Sonic Activation: New Paradigm for Composite Resins

INTRODUCTION
The ultimate challenge in dentistry today is the quick and economic dentition restoration that is fail-proof. With every new technique introduced, dentists' abilities and their understanding of the mechanical and physical properties of the materials used and their practical application is tested.1,2
With every new technological advance we hopefully get closer to finding "The One" simple direct restorative material that fulfills all our quality prerequisites and can give us a predictable result.

Sonic-Activated Composite Resin System
Materials continue to improve and make our lives easier.3 SonicFill4 (Kerr) is one of these new and already available technological advances that solve past dilemmas in the use of resin composite technology.5 Until recently, the one thing that seemed to keep a lot of dentists from using only composites for direct restorations in their practices, and getting away from amalgams, was the inability to bulk-fill and at the same time achieve proper, full-cure of the material.6 That problem has now been solved. This new sonically activated composite resin permits us to bulk-fill composite (up to 5 mm depth) and achieve complete cure all the way to the bottom of the restoration in one simple step!4
The system used in this placement technique is comprised of an adjustable sonic handpiece (KaVo) used with prefilled composite resin cartridges. The nanohybrid composite in the cartridge starts off as a highly viscous material that, once activated in the handpiece by the sonic vibrations, softens temporarily almost to the consistency of a flowable resin. In the past, many dentists have been known to warm up their resins to try to achieve the same result, thus risking contamination and molecular structure change of the composite in its final state. Another common practice was to line the preparations with flowable composites for better, void-free restorations.

Before Image. Patient presented with old composite restorations and decay. After Image. Postoperative photo at 4 weeks.
Figure 1. A rubber dam (Ivory Rubber Dam and Clamp [Heraeus Kulzer]) was placed for proper isolation. Figure 2. The old composite resin restorations and decay were removed.
Figure 3. A self-etch, light-cured universal adhesive system was used in this case (OptiBond XTR Primer and Adhesive [Kerr]).

With this sonically activated composite resin system, the material is extruded in a soft state from the tip of the SonicFill handpiece into the preparation. The adaptation of the composite in this less viscous state is impeccable—not only due to the flowability of the material, but also due to the pressure exerted by the rest of the extruded material and the sonic vibrations that allow its dense placement. Once the cavity is filled and the handpiece is removed, the material begins to regain its original state of high viscosity—it begins to harden.
With the help of the sonic energy vibration, this composite drops its viscosity by 87%. The release or loss of sonic energy is fairly slow (approximately 20 seconds), which gives the practitioner ample time to sculpt the occlusal surface of the material prior to the composite regaining its original hardness. Proper curing completes the process, yielding a very strong, well adapted restoration, with the lowest shrinkage rate on the market today.7 An exposure for final cure to a light source with as little as 550 mW/cm2 output is sufficient to thoroughly cure the material.8 Studies have shown this bulk fill composite to be one of the strongest composite restoratives available today.7

Figure 4. Application of the primer. Figure 5. Application of the adhesive.
Figure 6. Light-curing (Demi Plus light [Kerr]) the adhesive. Figure 7. The system used in this placement technique is comprised of an adjustable sonic handpiece (SonicFill Handpiece [Kerr]) used with prefilled composite resin
cartridges (SonicFill).

Excellent Aesthetics Are Achievable in Less Time
From an aesthetic viewpoint, although not marketed this way, it is my personal opinion that this composite is also one of the most cosmetic restoratives for the posterior sector available today. Having used a vast array of composites, and continuously striving for the probably unattainable "perfection," I have been amazed by the beautiful cosmetic blending with the natural tooth that this material offers.
As you will see in the following case presentation, using this material coupled with a self-etch, light-cured universal adhesive system, I was able to achieve virtually indistinguishable, strong restorations in literally minutes—it takes much longer to anesthetize the patient and to place the rubber dam than to complete these restorations.

Figure 8. Application of the composite resin with the sonic handpiece. Figure 9. Contouring of anatomy with a composite instrument (XTS Stainless Steel Composite Instrument No. W3 [Hu-Friedy]).
Figure 10. Final light-curing of the restorations was completed. Figure 11. The completed composite resin restorations.

