Stable Restorations in a Less-Than-Stable Economy!

INTRODUCTION
During the past few years, dentists have had to change their approach to restorative dentistry, mostly because of the declining economy. Fortunately, the improvements in composites and adhesive bonding agents have brought clinicians the needed material support. Due to more advanced technologies, we are able to bridge the gap between necessary treatments and accepted restorative processes, successfully delivering long-lasting and yet more affordable restorations.
My personal approach has always been to be minimally invasive whenever possible, striving to restore what is lost, while respecting the remaining natural tooth structure. However, due to a generalized trend in the past 20 years toward full-mouth reconstructions and aesthetic porcelain veneering, many newer dentists have somewhat neglected the art of direct restoration, relying more upon their dental laboratory teams to deliver beautiful results to their patients. Economic changes in discretionary income are now forcing doctors to find the best and longest-lasting restoratives for proper direct applications. A “going back” to the beautiful basics of the art of dentistry, so to speak. With all that being said, the modern dentist has to go back to the basics and be able to restore teeth directly and cost effectively, helping them last long and be beautiful at the same time.

Material Control
The key element is dental material knowledge. The market seems to be flooded with new composites and adhesive systems, all claiming to deliver “the best” results. The key to success is believed to be the right combination of personal accumulation of knowledge (by reading independent studies on the materials being considered) and the application of this knowledge by a skilled practitioner, when he or she likes how a material handles.
Bulk-fill composite or conventional layered technique applied composite: Do we need to pick one or can we use both in the same case? I believe that materials are to be used as needed within their ability to satisfy certain treatment objectives, and should be approached similarly in a multidisciplinary case: a multimaterial case in the same patient.¹

A Strong Bond
Bonding techniques differ based on the doctor’s belief.² Many dentists believe in the total-etch technique, while many others prefer self-etching materials. I belong to both schools of thought, and find myself choosing one over the other strictly on a case-by-case basis. I feel strongly that one should always stay with the same line of products (bonding agent, composite, etc) from beginning to end, rather than use multiple manufacturers’ products in the same restoration. Efficient application of direct materials allows for beautiful, harmoniously integrated, reliable, and long-lasting restorations.

CASE REPORT
Diagnosis and Treatment Planning
A teenage girl was referred to my office following a traumatic cheerleading accident (Figure 1). Upon collection of initial information, it was revealed that she also suffered from posterior tooth sensitivity, yet had no desire for any “costly” and “involved” restoration process, but only the anterior cosmetic fix and disease eradication in the posterior area. A complete exam revealed numerous large interproximal lesions that, if not restored, would surely lead to serious oral problems (Figures 2 and 3).

Figure 1. Preoperative picture showing the Class IV fracture of tooth No. 8.	Figure 2. Bite-wing radiograph demonstrating extensive decay.

Figure 3. Preoperative photo of the posterior quadrant, showing failing restorations and decay.

The severity of this case, complicated by the lack of previous dental care together with the desire of minimal financial parental contribution, became the example of today’s dental needs. The approach for restoring and maintaining a beautiful smile had to include the use of excellent dental materials. In order to satisfy the patient with immediate anterior cosmetic results, and to also satisfy my desire for proper aesthetic and restorative results (all with the request for short chair time), the decision was made to complete the anterior fracture and just one of the quadrants in the first appointment (described in this article). The rest of the work needed would be completed at a later time.
In line with my belief for a conservative course of treatment, the choice was made to use direct composites to complete these restorations.³

Anterior Restoration: Step-By-Step
Local anesthesia (Lidocaine HCL 2% with 1:100,000 Epinephrine [Darby Dental]) was administered. Due to the young age of the patient, and in line with a more conservative approach, no additional tooth structure was removed for beveling (which would aid in smoother composite to enamel interface). Only plain pumice with water was used to clean the affected area. Then, the bonding adhesive (OptiBond XTR [Kerr]) was applied to the enamel/dentin surface with a disposable applicator.
OptiBond XTR is a self-etch universal adhesive system, comprised of only 2 components: a self-etch primer and a universal adhesive. The self-etch primer provides effective etching to enamel and dentin without requiring any additional phosphoric acid etching. The light-cured adhesive component is 50% filled with 0.4 µm barium glass to help reinforce bond strength.
We scrubbed the surface, wet with the adhesive, for 20 seconds and then air-thinned it for 5 seconds. The OptiBond XTR adhesive was then applied again with another disposable applicator to the enamel/dentin surface for 15 seconds and air-thinned for 5 seconds. The tooth surfaces were then light-cured (DemiPlus light [Kerr]) for 20 seconds.
Next, the lingual shelf was built with a dentin shade (A2) of Herculite Ultra (Kerr), and sculpted into the natural mammelon formation, then light-cured for an additional 20 seconds. Enamel shade composite (A1) of Herculite Ultra was then layered onto the facial aspect of the restoration, sculpted into ideal anatomy, and light-cured for 40 seconds.
Herculite Ultra is a nanohybrid light-cured composite resin. Based on the manufacturer’s instructions, Herculite Ultra is indicated for all cavity classes in anterior and posterior teeth. According to the manufacturer, its best attributes include excellent aesthetics, handling and mechanical properties, easy polishability with retention of clinical luster, and a lifelike appearance with replication of the fluorescence and opalescence of the natural teeth. This nanohybrid composite resin also possesses excellent fracture toughness and wear resistance.⁴

