Direct Composite Resins Continue to Evolve

INTRODUCTION
Direct composite resin is today the “go to” material for the restoration of both anterior and posterior teeth. Its wear properties and aesthetic appearance allow us to utilize it as a final restoration with lasting results. Additionally, the placement of resin composites utilizing an adhesive allows for the use of the material where minimal retention and resistance form can be developed. The combination of these properties has opened up the opportunity to phase treatment for patients who need extensive restorative dentistry that did not exist previously. In the early years of my practice, if a patient presented with significant restorative needs coupled with time or budget constraints, my options were limited. We might have tried to utilize a long-term acrylic provisional, managing the nuisance of recementing provisionals and preventing recurrent decay until the indirect restorative work could be completed. Often, this resulted in some teeth being restored while others suffered further breakdown. Currently, the gift of composite resin allows me to eliminate caries, restore occlusions, and return the patient to aesthetic harmony quickly; then transitioning to indirect restorations over time, in a way that meets the patient’s circumstances.

CASE REPORT
Diagnosis and Treatment Planning

A 35-year-old female presented for a new patient exam and hygiene visit. A local dentist, whose practice is limited to temporomandibular joint disease (TMD), referred her to our office aware that she had significant restorative concerns. The patient was currently wearing a mandibular appliance, and had been doing so 24 hours a day for the last 10 years in an attempt to manage joint and muscle pain. Having recently moved from the East Coast to Arizona, she sought out a dentist to continue her TMD therapy. At her first appointment, she had inquired about the breakdown and appearance of her teeth.
The patient’s medical history included Sjögren’s syndrome and rheumatoid arthritis, for which she took multiple medications each day, resulting in significant xerostomia. The clinical and radiographic exam revealed generalized moderate-to-severe caries, along with generalized severe decalcification (Figures 1 to 5).

Figure 1. Lips at rest, pre-op. Figure 2. Lips retracted, pre-op.
Figure 3. Upper occlusal, pre-op. Figure 4. Lower occlusal, pre-op.
Figure 5. Lower right quadrant, pre-op.

To help her gain optimal periodontal health, although her bone levels and sulcus depths were within normal limits (Figure 6), we recommended a full-mouth debridement and localized scaling and root planing to remove any deposits. From an occlusal perspective, the goal was to resolve her current symptoms and to find an occlusal position from which to restore her. This can take an extended period of time to determine, so her preliminary occlusion was created based on her existing intercuspal position.

Clinical Protocol
The patient received a full-mouth debridement and localized scaling and root planing over the course of 2 appointments to resolve her gingivitis and to create an optimal restorative environment. A rigorous protocol for the control of high caries risk was implemented; this included application of chlorhexidine varnish (Cervitec Plus [Ivoclar Vivadent]) at her 3-month recall appointments, prescription-strength toothpaste for home use twice daily (Clinpro 5000 [3M ESPE]), and once-a-week tray deplaquing with 10% carbamide peroxide whitening gel.
The restorative phase of care began on the lower right posterior. First, local anesthetic (Lidocaine HCl 2% 1:100,000 [Cook-Waite Anesthetic]), was delivered using a 2-stage technique. Following the application of topical anesthetic, plain carbocaine (Carbocaine 3% plain [Cook-Waite Anesthetic]), the local anesthetic was delivered, injecting ahead of the needle penetration to anesthetize the site of the inferior alveolar nerve (IAN) block. Allowing about 45 seconds for anesthesia, lidocaine with epinephrine was then used to perform the IAN block on the right side. In an effort to manage the patient’s TMD, she had been premedicated with 5 mg of Flexoril, and her restorative appointments were divided up to limit the time she had to have her mouth open.
Once anesthesia was profound, operative isolation was achieved using a dryfield illumination device (Isolite [Isolite Systems]). This device allowed the patient to rest her jaw, created adequate isolation and improved visibility for the adhesive placement of the composite resin, and was easily removed so the patient could take breaks to rest her jaw.
Prior to tooth preparation, teeth Nos. 18 and 19 were prewedged. Prewedging allows for ease of creating tight interproximal contacts by maximizing compression of the periodontal ligament during the preparation phase. In addition, it prevents injury to the interproximal papilla when cutting the box form. Initial preparation was done using a 245 sabre cut carbide bur (Brasseler USA). These burs also easily remove any previously placed composite restorative material. All infected and soft dentin was removed, secondary dentin and discoloration was left as it was firm to probing. The margins of the preparation and the peripheral decalcified enamel was beveled and included in the tooth preparation. The intention was to overlay as much of the damaged enamel and protect it from further breakdown until the indirect restorative phase could be completed. This part of the preparation was completed with a fine mosquito diamond (Figure 7).
The teeth were filled independently to allow proper closure of the interproximal contacts. The prewedge was removed; a Composi-Tight 3D clear sectional matrix (Garrison Dental Solutions) placed; the wedge returned to the gingival embrasure and a ring placed to add tension to separating the adjacent teeth. The purpose of the matrix is to recreate the form of the teeth interproximally, and around the labial and lingual line angles. The wedge seals the matrix against the gingival floor of the box, preventing the leakage of composite material and aiding in separating the teeth enough to compensate for the thickness of the matrix. The ring seals the matrix against the buccal and lingual walls of the tooth and assists the wedge in tooth separation. The 3-dimensional clear sectional matrix system has a very natural shape, holding the form of the tooth on the buccal and lingual, as well as rolling over the marginal ridge and preventing composite flash that has to be trimmed interproximally.