CASE REPORT
Diagnosis and Treatment Planning

A patient presented with failing composite restorations exhibiting secondary caries, as well as new decay on teeth Nos. 12, to 14 (Before Image). The treatment plan included removal of all new decay, the old composite fillings with associated decay, and the placement of new composite resin restorations.

Placement Technique Protocol
After delivery of the local anesthetic, a rubber dam (Ivory Rubber Dam and Clamp [Heraeus Kulzer]) was placed to ensure proper isolation from oral fluids for the teeth to be restored (Figure 1). All the old composite resin restorations and caries were removed from teeth Nos. 12 to 14 (Figure 2). Complete decay removal was ensured by application of a caries detection agent. A bonding primer (OptiBond XTR Primer [Kerr])9 (Figure 3) was applied to the enamel and dentin for 20 seconds (Figure 4) and air-thinned for 5 seconds. Next, a bonding adhesive was applied (OptiBond XTR Adhesive [Kerr]) to the enamel and dentin for 15 seconds (Figure 5) and then air-thinned for 5 seconds. The preparations were then light-cured (Demi Plus light [Kerr]) for 10 seconds each (Figure 6).
The nanohybrid composite shade that matched the patient's dentition was selected (A2),10 and the prefilled cartridge was placed into the SonicFill handpiece (Figure 7). The handpiece was then engaged and the composite was extruded, one tooth at a time, to fill the preparations completely (Figure 8). Once a cavity was filled, the SonicFill handpiece was deactivated and removed from the tooth. The composite was then contoured to the tooth's natural anatomy with a composite instrument (XTS Stainless Steel Composite Instrument No. W3 [Hu-Friedy]) (Figure 9) and final light-curing was done for 20 seconds (Figure 10). The same procedure was followed for each individual tooth.

Sorry! It's Part of the Restoration

Tom M. Limoli, Jr
By far some of the most commonly performed dental procedures are those identified as direct restorations. All codes in the 2100 and 2300 sequence are considered to be chairside procedures that utilize a direct technique. (A direct restorative procedure is defined as that which is performed directly on a tooth without the use of a die.)
Of note with Dr Cuevas' case report are the images in Figures 1 and 5. The completed outline form clearly shows teeth Nos. 12 and 13 as being prepared for single occlusal restorations that clearly involve both enamel and dentin while tooth No. 14 is prepared for 2 separate occlusal restorations as well as a single occlusal-lingual restoration. That is 3 separate restorations on a single tooth.
Teeth Nos. 12 and 13 would simply be coded and billed individually as D2391. Tooth No. 14 would be coded and billed as 3 separate line items of D2391 (occlusal), D2391 (occlusal) (second time) and D2392 (occlusal lingual). There remains no doubt that the coding and billing is clearly as well as accurately reflective of these 5 individual restorations that were placed. Although most benefit plans will contractually only reimburse once per series for any individual or multiple surface restoration per tooth we must always code and bill for exactly the service(s) that were rendered.
With this example, be prepared for the plan to accept reimbursement liability for the individual D2391s on teeth Nos. 12 and 13 as well as only the D2392 on tooth No. 14. The remaining balance of the D2391s will be the out of pocket responsibility of the patient.
Third-party payers contractually reimburse only for completed procedures and restorations. They do not reimburse for individual subcomponents or techniques required to complete the procedure. With bonded restorations, the bonding is nothing more than the technique used to complete the procedure. As such, the procedure would simply be coded as the completed procedure. The additional cost of the bonding agent should be reflected in your total fee charged for the restoration.
It is most unethical to charge the patient a separate "upgrade" fee for the bonding technique or for correcting any dentin staining. We do not recommend separate fees for bonded and nonbonded restorations. When taking into consideration your usual fee for the procedure, examine the number of bonded and nonbonded restorations that you routinely perform. Your single fee should equally address both restorative techniques.
A restoration must complete the external anatomical outline form of a tooth that is subject to oral bacteria and forces of mastication. Cavity liners and cement bases have no such function and are, therefore, not separately identifiable as concerns reimbursement. Bases and liners are part of the restoration technique.

