Show Your Work: Finish, Polish and Forget It by Dr. James H. Peyton

Creating restorations that stand the test of time

by Dr. James H Peyton

One of the best ways to judge the quality of a composite restorative material is by seeing how long the restoration lasts. A high-quality composite material should not only be able to polish well but also maintain that polish. The composite should be able to withstand the forces of mastication, clenching, grinding and normal occlusal wear.

These clinical cases demonstrate how the clinical procedure can be performed, including finishing and polishing procedures. Postoperative views at 8 months, 10 months and more than 12 months will be shown.

Case 1

50-year-old patient presented with several noncarious cervical defects on Teeth 24–26. During the course of the composite restoration, #22 had a porcelain crown placed and the patient was holding off on having #25 being restored, so the teeth restored with composite were #24 and #26. Tooth 23 had previously been restored with composite (Fig. 1).

The patient was given local anesthetic with 1.8 milliliters (one carpule) of 4% Citanest. Teeth 24 and 26 were prepared for Class V restorations, which included beveling the incisal aspect of the restoration and removing the stain and surface debris from the rest of the area to be restored. The surface to be restored was acid-etched with 35% phosphoric acid (Ultra-Etch, Ultradent) before the bonding agent (Bond Force, Tokuyama Dental) was applied to the teeth and light-cured.

Omnichroma composite (Tokuyama Dental) was applied to the teeth, sculpted and light-cured. The product is very high in value before light curing, but it blends into the natural color of the tooth afterward (Fig. 2).

With a Class V composite, a flame-tip diamond is used to contour the gingival margin and reduce over-contoured areas. A small coarse disc (red, Soflex-XT, 3M) works well to evenly contour the facial surface; this disc will eliminate all the rough areas and uneven surfaces. To further reduce the roughness, use successive finer-grit discs. A patient can easily tell if the surface texture is rough or uneven. A medium rubber cup (blue cup, Cosmedent) is used with water, then followed up with a fine rubber cup (pink cup, Cosmedent). To achieve a high polish, use a Jiffy brush. A high polish is always desirable, but it is more important to achieve an even and smooth surface. Fig. 3 shows the immediate postprocedure view, while Fig. 4 was taken at an eight-month follow-up appointment.

Fig. 1

Fig. 2

Fig. 3

Fig. 4

Case 1’s 18-month follow-up

More than a year later, the same patient returned for treatment on Tooth 25.

Fig. 5: Preoperative view of the Class V defect on Tooth 25.

Fig. 6: Adding Omnichroma composite to the facial of #25 before light-curing.

Fig. 7: After light-curing.

Fig. 8: The initial contouring of the facial and the gingival margin was done with a flame-tip diamond bur.

Fig. 9: The facial surface was smoothed and evenly reduced with a coarse disc.

Fig. 10: A polishing cup was used to obtain a high polish.

Fig. 11: The completed restoration can be compared to the composite restorations done more than a year before on Teeth 23, 24 and 26.

Fig. 12: Smile view of the completed restorations on Teeth 23–26.

Case 2

The second clinical case features a 55-year-old patient who also had several noncarious cervical defects on #11–13. Tooth 12 had a previously treated Class V composite that needed to be replaced. A history of bruxism was evident by the wear of the incisal edges of his teeth. The patient admitted to a reluctance to wear his night guard (Fig. 13). The patient was encouraged to wear the night guard to decrease the incisal wear as well as preventing the cervical erosion/abfraction lesions.

The teeth were anesthetized with 1.7ml (one carpule) of Lidocaine HCl 2% with 1:100,00 epinephrine. Packing cord (00 Ultrapak, Ultradent) was placed below the gingival margin of the teeth to provide retraction of the gingival tissue and some moisture control at the gingival tissue margin. Once the composite is cured, the cord also acts as a landmark to locate the gingival margin.

The facial margins on the teeth were beveled to increase the enamel bond and to help blend the color of the composite material seamlessly into the enamel of the tooth. The old restoration on #12 was completely removed to ensure the greatest bond to the tooth. A slow-speed round bur was then used to remove the surface dentin layer from #11 and #13. The teeth were then acid-etched, rinsed and dried before the bonding agent (Bond Force, Tokuyama Dental) was applied to all three teeth and light-cured. Omnichroma was applied in a single layer one tooth at a time and evenly spread out with a thin IPC sculpted, taking time to make sure the gingival margin is sealed. A #3 brush is helpful to evenly spread out the composite; there is no need to rush because the composite material is very sculptable and holds its shape. Next, the composite was light-cured (Fig. 14).

As with the first clinical case, a flame tip diamond bur on a high-speed handpiece was used to contour the gingival margin area. If there is a large excess of composite material, then the diamond bur can be used to reduce the composite close to the final contour. The final contour is best done with a thin, coarse disc (e.g., Soflex-XT, 3M) to achieve a smooth and uniform contour (Fig. 15). Once this contour has been achieved, a higher polish can be accomplished with a medium and then a fine rubber cup polisher (e.g., Blue & Pink Flexicups, Cosmedent, Fig. 16). To achieve an even higher polish, use a Jiffy brush or a felt buff wheel (FlexiBuff, Cosmedent). If there is still an over-contoured gingival margin, a #12 Bard Parker scalpel can also be used to trim the excess composite (Fig. 17, demonstrated here on a Typodont). A high polish is always desirable, but it is more important to achieve an even and smooth surface with a nicely sealed gingival margin. Fig. 18 shows an immediate postprocedure result; Fig. 19 was taken after 11 months.

Fig. 13

Fig. 14

Fig. 15

Fig. 16

Fig. 17

Fig. 18

Fig. 19

Conclusion

Postoperative photos taken at 8-, 10- and 12-month follow-up appointments show that these restorations can hold polish and color. For direct veneers and large Class IV restorations with a high polish, it is advised to have the hygienist either skip these surfaces when using a coarse prophy paste or use fine polishing paste.