Figure 6. Bite-wing radiograph showing bone levels. Figure 7. Initial preparations with decay present.
Figure 8. Composi-Tight Matrix (Garrison Dental Solutions) for tooth No. 31. Figure 9. Composite placement tooth No. 31.
Figure 10. Matrix for distal of tooth No. 30. Figure 11. Final composite resin (SonicFill [Kerr]) restorations.

With the matrix system in place (Figure 8), the tooth was prepared for composite placement. The first step is placement of phosphoric acid gel to increase etching and bond strengths to the enamel tooth surfaces. One of the leading reasons for postoperative sensitivity when doing adhesive procedures is over-etching of the dentin. Self-etching dentin adhesives are a great way to prevent this postoperative sensitivity as well as avoid the complication of rinsing and over- or under-drying the dentin. This “selective” etching technique allows the benefits of phosphoric acid on the enamel and the benefits of a self-etching product on the dentin. The gel was rinsed off, and then the tooth was dried to remove any pooled water. OptiBond XTR (Kerr) was used to prepare the dentin surfaces and to create an adequate hybrid zone. The primer/etch component was applied to the dentin with a microbrush and agitated for 20 seconds. This step was air-dried to evaporate the excess solvent prior to application of the resin. The resin layer was coated into the prep for 15 seconds, air-dried, and finally light-cured (Bluephase Elite [Ivoclar Vivident]).
Shade A1 composite resin (SonicFill [Kerr]) was placed in a single increment. The tip was placed at the depth of the interproximal box form and composite injected. The tip was lifted to the occlusal slowly as the composite filled around it so as not to create a void in the material. Once the prep was filled beyond the occlusal margins, the material was shaped using a series of gold tipped composite hand instruments. The SonicFill composite shapes and sculpts easily due to the consistency change over time. Following initial placement, the material was lightly condensed (although the delivery method creates a solid fill). Excess composite beyond the margins was removed with the end of the condenser. As the material reached a more firm consistency, occlusal form was created with an acorn burnisher and bladed plastic instruments. My goal when placing composite is to have very little sculpting to do with high-speed instrumentation. Once the composite was shaped and formed, it was light-cured for a full 20 seconds.
Once cured, the separator ring, matrix, and wedge were removed (Figure 9). Next, the composite resin was trimmed with a friction grip brownie point running at half speed. The brownie easily cut through the composite without damaging the tooth structure, allowing the creation of perfect marginal interfaces. Occlusal anatomy was created and defined using a friction grip white stone and an acorn diamond. Then, the interproximal margins were trimmed using a mosquito diamond and then polished. With the interproximal contour of the first tooth created, a new matrix band, wedge, and separator ring were placed to allow the second tooth to be filled (Figure 10). Following the same procedure, the teeth were filled moving from posterior to anterior (Figure 11).
Once both teeth were completed, the Isolite device was removed and the occlusion was checked (AccuFilm II [Parkell]). The interproximal contacts were flossed to confirm that they were of sufficient strength to prevent food impaction. Finally, the restorations were polished using an intraoral polishing system where the last step employs a diamond-polishing paste on a brush (Dialite [Brasseler USA]).

