Correct use of composite resins

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Correct use of composite resins
K. William Mopper, DDS, MS,
explains his protocols for
choosing anterior and
posterior composite resin
materials in aesthetic
restorative dentistry
Figure 1: Maxillary anterior composite restorations at 22.5 years
postoperatively. Only minimal chipping and slight recession can
be seen. Note the highly polished surface of the microfill
composite resin material (Renamel Microfill, Cosmedent)
K.
William ‘Buddy’ Mopper, DDS, MS, is in private practice in
K.William
Winnetka,
Winnetka, Illinois, where he has been involved with creating
dental
dental aesthetics for 42 years. He is an internationally
renowned
renowned lecturer in aesthetic dentistry with an emphasis on
composite
composite bonding using direct application techniques. He
co-authored, A Complete Guide to Dental
Bonding, which was the first definitive
book for the dental profession describing
bonding techniques. He is a member of
the Academy of Esthetic Dentistry, and a
fellow of the American Academy of
Cosmetic Dentistry, diplomat of the
American Board of Pediatric Dentistry,
and
and aa fellow of the American College of Dentists. He taught
direct
direct resin bonding at many major Universities including the
University
University of Minnesota, State University of Iowa, the
University
University of Nebraska, Louisiana State University, the
University
University of Illinois and the University of Kentucky. He is the
recipient
recipient from the American Academy of Cosmetic Dentistry
of
of an
an award for ‘Lifelong Commitment to Providing Excellence
in
in Continuing
Continuing Education in Cosmetic Dentistry’ and an award
for
for ‘Outstanding
‘Outstanding Contribution to Cosmetic Dentistry.’ He
received
received the New York University College of Dentistry Irwin
Smigel
Smigel Prize in Aesthetic Dentistry, and the Lifetime
Achievement
Achievement Award from GenR8TNext seminars. He is
director
director of education for the Center for Esthetic Excellence
(Chicago)
(Chicago) and is co-founder and chairman of Cosmedent, Inc.,
where
where he is responsible for its educational programs and
product
‘Buddy’ Mopper will be speaking at the
product development.
development.‘Buddy’
World
World Aesthetic Congress on Friday 12 – Saturday 13 June
2009
2009 in London. For further information and to book your
places,
places, please call Independent Seminars on 0800 371652 or
visit
visit www.independentseminars.com/wac.
www.independentseminars.com/wac.
Figures 3a and 3b: A shallow labial prep is placed ranging
from 0.8 mm at the incisal to 0.4 mm at the gingival. The
gingival margin is placed 0.3 mm below the free margin for
aesthetics. The application of Complete (Cosmedent) bonding
adhesive after a total-etch technique was performed
Today, in an attempt to replicate lifelike tooth structure
aesthetically, there are a multitude of anterior and
posterior composite resin materials from which to
choose.
As a result, dentists face a dilemma in deciding what
product to use, and when. This article will explain the
protocol that I follow and will also help readers identify
and utilise the ideal product for a specific use that they
may have in mind.
In my experience, there is no other dental material as
versatile and useful as this category of restorative
products. There are many advantages to understanding
and using direct composite resins regularly in your
practice (Table 1).
When one truly understands how to properly use
these materials, long-lasting, truly aesthetic results are
easily achievable. Composite resin can help you produce
invisible aesthetic restorations of all types. I know this
from my personal, long-time clinical experiences with
this class of dental materials and their associated
techniques.
I have been using light-activated direct composite
resin restoratively for more than 35 years, and for the past
20 years my practice has been limited to producing
Figure 2: Microfills are exceptionally color stable and wear
resistant. Note the excellent color match of the restoration to
the shade tab (VITA Classical, Vident) after 22.5 years
Figures 4a and 4b: Lingual surface of tooth six is reduced
about 0.5 mm across the entire incisal third, allowing a
complete labial-lingual wrap of incisal edge, creating better
fracture resistance/retention form. The first application of
Renamel NANO A2 is placed lingually to establish canine rise.