Figure 4. Application of the adhesive (OptiBond XTR [Kerr]) (per manufacturer’s directions). Prior to bonding, there was no additional removal of tooth structure; the tooth was cleaned with only a plain pumice and water slurry.	Figure 5. After the adhesive was light-cured (DemiPlus [Kerr]), the lingual shelf was built with a dentin shade of a nanohybrid composite resin (Herculite Ultra [Kerr]), sculpting a natural mammelon formation.
Figure 6. The dentin (composite resin) layer was light-cured.	Figure 7. Enamel-shaded composite was then layered onto the facial aspect of the restoration.
Figure 8. Final light-curing was done.	Figure 9. Polishing was completed (OptiDisc Finishing and Polishing Discs [Kerr]).

Figure 10. The completed direct nanohybrid composite resin (Herculite Ultra) restoration.

The restoration was then polished with a 4-disc sequence of polishing discs (OptiDisc Finishing and Polishing Discs Kit [Kerr]) (Figures 4 to 9). Finally, the restorations were checked for interferences in lateral and protrusive excursions; none were found, so no adjustments were necessary (Figure 10).

Posterior Restorations: Step-By-Step
Once the patient’s main concern (the fracture of her upper central incisor) was addressed, the restoration of her upper right posterior was to be done. There were 6 interproximal lesions with old and failing restorations; and, in addition, occlusal and occlusolingual decay present in teeth Nos. 2 to 5.
After administering local anesthesia (Lidocaine HCL 2% with 1:100,000 Epinephrine), a rubber dam was placed (Flexi-Dam [Coltène]). Then, a contact-by-contact approach was applied, beginning interproximally at teeth Nos. 4 and 5, and moving posteriorly. Each restoration was completed using the same technique, as explained here.
After decay/old restoration removal, the Garrison 3D XR matrix system was placed per manufacturer’s directions. Then, OptiBond XTR was applied to the enamel/dentin surface with a disposable applicator. We scrubbed the surface for 20 seconds and air-thinned for 5 seconds. The OptiBond XTR adhesive was then applied with another disposable applicator to the enamel/dentin surface for 15 seconds and air-thinned for 5 seconds and then light-cured for 20 seconds. A small amount of SonicFill composite (shade A2) was placed at the bottom of the Class II cavity floor via the SonicFill handpiece, and was formed into ideal and tight interproximal contact anatomy using the PreForm Contact Instrument (Garrison Dental Solutions). The material was then light-cured for 20 seconds using the Demi Plus LED Curing Light. (Kerr) The remaining cavity was then completely filled using the same SonicFill composite, the anatomy was sculpted using a composite instrument, and light-cured for 40 seconds.

Figure 11. Application of the bonding adhesive OptiBond XTR (per manufacturer’s directions), after placement of rubber dam and removal of decay.	Figure 12. Light-cure of adhesive for 20 seconds with DemiPlus Light [Kerr].
Figure 13. Application of SonicFill (Kerr) composite with the SonicFill (Kerr) handpiece. (Note: Each cavity was completed separately to ensure ideal contour.)	Figure 14. Final composite sculpting was completed using a composite instrument.
Figure 15. Final light-curing was completed.	Figure 16. Ideal restoration contour, immediately after matrix removal.
Figure 17. Second restoration performed using the PreForm Contact Instrument (Garrison Dental Solutions) for ideal interproximal contour and contact.	Figure 18. Completed premolar restorations.
Figure 19. Removal of decay and placement of the ComposiTight 3D XR Sectional Matrix System (Garrison Dental Solutions).	Figure 20. Application of the bonding adhesive.

