Exceptional Direct Restorations: New Diagnostics, Composite Materials, and Sectional Rings

Dr. Todd Snyder

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As technology and materials science continue to develop in dentistry, patients increasingly expect less invasive, more aesthetic, more durable restorations. Furthermore, patients expect them to be completed in a shorter amount of time. Fortunately, the combination of new diagnostic devices and advanced composite resin materials has made it possible to meet these expectations in many situations, including when treating caries. Early diagnosis expands the clinician’s options for treatment,1 and new materials utilized in conjunction with the appropriate techniques can provide restorations that blend in with the natural dentition better than ever before.

The stage at which pathology is identified inside the tooth can directly impact the ability to treat damaged tooth structure.1 Whereas endodontic treatment may be required if a problem is identified late, locating tooth pathology early can minimize the treatment necessary and allow the dentist to preserve maximum tooth structure. Radiographs have been the standard tool utilized for detecting these issues since their first implementation in a dental office in 1896,2 but visible caries on a radiograph typically indicate that a larger defect and more decay exist. Caries are often found late due to the lack of sensitivity in the radiograph’s diagnostic capabilities, and minimal damage is often undetectable with this technology. However, newer devices such as the Canary System (Quantum Dental Technologies) and the CariVu (DEXIS) have provided clinicians with the ability to see or quantify damaged tooth structure far earlier than the traditional modalities, allowing for better treatment of those teeth than would have been possible previously.3 Using modern caries detection devices to locate pathology that would have been missed on radiographs, dentists can reverse or remove the damage while being less invasive in the process. Additionally, the life of the restorative materials being used can be extended because the presence of enamel along the cavosurface and the decreased amount of occlusal loading create a smaller footprint than would a larger restoration adhering mostly to dentin.4

Figure 1. Preoperative photo.

Lastly, new flowable and nano-enhanced restorative composites are stronger, more aesthetic, more polishable, handle better, and have less shrinkage, allowing for clinicians to efficiently and effectively treat early tooth decay.5,6 The following case demonstrates how these new composite materials can be used with sectional rings to provide exceptional direct restorations.

CASE REPORT
A patient presented for a recall visit for an examination, radiographs, and cleaning. Visually and radiographically, the patient’s teeth appeared to be caries-free (Figure 1). A breakdown in the composite material on tooth No. 14 was noted visually, but otherwise the examination revealed nothing noteworthy. The utilization of the CariVu diagnostic tool, however, revealed decay interproximally on teeth Nos. 13 and 14. With traditional diagnostic tools, the decay would not have been detected until later visits, when it was more advanced and a larger preparation would have been required. However, having diagnosed the caries earlier, the author was able to be more conservative in the restorative preparation technique. Additionally, being able to see the exact positioning of the caries inside the tooth allowed for faster treatment than with radiographic diagnostics.

Figure 2. A rubber dam was placed for isolation, and a TrioDent WedgeGuard (Ultradent Products) was placed interproximally to minimize risk for iatrogenic trauma. Figure 3. A pear-shaped diamond bur was used to expose the top of the tooth decay.
Figure 4. The preparation design after complete removal of the decay and verification with a caries indicator (Caries Detector [Kuraray America]). Figure 5. The same technique was utilized to remove interproximal decay from the mesial surface of tooth No. 14.
Figure 6. With all of the pathology and failing restorations removed, the teeth could begin to be restored. Figure 7. Sectional matrices (DUAL-FORCE Sectional Matrix System [CLINICIAN’S CHOICE Dental Products]) were used to create consistently tight anatomical-shaped fillings interproximally.
Figure 8. A total-etch technique was utilized with a 35% phosphoric acid (Max Etch 35% Phosphoric Acid [CLINICIAN’S CHOICE Dental Products]) due to all the cavosurface margins being in enamel. The small size of the preparation made it impossible to utilize a selective-etch technique on just the enamel margins. Figure 9. A highly filled, fifth-generation bonding agent was applied to the tooth with a scrubbing motion and allowed to sit before air thinning and curing with a curing light (VALO Grand [Ultradent Products]) for 20 seconds.
Figure 10. A small lining of flowable composite (Evanesce Flow [CLINICIAN’S CHOICE Dental Products]) was placed on the floor of the proximal box. It was then cured for 20 seconds.

