Minimal Prep, Minimal Fuss: Direct Composite Bonding

LetÌs suppose that there is a mutual agreement between you and your patient that a dental Ïspruce-upÓ is in order. LetÌs add to the mix that you've agreed that it needs to be fast and economical, will result in little to no tooth reduction, and will leave the gum tissues unaltered. Nor will treatment close the door to future upgrades such as use of a ceramic restorative and/or possibly the inclusion of more teeth. Given that scenario, the first thing that enters my mind is, ÏHow much time can I devote to this project and stay within the patientÌs budget and still remain profitable? (We are running a business, arenÌt we?)
The next thought involves a material selection issue. That is, what can I place quickly and with minimal fuss, such that the entire process is simplified and thus accelerated (as in no matrices, an absence of complicated shade recipes, and without placement of Ïmaverick shadesÓ), that lends itself to easy finishing and polishing? In years gone by, this might have been a tall order. Fortunately, the advent of nonslumping, sculptable micro-hybrid composite resins (now with nanoparticle filler sizes) has made this order a reality. IÌm happy to report that most of whatÌs out there in this category is good! Choices abound! As one might expect, each composite system has individual packaging and handling characteristics that help to distinguish  it from the others; and each takes its own approach to putting together what might be construed as a complete system. LetÌs explore that concept a bit further.
Ask yourself, ÏHow many shades are found on a standard Vita shade guide?Ó Once you answer that question, youÌll know what manufacturers are up against when they are faced with bringing a new composite system to market. You already know what we are up against when it comes to deciding which shades to stock, let alone which shades to use to obtain that perfect match. We often stock little-used shades as a trade-off for the security of knowing that if it breaks, we can fix it. Most often these shades remain in the box and quietly expire over the years.
Enter a new approach based upon a Ïnot-so-newÓ understanding of tooth color.1,2 Synergy D6 (Coltne/Whaledent) relies upon a simplified approach to color creation termed the Ïmodern 2-layer concept.Ó3 This shading concept emphasizes that natural tooth structure is composed of a dentin mass encapsulated by an enamel mass. Color reproduction, as part of a simplified layering process, is achieved by replacing equivalent amounts of properly colored tooth mass where its corresponding natural tooth structure once existed. The D6 stands for 6 Dentin Duo Shades, which are created by grouping shades with similar hue (color), chroma (intensity or saturation), and value (lightness and darkness). The result is an entire system based upon the following Duo Shades: White Bleach (WB), A1/B1, A2/B2, A3.5/B3, A3/D3, C2/C3.
Have you ever had a difficult time deciding whether to use an A1 or B1 shade, or a C2 or C3 shade? I have. This is because they are remarkably similar. Dr. Didier Dietschi of Geneva, Switzerland, conducted a colorimetric study of extracted teeth and reached a conclusion that dentin hues fell within 7 recognizable shades. The variety of tooth shades encountered within nature had more to do with the thickness and optical quality of the translucent enamel covering the dentin, which in turn is mostly related to age.4 To complete the Duo Shade approach, a Universal enamel (translucent) and a White Opalescent enamel (suitable for younger teeth) are included in a D6 kit, allowing the operator to achieve a variety of shade effects simply by applying the enamel over the surface of the chosen dentin shade. The included shade guide provides for ÏnestingÓ of the dentin and enamel shades so as to preview the effect. In keeping with todayÌs demand for tooth whitening, a Dentin White Bleach shade is also part of the kit, fulfilling the sixth shade of the system. Ultimately, 6 dentin shades and 2 enamel modifiers provide the operator with a single-box approach to shade creation...a refreshing approach.
What follows is a case report utilizing the D6 system for direct composite veneering. While not an ideal demonstration of the modern 2-layer concept (as a class IV restoration might be), the reader will grasp the use of the shade creation method. It is important to understand that ultimately the final shade depends upon the thickness of the respective restorative materials.

Case Report

Figure 1. Retracted preoperative view.

Figure 2. Relaxed smile.

She entered my practice as a new patient. Following full examination it was determined that a course of managing the soft tissue was necessary to stabilize her periodontium. Her restorative needs were minimal. She, however, had an agenda of her own: bolstering her self-esteem. She was displeased with the diastemas present in her existing smile as well as the less-than-ideal alignment observed on the left side of her smile, ie, teeth Nos. 9 to 11 (Figures 1 and 2). It was explained to she that this spacing was occurring due to a loss of canine protection brought on both by a bruxism habit and a weakened periodontium. It was also explained that if these circumstances were not controlled, any quick fixes provided would likely reverse themselves as time progressed. A compromise was reached in that she would undergo a nonsurgical course of managing the soft tissue as well as agree to a post-bonding bruxism appliance that would serve dually as a retainer, minimizing chances of her teeth migrating further. Direct composite bonding was chosen as the perfect fit for a transitional approach to correcting what she disliked most about her smile. While tissue height discrepancies were noted with respect to her lateral incisors, they were not objectionable to she and thus not planned for correction. Focus was indeed placed upon a rapid, economical, conservative, no fuss approach. While she wished only to have teeth Nos. 7 to 10 bonded, she was convinced to include teeth Nos. 6 and 11 so that canine protection could be re-established. Shade would be "punched up" some but kept within the existing shade range of her posterior and lower dentition.