SonicFill is a nanohybrid light-cured composite. Its use is made possible by sonic activation with the SonicFill handpiece, which makes it applicable in all posterior cavity classes. The SonicFill handpiece works as follows: upon activation, the handpiece vibrates sonically, which significantly drops the composite’s viscosity. The now more liquefied composite enables an intimate adaptation of the material to the cavity preparation walls. Deactivating the handpiece stops the sonic vibration, which allows the composite to slowly return to its original viscous state (86% filled), without losing any of its desired physical properties. The material is nonsticky and nonslumping, which allows for quick, easy shaping and sculpting. Because of these benefits and the capability of a high depth of cure, a cavity of up to 5.0 mm in depth can be filled and light-cured in a single bulk increment.⁵

Figure 21. Application of SonicFill composite with the SonicFill handpiece. (As done previously, each cavity was completed separately to ensure ideal contour.)	Figure 22. Final light-curing was done after sculpting.
Figure 23. Final occlusal adjustment with a diamond bur after removal of matrix system and rubber dam.	Figure 24. Postoperative radiograph showing ideal composite adaptation with proper contact adaptation in the upper right quadrant.

Figure 25. The completed posterior restorations.

The PerForm Proximal Contact Instrument from Garrison Dental Solutions was used to aid in the formation of ideal anatomy of the interproximal contacts on posterior composite restorations. Since the curing light is placed directly on the Fresnel lens of the instrument, the curing light is directed deep into the proximal box, thus enabling assurance for total-cure, regardless of composite used.⁶ Tight, anatomical contacts on all Class II restorations were achieved with the help of the Composi-Tight 3D XR Sectional Matrix System (Garrison Dental Solutions). This system is comprised of contoured sectional matrix bands (for the creation of proper tooth anatomy and tight contacts) and rings (for creating the required tooth separation).⁷
The removal of the matrix system and the rubber dam was immediately followed by a thorough assessment of the occlusion, along with any needed adjustments. If proper anatomy is achieved during the placement/sculpting process, occlusal adjustments are usually minimal and sometimes completely unnecessary. Polishing in this case was not necessary due to the high gloss and luster of the material (Figures 11 to 23).
Postoperative pictures and bite-wing radiograph were taken to show proper restorations (Figures 24 and 25).

IN SUMMARY
Direct restorative dentistry can be achieved in minimal time with stable, beautiful results.⁸
The advancements in dental materials helped ensure the direct delivery of quality restorations with guarantee for longevity.⁹

References

1. Nash RW. Direct composite resin restorations for today’s practice. Dent Today. 2013;32:114-118.
2. Ruyter IE, Oysaed H. Composites for use in posterior teeth: composition and conversion. J Biomed Mater Res. 1987;21:11-23.
3. Kerr Dental. OptiBond XTR. kerrdental.com/kerrdental-bonding-optibond-xtr-2. Accessed July 25, 2013.
4. Kerr Dental. Herculite Ultra. kerrdental.com/kerrdental-composites-herculite-ultra-2. Accessed July 25, 2013.
5. Kerr Dental. SonicFill. kerrdental.com/kerrdental-composites-sonicfill-2. Accessed July 25, 2013.
6. Garrison Dental Solutions. PerForm Proximal Contact Instrument. garrisondental.eu/index.php/en/produkte/instrumente/contact-former-perform. Accessed July 25, 2013.
7. Garrison Dental Solutions. Composi-Tight 3D XR Sectional Matrix System. garrisondental.com/store/matrix-systems/composi-tight-3d-xr/composi-tight-3d-xr-sectional-matrix-system.cfm. Accessed July 25, 2013.
8. Rubinstein S, Nidetz AJ. Posterior direct resin-bonded restorations: still an aesthetic alternative. J Esthet Dent. 1995;7:167-173.
9. Combe EC, Burke FJ. Contemporary resin-based composite materials for direct placement restorations: packables, flowables and others. Dent Update. 2000;27:326-336.

Dr. Cuevas received her DDS from the University of Texas, San Antonio, in 1995. Dr. Cuevas is the founder and CEO of The Institute of Esthetic Dentistry. She maintains a private practice in San Antonio, emphasizing aesthetic and restorative dentistry. She is a member of numerous dental associations and has served as a contributing editor for the Journal of Cosmetic Dentistry and has published numerous professional articles on direct and indirect bonding techniques. Dr. Cuevas has become known for being at the forefront of implementing new techniques and materials into the restorative aesthetic dental space. She has lectured internationally on aesthetic dentistry and is an active consultant for several dental manufacturers in the area of new product development and refinement. She can be reached at simona.dds@gmail.com.

Disclosure: Dr. Cuevas reports no disclosures.