Figure 11. The second increment of composite was applied with a new nano-enhanced material (Evanesce Nano-Enhanced Universal Restorative Composite [CLINICIAN’S CHOICE Dental Products]), followed by curing for 20 seconds.

Figure 12. Excess resin flash was removed with the Composite Ninja (CLINICIAN’S CHOICE Dental Products) blade. Figure 13. The Composite Ninja instrument allows easy access interproximally to quickly cut away excess composite resin.

A TrioDent WedgeGuard (Ultradent Products) was placed next to the tooth being prepared (Figure 2) in order to avoid the bur causing iatrogenic trauma to the adjacent tooth.7 The tooth was prepared with a small, pear-shaped diamond bur. The top of the caries was easily exposed with minimal removal of tooth structure because of how early it was detected (Figure 3). The rest of the decay was removed, and this was confirmed with a caries disclosing agent (Caries Detector [Kuraray America]). The adjacent tooth was unharmed by the procedure due to the protection provided by the WedgeGuard (Figure 4).

With the caries removed, the molar was again isolated from the adjacent tooth with a WedgeGuard to allow for a faster preparation technique. Without a WedgeGuard, it is necessary for the clinician to work more slowly in order to avoid touching the adjacent tooth; with it, the author had the confidence to work quickly, as it is very difficult to damage the adjacent teeth with it in place (Figure 5). The failing composites in the molar were then removed (Figure 6).

Recreating the anatomical shape of the teeth typically requires the utilization of a modern sectional ring system. In this case, the author chose to use the DUAL-FORCE Sectional Matrix System (CLINICIAN’S CHOICE Dental Products), a unique system that utilizes dual NiTi round wires to create the increased displacement pressure necessary to move the mesial and distal feet of the device, more evenly distributing force between the teeth. The system is available with 2 different sizes of rings, allowing it to meet any needs for posterior composites. The DUAL-FORCE rings are able to separate the teeth and easily create strong interproximal contacts. In addition, by stacking the rings on top of each other, it is possible to work on multiple units simultaneously, making the process fast and time efficient and creating consistently tight, anatomically shaped contacts (Figure 7). When the clinician is able to do this, the entire restorative process becomes faster, easier, and less invasive due to the preparation size. Because the technique is minimally invasive and the occlusal footprint of the restoration is small, the small amount of occlusal loading pressures will make the restorative material more likely to be reliable and durable over the long term. Furthermore, a total-etch technique using a fifth-generation bonding agent (MPa MAX [CLINICIAN’S CHOICE Dental Products]) can offer great results because all of the cavosurface margins are still in enamel and there is less exposure of dentin that must be managed. MPa MAX is one of the few adhesives that contains 0.2% clorhexidine, which helps to prevent the adhesive bond degradation caused by MMPs and subsequently improves longevity. The author used a total-etch technique with Max Etch 35% Phosphoric Acid (CLINICIAN’S CHOICE Dental Products) (Figure 8). Due to the small size of the preparation, it would have been impossible to utilize a selective-etch technique on only the enamel margins. Max Etch 35% Phosphoric Acid was applied to the tooth for 20 seconds to properly condition the tooth and ready it for the placement of the fifth-generation, heavily filled bonding agent. The bonding agent was then applied to the tooth with a scrubbing motion and allowed to sit before air thinning and curing with a VALO Grand curing light (Ultradent Products) for 20 seconds (Figure 9).

Figure 14. The excellent aesthetics and strength imparted by the materials used in this case are obvious after removing the rubber dam.