Table. Laser Codes and Fees
Code Description Low Medium High National Average National RV
D2391 Resin-based composite
one surface posterior
$116 $150 $191 $152.40 3.31
D2392 Resin-based composite
2 surface posterior
$144 $192 $245 $196.80 4.28
D2393 Resin-based composite
3 surface posterior
$174 $245 $349 $250.80 5.45
D2394 Resin-based composite
4 surface posterior
$221 $275 $372 $293.20 6.37
CDT-2011/2012 copyright American Dental Association. All rights reserved. Fee data copyright Limoli and Associates/Atlanta Dental Consultants. This data represents 100% of the 90th percentile. The relative value is based upon the national average and not the individual columns of broad-based data. The abbreviated code numbers and descriptors are not intended to be a comprehensive listing. Customized fee schedule analysis for your individual office is available for a charge from Limoli and Associates/Atlanta Dental Consultants at (800) 344-2633 or limoli.com.

Adjustment of the occlusion after rubber dam removal was minimal. No polishing was necessary and the patient was released. The length of the appointment was less than if traditionally placed composite resin had been used. Figure 11 shows the restorations immediately after treatment completion. After Image depicts the same restoration 4 weeks after initial placement. No wear or loss of initial material gloss was evident. The patient also reported absolutely no sensitivity or sensation of roughness on the restored teeth.

CLOSING COMMENTS
As clinicians, we all continuously strive to elevate our skills, to produce longer lasting, more beautiful restorations and to provide our patients with faster placed better-looking composite restorations that will stand the test of time. The sonic-activated composite resin system described in this article represents an important technical advancement, giving clinicians the ability to create amazing looking restorations in less time, without sacrificing quality or aesthetics.


References

  1. Ferrari P, Veneziani M. A comparison of various adhesive composite restorations in the posterior regions. Pract Proced Aesthet Dent. 2007;19:503-509.
  2. Terry DA, Geller W, Tric O, et al. Anatomical form defines color: function, form, and aesthetics. Pract Proced Aesthet Dent. 2002;14:59-67.
  3. Minguez N, Ellacuria J, Soler JI, et al. Advances in the history of composite resins. J Hist Dent. 2003;51:103-105.
  4. SonicFill Web sites. www.sonicfill.kerrdental.com and www.sonicfill.eu. Accessed May 18, 2011.
  5. Jackson RD. Placing posterior composites: increasing efficiency. Dent Today. 2011;30:126-131.
  6. Blank JT. Simplified techniques for the placement of stratified polychromatic anterior and posterior direct composite restorations. Compend Contin Educ Dent. 2003;24(suppl 2):19-25.
  7. Thompson J. Laboratory Research Report: Evaluation of SonicFill Composite. NOVA Southeastern University, October 2010.
  8. Ritter AV. Direct resin-based composites: current recommendations for optimal clinical results. Compend Contin Educ Dent. 2005;26:481-490.
  9. Bonding agent embodies power of a total-etch adhesive and simplified protocol of a self-etch technique. Innovations. Dent Today. May 2011;30:44.
  10. Jackson RD. Understanding the characteristics of naturally shaded composite resins. Pract Proced Aesthet Dent. 2003;15:577-585.

Dr. Cuevas is the head of The Institute of Esthetic Dentistry in San Antonio, Tex, where she also practices full-time general dentistry with an emphasis on cosmetic and restorative dentistry. She is a former assistant clinical professor at University of Texas Health Science Center at San Antonio, Department of Esthetics. She was a contributing editor for the Journal of Cosmetic Dentistry for more than 10 years and has published numerous articles in the field of aesthetic dentistry. She has lectured internationally on the topics of direct composite bonding, facial smile aesthetics, and indirect cosmetic restorations. She can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Disclosure: Dr. Cuevas reports no disclosures.