Figure 3a. Separated Synergy D6 enamel and dentin shade tabs.

Figure 3b. Nested shade tabs to approximate final shade.

Figure 4. Conservative, enamel-based tooth preparation.

Figure 5. Preliminary width measurements.


Patient Perspective

I contacted Dr. Martin B. Goldstein with a couple of issues concerning my teeth.
I had previous cosmetic dentistry done several times, which was now disintegrating. In addition to this, my teeth were shifting out of place due to tooth removal. I was extremely upset about the way my teeth looked; it was affecting my appearance and general well-being.
Working with the public for many years taught me that most people base their opinions of others on first impressions. I have always tried to maintain a happy disposition and a smile when meeting others. One’s smile is an important part of any greeting, whether during a first meeting or when seeing an old friend. The spaces emerging throughout my mouth and the condition of my teeth were preventing me from smiling and even talking normally. I tried not to look directly at people when speaking with them, and I was very careful not to show any teeth when smiling. I was embarrassed because of the condition of my teeth.
I met with Dr. Goldstein, and he explained what he could do for me, how he could do it, and what could be done to maintain his work. I had previous cosmetic dentistry done several times before, which never seemed to last very long, so I must admit, I was skeptical. Dr. Goldstein was wonderful during the whole process. He was clear and concise concerning the de-scription of procedures. He made sure it was as pain free as possible and made me feel secure sitting in the chair. With painstaking detail he “rebuilt” my teeth. Once the work was completed, he made sure I was happy with the look and feel of my “new” teeth before letting me out of the chair. He also followed up several times after the work had been done to ensure I was still happy.
I cannot begin to tell you how much better I feel about myself since Dr. Goldstein completed his work. I can smile and laugh again without worrying about my teeth. I can talk to people and look them straight in the eye with no concerns. I have my confidence back, which has definitely boosted my well-being.

While waiting for local anesthesia to settle in, the desired shade was selected/created by nesting the A2/B2 Duo Shade tab and Universal enamel shade tab so as to preview what might be anticipated in the final shade (Figures 3a and 3b). Exact replication of this shade might only occur if layer thickness approximates that of the shade tabs. Fortunately, Synergy D6Ìs dentin shades possess sufficient opacity to reduce the influence of the underlying tooth structureÌs color. This property, balanced by a chameleon effect, induces a pleasing blend between the existing dentin shade and the A2/B2 Duo Shade paste.
Following onset of anesthesia, ultra-conservative tooth preparation was completed, keeping bonding surfaces mostly in enamel and removing old composite where needed (Figure 4). Time was also taken to pre-measure the combined incisal edge and diastema width to serve as a guide for freehand placement of the restorative material. Erskine DentalÌs Dentagauge T1, providing digital measurement readouts, proves a useful tool for this purpose (Figure 5).
It is worth noting that certain dental morphologies (notably smaller, somewhat retruded teeth) lend themselves to what is often termed Ïmore volume.Ó This is helpful when wishing to apply composite resin layering with minimal tooth modification. The somewhat thicker bonded tooth actually enhances smile appearance and allows for truer shading, as was the case with her smile.

Figure 6. Isolated and etched central incisor.

Figure 7. Application of ParkellÌs Brush&Bond.

Figure 8. Bulk placement of dentin shade A2.

Figure 9. Gross shaping with Almore International composite instrument.

Figure 10. Fine shaping with Hu- Friedy composite instrument.

Figure 11. Finger formation of enamel layer of composite.

Figure 12. Cured enamel layer on tooth No. 9.

Figure 13. Shaping with carbide finishing bur.

Figure 14. Polishing with DENTSPLY Caulk Enhance cup.

Figure 15. Application of glaze coat.

Figure 16. Completed case.