(Note this material’s no-slump, no-stick properties allow easy
sculpting/shaping of the incisal tip)
Table
Table 1:Advantages
1: Advantagesofofdirect
directcomposite
compositerestorations
restorations
Aesthetics:
Aesthetics: When
When done
done properly,
properly, one
one of
of the
the most
most aesthetic
aesthetic
restorations
restorations attainable
attainable
Timesaving:
Timesaving: Placed
Placed in
in one
one practice
practice visit
visit
Control:
Control: Aesthetic
Aesthetic and
and functional
functional results
results are
are in
in your
your hands
hands
Minimally
Minimally invasive:
invasive: The
The most
most conservative
conservative restorative
restorative
material
material choice
choice available,
available, helping
helping to
to ensure
ensure long-term
long-term health
health of
of
the
tooth
the tooth
Biologically
Biologically compatible:
compatible: Extremely
Extremely compatible
compatible with
with the
the
gingival
gingival tissue,
tissue, when
when properly
properly placed
placed and
and polished
polished
Wear:
Wear: Will
Will not
not wear
wear the
the opposing
opposing dentition
dentition
Handling
Handling properties:
properties: Easy
Easy to
to handle,
handle, manipulate,
manipulate, and
and
control
control
Creative:
Creative: Maximum
Maximum creativity
creativity according
according to
to choice,
choice, technical
technical
and
and artistic
artistic abilities
abilities
Reparability:
Reparability: Easy
Easy to
to repair
repair and
and can
can also
also be
be used
used for
for allallceramic
ceramic and
and PFM
PFM repairs
repairs
Long-lasting/high
Long-lasting/high strength:
strength: Modern
Modern chemistry
chemistry
(research
(research on
on particle
particle size
size and
and filler
filler content)
content) has
has increased
increased the
the
strength
strength and
and longevity
longevity of
of composite
composite restorations.
restorations.
Article reprinted by permission of Dentistry Today, ©2008 Dentistry Today. Mopper KW. Let’s talk composites! Dent Today October 2008;27:118-122.
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Clinical
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aesthetic changes using only composite resin. Although
my practice is all encompassing, with my partners doing
indirect restorations of all kinds, I have limited my
practice to direct placement restorative techniques.
Procedures that I use direct composite resins for include:
• Class I restorations
• Class II restorations
• Class III restorations
• Class IV restorations
• Class V restorations
• Tooth shaping
• Tooth alignment
• Diastema closure
• Repair of intraoral defects
• Veneering for colour change
• Veneering mutilated dentitions
• Tooth lengthening
• Incisal edge reinforcement
• Composite and porcelain repairs.
Composition of composite resins
What categories of composite resin materials are available
to us for use in our clinical armamentarium? Let’s
examine them by discussing their properties and seeing
where they fit into our clinical techniques.
Microfills
Microfills are important if you want to create truly
aesthetic, life-like restorations. This class of composite
resins offers the highest level of aesthetics because they
most closely simulate the actual enamel surface of a
tooth. Since microfills have the smallest average particle
size (0.04 microns) of direct composite resins, they
polish to a higher lustre than any other material on the
market. They also hold their polish over time and
exhibit better wear characteristics than other types of
composite resins. Microfills are also more stain and
plaque resistant, making them more biologically
compatible with the gingival tissue. In addition, they
have the highest refractive and reflective index of any
composite resin category, producing the most realistic
translucency.
However, microfills are less filled than other
composite resins. As a result, they will not exhibit the
same strength-properties as microhybrid or nanofill
composites. Because of this, I use a layering technique
placing an ‘enamel’ layer of microfill composite resin
(Renamel Microfill, Cosmedent) over a stronger, ‘dentine’
layer composite. For the ‘dentine’ layer(s) I use either a
microhybrid or nanofill composite (Renamel Microhybrid
or Renamel NANO, Cosmedent). Restorations built in
this way exhibit optimal aesthetics and wear resistance
due to their outer microfill ‘enamel’ layer.
Microhybrids
Microhybrids are able to most closely simulate the
dentine of natural tooth structure. Because of their
higher strength and greater opacity, microhybrids are
perfect for supporting the microfill ‘enamel’ layer.
Microhybrids have a larger particle size than the nanofill
and the microfill composites, resulting in higher-strength
properties. Since microhybrids are the most opaque of
the three composite types, they are also great for masking
out unwanted colour and achieving extreme colour changes.
Microhybrids are also less polishable, more difficult to
marginate, and will wear faster than microfill resins. As
microhybrids most closely simulate the dentine of tooth
structure, they will not obtain the same aesthetic results
for an ‘enamel’ layer as a microfill resin. In my practice, I
use microhybrids as the substructure under microfills in
areas that require high strength.
Nanofills
Nanofills
The incorporation
incorporation of nanofill technology into composite
The
resins is
is an important advancement in the field of
resins
aesthetic dentistry. Nanofill composites combine
aesthetic
conventional-filler technology with nano particles to
conventional-filler
achieve both
both strength and aesthetics in one material.
achieve
Currently, there are two distinct types of nanofill
Currently,
composites in the marketplace: completely nanofilled
composites
resins and
and nano-hybrids (i.e. Renamel NANO,
resins
Cosmedent).
