Success With Composites in the “New Economy”

Introduction
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.


On the upside, you improve several teeth versus one, and can often remain within the limitations of your patient’s coverage, thus meeting far less resistance when making your treatment recommendations. This is not to say that the only good amalgam is one replaced. Of course, many that are still serviceable can, and should be, left alone. There are enough, however, that have seen better days and can justifiably be turned over and converted to a “contemporary” composite restoration, that much to your patient’s delight, looks like a tooth! 

That said, a comfortable “strategy” for renovating a quadrant of old alloy restorations becomes a necessity. It is an easy matter to “blow away” a quadrant of alloy in a matter of minutes with today’s electric hand pieces, yet quite another matter to replace multiple multisurface restorations with composite. Simply put, the reconstruction task can be overwhelming without a game plan set down before beginning the “renovations.” 

What follows is a description of a garden variety baby boomer quadrant of alloy removed and restored in composite resin during a 90-minute visit. Along the way, I will share the what and why of this case, as well as plug in a few products that can make our restorative lives easier.

CASE REPORT

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.


Note the purple drape (Flexi-Dam [Hygienic]) that has been loosely placed using a slit cut in the dam as opposed to individual holes for each tooth. Its primary purpose is to trap most of the alloy debris generated, as well as manage the tongue and cheek. Moisture isolation is assisted, but certainly not absolute. Use of a rubber dam will dramatically increase your speed. Not having to chase alloy down your patients’ throats with a suction tip is an enormous time saver. In addition, there is no need to keep pulling the tongue and cheek out of your line of sight. This dam configuration can be placed in under 30 seconds. Tearing the dam is close to impossible due to its ribbed, nonlatex construction.

You’ll also notice the placement of a FenderWedge (Garrison Dental Solutions) (Figure 2). This item does 2 things: First, it preseparates teeth, which ultimately facilitates sectional matrix placement. Second, and in this case the primary reason for use, it prevents nicking of the adjacent “virgin” proximal surface of tooth No. 20. The scratch marks seen in Figure 3 on the separating “fender” could just as easily been on the enamel of tooth No. 20, creating a new site for future caries. We’ve all been there. The one glitch using the FenderWedge is that its removal will likely trigger bleeding as the papilla is disrupted when placed. It’s best to do your etching and bonding before removing the FenderWedge, when possible. 

One other little tip following alloy removal involves the use of a barrel shaped diamond or similar to bevel the cavity prep margins. This will enhance marginal adaptation and bonding efficiency. A flat-ended tapered cone diamond (Brasseler USA) is used to that end (Figure 4).

In Figure 5 we view the quadrant awaiting restoration. At this juncture, I noticed that the interproximal tissue between teeth 18/19 and 20/21 was a bit on the weepy side. To prevent bleeding and its consequent contamination during the bonding procedures, a diode laser (ezlase [BIOLASE]) was used to slightly trough and cauterize the interproximal tissues (Figure 6). Alternatives to the laser would be short segments of epinephrine-impregnated cord (Gingibraid No. 0 [DUX]) or using electrosurgery (Sensimatic 600E [Parkell] or Dento-Surge 90 [Ellman]) with the system at its cut and coagulate setting. Expasyl [Kerr] can also be used for this purpose. Taking these steps when indicated, prior to application of bonding resins, will help to ensure a more reliable bond. 

Figure 7 demonstrates phosphoric etching of cut enamel surfaces prior to placing of the self-etching bonding agent, (Brush&Bond [Parkell]) as seen in Figure 8. Etch is placed for 5 to 10 seconds prior to rinsing. This extra step is recommended by the manufacturer to ensure complete etching of the enamel. I’ve found over the last 7 years that Brush&Bond, in addition to being an excellent bonding agent, is wonderful at preventing any postoperative sensitivity. 

Up until this point, it’s all been easy. Now starts the “fun” part. My composite resin restorative strategy is as follows:

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.


An alternative approach to restoring the anchor tooth, for those seeking a conventional matrix-guided multilayer approach, involves the use of the Walser Matrix as shown in Figure 12. This clever contraption lends itself to freestanding MOD restorations, and often does not require a wedge. Certainly, sectional matrices can be used for MOD construction, but with considerably more effort and manipulation than is called for with the Walser system. The trade-off for convenience is that the matrix band itself is devoid of anatomic contour, resulting in proximal surfaces that are for the most part flat.

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.


A word on sectional matrix systems might be in order here. Discussion of such systems amongst dentists is not unlike the old advertisements that compared one light beer against another. Each party feels that they’ve aligned themselves with the only real solution. It should be noted that Garrison Dental Solutions, Palodent, Triodent, and Danville all offer quality products. Why one becomes a favorite over another seems to rely upon which system the operator has enjoyed the most success. I’ve found it handy to keep several systems available, but the Garrison system is my “every day” matrix system for reasons listed above. Even with the best system, occasionally there are circumstances when another approach might work better.

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.

CONCLUSION
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.


Dr. Goldstein is a Fellow of the International Academy of Dento-Facial Esthetics, practices general dentistry in Wolcott, Conn. Recognized as a leader in continuing education by Dentistry Today for the last 5 years and for his expertise in the field of dental digital photography, he lectures and writes extensively concerning cosmetics and the integration of digital photography into the general practice. Known also for his relaxed approach to restoring smiles and for being a frequent contributor to Dentistry Today, he has also authored numerous articles for multiple dental periodicals both in the United States and abroad. He can be reached via e-mail at martyg924@cox.net or drgoldsteinspeaks.com.

 

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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