To summarize the placement of each of the 6 direct composite veneers, the following steps were taken:

(1) Isolation of each tooth with Dead Soft Metal Matrix Strips (Den-Mat).
(2) Etching with 37% phosphoric acid-etch for 10 seconds to serve as a cleanser (Figure 6).
(3) Placement of Parkell Ìs Brush&Bond, a self-etching bonding agent (Figure 7). Note that the Synergy D6 Welcome Kit comes with its own self-etch bonding agent, OneCoat Self-Etching Bond, that would serve equally well.
(4) Bulk placement and shaping of the Dentin Duo Shade A2/B2 (Figures 8 to 10) using Hu-FriedyÌs 2 Goldstein Flexi-Thin XTS Composite Instrument for fine shaping and Almore InternationalÌs Gold Microfil composite instrument for gross shaping and blending. Interproximal placement is a ÏfeatheringÓ process similar to a no-prep or minimal-prep porcelain veneer, with the composite being thinned as it approaches the contact. The exception to this, of course, would be diastema management. Medium to high polishing of the mesial surface of tooth No. 8 enables a ÏnonstickÓ placement of the mesial surface of tooth No. 9. This process is enhanced/enabled by Synergy D6Ìs nonslumping, highly sculptable handling. When in doubt, the Dead Soft Metal Matrix Strip can be left in place as the adjacent contact surface is placed. The entire process is enhanced by the use of Detak from George Taub Dental Products, a silicone-based, nonstick instrument dip that allows for easier sculpting both interproximally and labially.
(5) A 0.5-mm to 1-mm cut-back of the dentin shade prior to placement of the universal enamel shade using a medium grit diamond.
(6) Bulk placement with gloved finger-forming followed by composite instrument-forming of the enamel shade (Figures 11 and 12).
(7) Preliminary shaping with an 8-fluted carbide finishing bur (Brasseler USAÌs ET 9), followed by 16-bladed finishing bur and rubber polishing cup (Figures 13 and 14).
(8) Optional placement of a clear coat of resin such as ParkellÌs DuraFinish or All Dental ProdxÌs QuikGlaze  (Figures 15 and 16). In fact, Synergy can be brought to a reasonably nice gloss with a variety of existing composite polishing systems. One favorite finishing tool would be CosmedentÌs FlexiBuff. This wheel will bring images of polishing/waxing your car, delighting you as the shine increases. It can become rather addictive!
This process was completed for each tooth. To be sure, the central incisors required the most fussing. Typically, their placement consumes nearly half of the time devoted to the case (in this instance 3 hours). Once they are placed and found to be pleasing to the eye, the other teeth follow more quickly.

Discussion

Perhaps itÌs time for you to re-explore the world of direct composite veneering. TodayÌs resins offer handling and polishing characteristics that do away with many of the former objections to the process. Even if you choose not to recreate smile morphology, tooth color as well as surface irregularities can be tamed in similar fashion to placing a set of todayÌs "no-prep" veneers. Potential advantages are obvious. Very conservative tooth reduction, as was noted in this case, will increase patient acceptance, as will reduced cost when compared to laboratory-created veneers. Patients, when explained the nature of composite, will accept the fact that a certain amount of maintenance may accompany placement of resin bonding, depending upon patient habits and recall frequency. (I have found it important to tell smokers that nothing will discolor composite resin as surely as smoking will, regardless of the polish placed. More frequent maintenance should be anticipated.) Most importantly, you will have another tool in your cosmetic belt to offer both as a smile enhancement option to your patient and an income enhancement to your practice.

Conclusion

A new composite system, ColtÀne/WhaledentÌs Synergy D6, seeks to ease the tooth reconstruction process with a simplified shading approach complemented by optimized handling. It can be looked upon as typical of an ever-improving selection of composite resins and unique in its approach to solving our Ïinventory issues.Ó In this instance, it would seem that less is more! Finally, todayÌs dialog concerning tooth conservation and minimally invasive dentistry would appear to be another incentive for practitioners to re-explore the direct bonding process.


References

1. Dietschi D, Ardu S, Krejci I. Exploring the layering concepts for anterior teeth. In: Roulet J-F, DeGrange M, eds. Adhesion: The Silent Revolution in Dentistry. Berlin: Quintessence; 2000:235-251.
2. Cook WD, McAree DC. Optical properties of esthetic restorative materials and natural dentition. J Biomed Mater Res. 1985;19:469-488.
3. Dietschi D. Layering concepts in anterior composite restorations. J Adhes Dent. 2001;3:71-80.
4. Dietschi D, Ardu S, Krejci I. A new shading concept based on natural tooth color applied to direct composite restorations. Quintessence Int. 2006;
37:91-102.


Dr. Goldstein practices general dentistry in Wolcott, Conn. He lectures and writes extensively concerning cosmetics and the integration of digital photography into the general practice. A regular contributing editor for Dentistry Today, he has also authored numerous articles for multiple dental periodicals both in the United States and abroad. He can be contacted at This e-mail address is being protected from spambots. You need JavaScript enabled to view it . His current speaking schedule and other articles published by Dr. Goldstein can be found at drgoldsteinspeaks.com.

Banner