Cosmedent). Completely nanofilled resins contain
nanometer-sized particles throughout the resin matrix.
nanometer-sized
Nano-hybrids, on the other hand, consist of larger
Nano-hybrids,
particles surrounded by nanometer-sized particles.
particles
Although these nanofill materials vary in composition,
Although
the
goal is
is the same, creating a ‘universal’ dental composite.
the goal
As previously
previously mentioned, nano-hybrids contain
As
nanometer particles combined with more conventional
nanometer
21282.indd 2
Figures 5a and 5b: After polymerisation of the incisal tip,
Renamel NANO (Cosmedent) was used on the mesial
proximal to add to the width of the cuspid to match the
other side of the mouth. Note the space between cuspid and
laterals is not fully closed because it would have delivered a
disharmony in size. Proper morphology of each tooth is
completed making finishing and polishing much easier
Figures 6a and 6b: Addition of facial NANO A2 and the use
gloved finger (no powder and clean and dry) to manipulate
material into place. Apply light pressure with a tapping
motion to allow for rapid and easy placement and precontouring
Figures 7a and 7b: Use of titanium-coated instruments ensures
easy placement of nanofills without sticking. Similar to buttering
bread, the composite is spread and thinned simultaneously. A G3
instrument (Cosmedent) allows for easy placement on facial
surfaces. An IPC Carver (Cosmedent) cleaves excess material
interproximally and at gingival margins. Morphology and
contours are achieved, but the material has not yet been
polymerised
Figures 8a and 8b: After polymerisation of facial surface,
Renamel NANO (Cosmedent) Medium Incisal shade is placed
with a Multipurpose instrument (Cosmedent) into the incisal
areas to enhance the overall lifelike appearance of the
finished veneer (Note colour and translucency of this
material). The G3 instrument is used along with finger
pressure to aggressively compress incisal material into the
pre-formed incisal grooves
Figures 9a and 9b: Incisal material in place and polymerised
(note the translucency difference between the incisal edge
and the body material). When gingival margins are involved,
apply a small amount of Renamel Microhybrid (A2)
(Cosmedent) material and sculpt with the IPC instrument to
completely seal gingival and proximal margins
Figures 10a and 10b: The G3 is used to smooth/sculpt
subgingivally to completely seal margin. Material application
and morphology is complete (note how much attention is
given to properly sculpted tooth form). Then the material is
light-cured for 60 seconds
filler technology. These large particles provide similar
strength properties to hybrid materials while exhibiting
higher polishability, as seen with the microfill resins.
Unlike microhybrids, nanofill composites have a lifelike
opacious translucency that is very natural in appearance.
It is important to note that these materials will not hold
their polish as long as microfill resins and, as a result,
may be more susceptible to plaque and staining over
time. However, when compared with conventional
microhybrids, nanofill composite resins will maintain
better surface smoothness and are thus great for the
single-product user.
Where should you use nanofill composites? Although
you can really use nanofill materials to create cosmetic
dental restorations of all kinds, I have identified a few key
areas where nanofill composites fit into my dental
practice. They are as follows:
• Posterior restorations
• Veneering lower anteriors
• Building up incisal edges
• The classic class IV restoration
• When restoring or increasing cuspid rise.
They can also be used when the dentist wants to use
only one material, instead of layering a microfill over a
microhybrid; as a support material for Class IV
restorations; any tooth lengthening; adding cusps to
worn molars or bicuspids; and for veneering mandibular
anterior teeth (when strength is a concern); and posterior
restorations.
Opaquers and tints
Opaquers and tints are key ingredients to creating
beautiful invisible restorations. During the restoration
procedure, opaquers allow you to block-out unwanted
colour while tints help you bring the desired colour back
into the tooth. The use of both is where your creativity as
a dentist can really shine! However, opaquers and tints
should always be used sparingly. Also, be careful when
choosing them as some manufacturers make these
materials too opaque. Let’s examine the difference
9/8/09 8:30:25 PM
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Figure 11: Final right cuspid
composite resin veneer
(tooth 6) after finishing and
polishing. (Figures 13-15
demonstrate finishing and
polishing steps on tooth 11)
between these two materials.
Opaquers: The main advantage of opaquers is that they
produce opacity and block light transmission. Use them
anywhere you would like to produce opacity in your final
restoration. Since opaquers increase the value of a
restoration, they are great for masking out metals and
dark stains.
Tints: Tints are used to help increase the hue and
chroma of your restoration. Since tints transmit light,
they are great for adding translucency back into your
restoration. Unlike opaquers, tints decrease value. I use
them to help develop a realistic-looking enamel surface
from within.
System advantages
To excel in direct composite resin techniques, you should
find a system that gives reliable and long-lasting results
— then stick with it! Ask yourself the following question:
How many composite materials have I shelved because
some guru says another product is better — only to be
disappointed once you have used it? When you are
looking for a system, you should consider certain criteria
(Table 2).
