Written by Martin B. Goldstein, DMD Saturday, 31 October 2009 19:00
Have you found yourself doing more composite restorations lately? This has certainly been the case in Wolcott, Conn. It seems that the downturn in the economy has generated reluctance on the part of many of my patients to commit to procedures that exceed their insurance plan’s coverage. This might be due to a spouse out of work, or simply the fear of being unemployed and having too many bills to deal with. Whatever the case, I seem to be hearing a lot more of “Can you just fill it?” than “Whatever you say, just do it.” You don’t need to be a math whiz to realize that single tooth composite repairs occurring too frequently in your daily schedule will put you in the red given the expenses of running a modern dental practice. There would appear to be safety in placement of multiple restorations so long as the opportunity presents itself, as it often does in our middle-aged baby boomer patients. They commonly possess mouthfuls of 20-plus-year-old alloys that, if examined closely, can stand replacement. What’s more, replacing a quadrant of old alloys in a reasonably short time can generate an hourly production rate comparable with what might be generated by doing a single crown.
Figure 1. Preoperative image of the quadrant to be restored with rubber dam applied (Flexi-Dam [Hygienic]).
Figure 2. FenderWedge (Garrison Dental Solutions) in place.
Figure 3. Damage prevented by use of the FenderWedge.
Figure 4. Flat-end cone-shaped diamond (Brasseler USA) employed to bevel the cavo-surface margins.
Nancy presented in hygiene with just a single quadrant remaining in need of restoration. She had decided that before retiring she would replace her alloy restorations with “updated white fillings,” as she liked to call them. Following her hygiene visit, during which this quadrant was photographed for her to see what lay ahead, she scheduled the restorative visit. As you can see from Figure 1, 4 multiple surface restorations showing their age were to be restored; three, 2-surface restorations, along with a mesio-occlusal-distal (MOD) restoration on tooth No. 19.
Composite Resin Protocol: The Anchor Tooth
Figure 5. Alloy removed; strategizing replacement.
Figure 6. ezlase (Biolase) used to cauterize and trough weeping gingival tissue.
Figure 7. Enamel margins etched with phosphoric acid per manufacturer’s recommendations
Figure 8. Brush&Bond (Parkell) bonding agent applied to prepared surfaces.
Figure 9. Bulk-filled tooth No. 19 using Synergy D6 shade A1 (Coltène Whaledent).
Figure 10. Free-hand sculpting the anatomy of tooth No. 19 with Synergy and Flexi-Thin plastic instrument.
When multiple multisurface restorations present, I always select an anchor tooth that will serve as a basis for good contacts throughout the quadrant. In this instance it is tooth No. 19. I will be able to build both the mesial occlusal (MO) of tooth No. 18 and the distal occlusal (DO) of tooth No. 20 against it once ideal contours have been established on tooth No. 19. There are 2 approaches possible when restoring tooth No. 19. In Figure 9, you’ll note that I have bulk-filled the prep with composite (Synergy D6, shade A1 [Coltène Whaledent]) and have begun to hand sculpt it with a plastic instrument (Flexi-Thin [Hu-Friedy]) (Figure 10). The Synergy D6 had first been warmed in a Calset (AdDent) oven (Figure 11) to optimize flow and adaptation of the composite resin to the cavity preparation. The Flexi-Thin plastic instrument has been dipped in a silicone lubricant (Detach [Taub]) that allows extra smooth sculpting strokes and keeps composite from sticking to the instrument. The composite resin is then light-cured (Bluephase 20i [Ivoclar Vivadent]) for 20 seconds each at the occlusal, buccal, and lingual surfaces. It is my opinion that the combination of the warmed composite and ultra-high intensity light, as well as the use of the lighter A1 shade, affords excellent polymerization with a minimum of shrinkage observed. Following polymerization, I will often optimize the shape of the proximal walls with a carbide-finishing bur, prior to laying down the adjacent restorations.
The Rest of the Story
Figure 11. Calset Oven (AdDent) with composite guns in place.
Figure 12. The Walser Matrix system demonstrating use for mesio-occlusal-distal construction.
Figure 13. Composi-Tight Silver Plus matrix and retainer (Garrison Dental Solutions) to restore tooth No. 18.
Figure 14. Composi-Tight 3D retaining ring (Garrison Dental Solutions) for restoring tooth No. 20.
|Figure 15. The Composi-Tight 3D retaining ring walked forward to restore tooth No. 21.||Figure 16. G-Block (Garrison Dental Solutions) carbide for occlusal anatomy refinement.|
Figure 17. Developing occlusal anatomy with a suitable G-Block carbide bur.
|Figure 18. Creating the “floss groove” with a fine-tapered flame carbide from the G-Block.|
|Figure 19. Polishing with a rubber point.||Figure 20. The completed quadrant of composite resin restorations.|
Following the placement of tooth No. 19, I begin the restoration of tooth No. 18 using a Composi-Tight Silver Plus (Garrison Dental Solutions) matrix and retaining ring system. This device (Figure 13), does not require much physical space for the retaining ring, and is therefore an excellent choice in the presence of a rubber dam clamp. Over time, I’ve become fond of the built-in contours found in the Garrison matrix bands, as well as their “flexible rigidity.” They possess an internal concavity that nicely recreates anatomically sound contact points, particularly when combined with their Wedge Wands system. Figures 14 and 15 show a new matrix system (Composi-Tight 3D matrix system [Garrison Dental Solutions]) that was employed to assist in contact formation when restoring the DO’s on teeth Nos. 20 and 21. This retaining ring’s strong suit is its ability to hug the outer walls of the tooth, while straddling the wedge without collapsing into even larger boxes. The result is wafer-thin flash that can be quickly removed with a finishing bur or No. 12 scalpel blade.
Summary of Composite Resin Placement
After the anchor tooth, tooth No. 19, was bulk placed, free-hand sculpted, cured and shaped, 2 Garrison matrix systems were used to place the MO of tooth No. 18, the DO of tooth No. 20, and the DO of tooth No. 21; in that order. At this juncture, the rubber dam was removed and occlusal adjustments were made. This operator has found it convenient to have all finishing tools in one location. While not the only solution, the G-Block (Garrison Dental Solutions) (Figure 16) places most of what one needs in one convenient autoclavable block. Figures 17 to 19 demonstrate 3 instruments in this kit that lend themselves to the usual shaping and polishing tasks for finishing composite resin restorations. Take particular note of Figure 18 where the ultrafine flame bur was used to shape what I term “the floss groove.” Even when contacts have become somewhat “boxed,“ owing to the need for excessive occlusal reduction, they can be reshaped by introducing this particular shape interproximally and reestablishing individuality to the proximal contacts. Figure 20 demonstrates the completed quadrant.
Wonderful new materials and tools are now available, and doctors need to develop a clinical protocol in order to use them successfully. Efficient and effective posterior resin placement is a key to the profitability of the current GP’s practice. Mastering the placement of posterior composite resin restorations placement, as well as developing a systematic approach to patient education and presentation, will almost always ensure success for doctors and patients alike.
Disclosure: Dr. Goldstein has received material and monetary support in the past from several manufacturers including Garrison Dental Solutions, Coltène Whaledent, and Parkell.
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