Next, it was necessary to place a small lining of flowable restorative composite on the floor of the proximal box. The author chose a new line of restorative material, Evanesce Flow (CLINICIAN’S CHOICE Dental Products), to capitalize on its strength, handling, aesthetics, and low shrinkage properties. Evanesce Flow’s 3.6% rate of shrinkage is significantly lower than the shrinkage rates of many similar materials, some of which can be up to 5%. It also has a high filler content of 62% by weight and 48% by volume, and its 200% AI radiopacity makes it clearly distinguishable from composite on a radiograph for easy diagnosis. After the small lining of Evanesce Flow was placed on the floor of the proximal box, the restoration was again cured with the curing light for 20 seconds (Figure 10).

A compule of Evanesce Nano-Enhanced Universal Restorative Composite (CLINICIAN’S CHOICE Dental Products) shade A2 was then injected on top of the flowable material, and it was cured again for 20 seconds (Figure 11). Evanesce offers exceptional handling with no slumping or stickiness. It blends effortlessly in the anterior and posterior dentition as a result of its optimized refractive index, which is similar to tooth structure. The “evanesce effect” is a result of the material’s outstanding polishability and its ability to make margins disappear. In many cases, only one shade is necessary to achieve superior aesthetics.

The Dual Force Sectional rings were then removed so that excess material could be cleaned off and the occlusion could be checked. Interproximally, the author prefers to use the Composite Ninja (CLINICIAN’S CHOICE Dental Products) instrument for removing excess resin flash because it has a sharp, double-ended blade system that allows for easy ergonomic access to interproximal areas to accurately and consistently remove or modify any excess composite resins (Figures 12 and 13).

The occlusion was checked with 8-μm-thick TrollFoil articulating paper (TrollDental USA). A 30-fluted carbide football bur was used to trim away any excess material while performing occlusal adjustments. After the occlusion was finalized with the carbide burs, A.S.A.P. All Surface Access Polishers (CLINICIAN’S CHOICE Dental Products) were used to polish the restorations to a high shine as they easily adapted to occlusal anatomy and interproximal areas. Finally, the rubber dam was removed, and the excellent aesthetics and strength imparted by the Evanesce materials were obvious (Figure 14).

CLOSING COMMENTS
With traditional radiographs, the patient’s tooth decay would have advanced further before being diagnosed. A more invasive and time-intensive treatment would have been required, and the restorations may not have been as aesthetic or durable. Early detection of caries and the strength, aesthetics, low shrinkage, and other advantageous properties of today’s advanced composite resin materials allow clinicians to provide exceptional, efficient, and aesthetic restorative treatment while preserving maximum tooth structure.


References

  1. Lowe RA. Differentiate yourself: early diagnosis, minimally invasive cavity preparation, and bioactive restorative materials. Dental Economics. 2017;107:70-99.
  2. Riaud X. First dental radiograph (1896). Dent Hist. 2014;59:87-88.
  3. Goff S. An up close look at an innovative caries detection device from DEXIS. Dental Products Report. April 5, 2016. http://www.dentalproductsreport.com/article/close-look-innovative-caries-detection-device-dexis. Accessed August 21, 2018.
  4. Peumans M, Van Meerbeek B, Lambrechts P, et al. Five-year clinical performance of porcelain veneers. Quintessence Int. 1998;29:211-221.
  5. Hernandes NM, Catelan A, Soares GP, et al. Influence of flowable composite and restorative technique on microleakage of class II restorations. J Investig Clin Dent. 2014;5:283-288.
  6. Owens BM, Phebus JG. An evidence-based review of dental matrix systems. Gen Dent. 2016;64:64-70.
  7. Lussi A, Gygax M. Iatrogenic damage to adjacent teeth during classical approximal box preparation. J Dent. 1998;26:435-441.

Dr. Snyder received his doctorate in dental surgery at the University of California, Los Angeles (UCLA) School of Dentistry and has trained at the F.A.C.E. institute. He is an Accredited Fellow of the American Academy of Cosmetic Dentistry and is a member of Catapult Education. Dr. Snyder was on the faculty at UCLA, where he created and co-directed the first 2-year graduate program in aesthetic and cosmetic restorative dentistry. In addition to lecturing internationally, he has co-authored 3 books and written numerous articles in publications around the world. He can be reached at the website drtoddsnyder.com.

Disclosure: Dr. Snyder reports no disclosures.

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