with less overall tooth reduction, less gingival margin trimming (to encourage perio concerns) and low cost. It’s hard to imagine a crown could offer better esthetics than this restoration. Does this mean the tooth won’t eventually require a crown—of course not. But for this patient at this stage, maybe this was the best treatment. (Aside from the fact that it was the only option he’d allow.)

Here’s what I did:
After removing the old restoration with a single use Parkell course diamond burr and eliminating caries, I was left with a deep, highly irregular preparation with lots of nooks and crannies. Despite the wide isthmus and depth, substantial dentin remained on the buccal and lingual wall. There was no evidence of cuspal crazing.

For fast bonding: Skip the acid-etch steps
For the bonding agent, I used Touch & Bond from Parkell. This is a highly fluid, thin-film self-etch adhesive with a great record of preventing post-op sensitivity. I have been using this adhesive for approximately 3 years for just about all of my direct bonding requirements. I chose it for its ease of use and its uncanny ability to prevent post-op sensitivity. Preventing sensitivity was particularly appropriate for this patient since immediate follow-up would be difficult and NOBODY wants to deal with tooth related sensitivity while on vacation.

For a fast liner: A core material instead of a flowable
Normally I’d use a very thin flowable light-cure composite (such as Heliomolar Flow) as a base. However, this case was different. For one thing, there was that irregular, pot-holed floor. I’d feel more comfortable with a dual-cure material because it would take the depth-of-cure variable out of the equation. And for another thing, there was that wide mesial box. To help prevent voids along the proximal box cavosurface margins, I like to place a thin flowable against the matrix band and margin. A conventional flowable composite would be too “flowable.” I’d have to apply it in 3 separate steps to keep it where I wanted it—apply/cure... apply/cure...apply/cure.

So instead, after placing a clear Mylar matrix (OmniBand/Ultradent) and mesial wedge, I expressed a thin layer of tooth-shade Absolute Dentin (Parkell) directly from the cartridge onto the floor of the preparation. This dual-cure composite is intended primarily for core build-ups, but it served the particular needs of this case quite nicely.

Absolute Dentin flows slightly as it first comes out the mixing tip and then begins to stack. This permits it to conform well to the surface without flowing all over the place. I could easily express all the material needed, and then spread it over the bottom of the prep and along the margins using an explorer.

After creating a thin film, I light-cured the tooth for about 20 seconds. Because Absolute Dentin includes self-cure as well as light-cure initiators, I could be confident it would set, even in the preparation’s darker recesses.

As a matter of fact, if cosmetics hadn’t been a significant concern, I might have taken advantage of the self-cure feature to further speed the procedure. If I had built a substantial portion of the restoration out of core material, and then laminated the occlusal surface with a cosmetic composite, I could have saved much of the time involved in incremental build-up.

However, there were some drawbacks to this approach. In a Class II restoration like this, the proximal walls would have been composed of core material. It wouldn’t finish the way I wanted. And though I was using the so-called “Tooth Shade” core material, it wasn’t the patient’s “tooth shade.” This might have been adequate if this were a short-term transitional restoration.

Though I’m pretty sure this tooth will have a PFM somewhere in its future (and I’ve told the patient this), he would not have been happy if I’d suggested we compromise cosmetics because the restoration “only had to last a year or so.”

For fast esthetics: an anterior composite instead of a posterior
I built the restoration incrementally using Epic-TMPT (Parkell) composite. I used shade A-3 for the first more internal layer to simulate the darker dentin color, and then used shade A-2 for the enamel layer.

According to Parkell, Epic-TMPT is intended primarily for anterior use. It’s a radiolucent microfill that’s a pleasure to place and a delight to polish. Parkell offers another version called Epic-AP for posterior use. Though Epic-AP offers greater strength and radiopacity, it’s just too thick and sticky for my taste.

So if the patient has a normal bite and the restoration isn’t truly massive, I occasionally find myself turning to Epic-TMPT for selected posterior cases. (By the way, the radiopaque Absolute Dentin liner will help make subsequent caries identifiable despite the composite’s radiolucency.)

What do I mean by “selected posterior cases”?
If I had been building a direct onlay, for example, I would have opted for the additional strength of a posterior composite. But when the prep doesn’t demonstrate fracture or craze lines (and this one didn’t) and when the buccal/lingual walls remain relatively strong, I’ve had excellent success over the years using a conventional MOD prep. I just make certain the margins don’t fall on a functional surface.

Epic-TMPT has the additional advantage of high-translucency. This allows considerable leeway in shade matching. Granted, on a second premolar the color and characterization are not critical. But even in the anterior, if you can just get the shade in the ballpark, an Epic-TMPT restoration will often appear to be dead on. Because of its translucency it tends to take on the tooth’s natural shade without complex layering or characterization. (Note: Of course, translucency can be a double-edged sword. If you’re trying to mask serious discoloration, Epic will require an opaquer.)

So there you have it! I walked into the operatory at 2 p.m. and I was sitting down with the next patient by 2:28 p.m., so the entire procedure (from amalgam removal through finishing) took less than 30 minutes. Amazing!

I was rather pleased with the result. And when I handed the patient the mirror, he was absolutely thrilled. I suspect he’s asking himself why Dr. Esposito never recommended this type of treatment before!

Michael A. Esposito, DDS, practices General Dentistry in Stroudsburg, PA. Dr. Esposito is a graduate and former clinical instructor of the School of Dentistry at SUNY-Buffalo. He is a boater, an avid fan of his daughter’s basketball team and occasional contributor on clinical subjects to various dental publications. Dr. Esposito can be reached at espo28@ptdprolog.net.

Townie Comments

namak26	8/28/2003 11:52:22 AM
It is beautiful work. Are you happy with all of the Parkell products?
mike_esposito_dds	8/28/2003 1:24:16 PM
I’ve been extremely pleased with most everything I’ve tried from Parkell. To be honest, I can’t remember ever sending anything back! Another great thing is one of the chief people there, Dr. Nelson Gendusa, is available anytime if there are questions. He’s often seen lurking on the DentalTown website as well.
desert_rat	8/28/2003 1:51:43 PM
Nice Mike, can you see white lines? It is hell to avoid them. I love this composite and use mega amounts of it. For a Class II, I worry because it is radiolucent. That makes finding decay radiographically hard. For a Class V it is ideal. Your results look beautiful.
mike_esposito_dds	8/28/2003 1:59:07 PM
Thanks for the compliment Mark! I usually don’t have too many problems with white lines because I’ve adopted John Kanca’s curing techniques, but every once in a while I’ll get one. You are very correct about the Epic-TMPT being radiolucent. Parkell came out with another version called Epic-AP, but I found it a bit stiffer and more difficult to place. The TMPT version is a pleasure to work with. On the radiographs I find that the TMPT is not completely radiolucent and does leave a bit of a shadow that I can visualize caries. Not ideal, but doable for certain situations like this one.
Drdandds	8/28/2003 2:33:51 PM
Beautiful Case! Looks great, Mike! Did you use that G3 you bought while we were out in Vegas? Takes nice pictures, huh?
mike_esposito_dds	8/28/2003 3:27:07 PM
Dan, yep, it’s the G3. One of the reasons I shot this case was to get myself using it! It’s been sitting waiting for me, but I always see myself as too busy. Now I leave it in the op and take pics as often as I can. I’m probably not going to get all the perfect angles and there is going to be lots of spit here and there until I get it down to a science, but practice makes perfect, right?