CLOSING COMMENTS
The phase one treatment plan was to restore and repair all of the teeth using a direct composite resin, breaking the mouth into sextants to minimize the appointment length and stress on the patient’s TMD condition. Once her dentition was stable and the gingivitis resolved, maintenance would be provided while she worked through appliance therapy to resolve her TMD symptoms. Phase 2 therapy would include indirect restoration of the anterior and posterior teeth that had been previously treated with large multisurface composites.
With advanced adhesive techniques and materials, as part of the first phase of care, clinicians can restore patients to optimal health and function both easily and economically. The durability of utilizing composite resin materials for this process offers the ability to feel confident in these preliminary restorations while the next steps of the treatment plan are completed, which may include TMD, surgical, or orthodontic modalities. In addition, this permits the patient to choose to phase the transition to permanent restorations allowing for personal financial and time considerations.


Suggested Readings

Carvalho RM, Manso AP, Geraldeli S, et al. Durability of bonds and clinical success of adhesive restorations. Dent Mater. 2012;28:72-86.
De Munck J, Van Landuyt K, Peumans M, et al. A critical review of the durability of adhesion to tooth tissue: methods and results. J Dent Res. 2005;84:118-132.
El-Safty S, Silikas N, Watts DC. Creep deformation of restorative resin-composites intended for bulk-fill placement. Dent Mater. 2012 May 30. [Epub ahead of print]
Flury S, Hayoz S, Peutzfeldt A, et al. Depth of cure of resin composites: is the ISO 4049 method suitable for bulk fill materials? Dent Mater. 2012;28:521-528.
Frankenberger R, Lohbauer U, Roggendorf MJ, et al. Selective enamel etching reconsidered: better than etch-and-rinse and self-etch? J Adhes Dent. 2008;10:339-344.
Kwon Y, Ferracane J, Lee IB. Effect of layering methods, composite type, and flowable liner on the polymerization shrinkage stress of light cured composites. Dent Mater. 2012;28:801-809.
Marchini L, dos Santos MB, dos Santos JF, et al. Establishing a stable centric position using overlays. Gen Dent. 2010;58:e179-e183.
Mine A, De Munck J, Cardoso MV, et al. Bonding effectiveness of two contemporary self-etch adhesives to enamel and dentin. J Dent. 2009;37:872-883.
Perdigão J. New developments in dental adhesion. Dent Clin North Am. 2007;51:333-357.
Peumans M, De Munck J, Van Landuyt K, et al. Five-year clinical effectiveness of a two-step self-etching adhesive. J Adhes Dent. 2007;9:7-10.
Souza-Junior EJ, Prieto LT, Araújo CT, et al. Selective enamel etching: effect on marginal adaptation of self-etch LED-cured bond systems in aged Class I composite restorations. Oper Dent. 2012;37:195-204.
Strydom C. Handling protocol of posterior composites—part 3: matrix systems. SADJ. 2006;61:18, 20-21.
Van Meerbeek B, De Munck J, Yoshida Y, et al. Buonocore memorial lecture. Adhesion to enamel and dentin: current status and future challenges. Oper Dent. 2003;28:215-235.
Van Meerbeek B, Peumans M, Poitevin A, et al. Relationship between bond-strength tests and clinical outcomes. Dent Mater. 2010;26:e100-e121.


Dr. Brady earned her DMD degree from the University of Florida College of Dentistry. For 17 years she worked in a variety of practice models from small fee-for-service offices to large insurance-dependent practices, as an associate and as a practice owner. Dr. Brady was invited to join the Pankey Institute as its first female resident faculty member and was promoted to clinical director within a year. She was asked by Dr. Frank Spear to join him in the formation of Spear Education and the expansion of his curriculum. As the executive vice president of clinical education at Spear Education, she managed the development and delivery of all programs. Dr. Brady maintains a private practice in Glendale, Ariz, in addition to her active teaching schedule. She enjoys researching and teaching these clinical disciplines as well as patient communications, case acceptance and team development. She is passionate about solving complex cases, understanding the needs and concerns of her patients, facilitating the success of colleagues, and helping dentists find balance in their lives. She can be reached via e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Disclosure: Dr. Brady reports no disclosures.

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