Application technique
First, one should understand that no material in itself will
deliver the ideal restoration. This is because material
selection is only one part of direct resin bonding. Second,
one must consider the dentist’s technical ability. Proper
technique involves many components including the
following: proper preparation technique for each
procedure; method of material placement — this involves
complete understanding of tooth morphology and
sculpting techniques necessary to achieve it; knowledge
of layering and how to use various materials in
combination to enhance the overall physical, aesthetic,
and biologic results of each procedure (i.e. when to use
microhybrid, nanofill, microfill, tints, and opaquers); and
using the proper finishing and polishing techniques to
achieve the most lustrous, plaque resistant, stain resistant
and wear resistant finished result. One must understand
when and how to use finishing burs, discs, rubber
impregnated points, and polishing paste to obtain the
desired result. (Note: knowledge and technical abilities in
Figure 12: Upper left cuspid (tooth 11). Composite application
complete and polymerised prior to finish (note the two most
important views when finishing and polishing are from the
incisal and profile. Incisal view: Sets up incisal gingival
contours, mesial distal contours and labial lingual relationships.
It also helps to visualise embrasure space development. Profile
view: Helps to silhouette one tooth against another to establish
the alignment and emergence profile)
Figures 13a and 13b: Use of discs to contour the labial
surfaces and to properly contour line angles and to develop
embrasure surfaces. Note retraction with an 8A instrument to
protect gingival tissue and an 8392-016 diamond (Brasseler,
USA) while trimming and defining the gingival tissue
Figures 14a and 14b: Further define tooth and pre-polish with
a fluted ET6 bur (Brasseler USA). A diamond-impregnated
point (Diamond Polisher Medium, Cosmedent) is used to
form/polish mesial and distal grooves and further develop
central lobe on cuspid
Table 2: Key questions when selecting a composite
resin system
1. How does the material handle?
2. Does the finished material truly match its selected shade
guide?
3. Does the system make colour matching or colour
development easy?
4. Is the finished product colour stable over time? (15 to 20
years?)
5. How easy is it to polish, and will the composite hold the
polish over time?
6. How strong is the restoration?
7. What are the translucency and opacity characteristics of the
material?
8. When finished properly, are the composite and the gingival
tissues biocompatible?
9. What material has adequate strength for the purpose of use?
10. What material is more wear resistant? Why?
all the above-mentioned areas can be greatly enhanced by
an excellent hands-on workshop experience. I would
recommend that you consider this if you have not already
done so.)
Case report:
direct composite resin technique
Many years ago, I placed direct composite resin veneers
on my son’s maxillary anterior teeth (6 to 11) to close
spaces using only a microfill (Renamel Microfill,
Cosmedent). Over considerable time, Robert had some
chipping due to aggressive eating habits. These defects
were easily repaired. Photos, taken at 22.5 years
postoperatively, show minimal chipping of the composite
material and excellent color stability of the material
(Figure 1). As mentioned previously, microfills hold their
polish long-term better than any other type of composite
resin material, especially when the right dentifrice and
toothbrush are used (Figure 2).
I made the decision to redo Robert’s case in autumn
21282.indd 3
Figure 15: Fine and superfine
disks (FlexiDiscs, Cosmedent)
are used to achieve a high
lustre while maintaining facial
anatomy. This is followed with
a buffing procedure (FlexiBuff
and Enamelize polishing paste,
Cosmedent) to achieve
exceptionally smooth surface
and immediate high polish. A
Felt FlexiPoint (Cosmedent)
and Enamelize polishing paste
are used to enhance the
mesial and distal grooves
Figure 17: Completed case: tooth numbers 6 and 11 were done
with Renamel NANO A2 Body and Medium Incisal. Tooth
numbers 7 and 8 were done with Renamel NANO and overlaid
with Renamel Microfill A2 Body and Medium Incisal. Tooth 9
was not veneered, but the mesial and distal diastema closures
were done using only Renamel Microfill
Figure 16: Note the excellent
colour match of the
completed veneer to an A2
shade tab (Vita Classical,
Vident)
2007. The treatment goals were to achieve great
aesthetics while establishing proper disclusion by
improving his canine rise. Therefore, the new aesthetic
restorations were done by utilising both nanofill and
microfill composites.
Let me take you through the reasoning involved in the
proper material-selection thought process. I could have
done the entire case using a nanofill and achieved
excellent results, but I wanted the best of both worlds,
both strength and aesthetics. I wanted a microfill surface
because of its long-term polishability and optimal,
life-like aesthetics. I used a nanofill to complete the
functional portion involving the right and left cuspids.
This would give me the strength required on a support
tooth, along with great aesthetics and an excellent colour
match to the laterals and centrals (the technique is shown
in detail in Figures 3-16). Now, many would ask, why not
Figure 18: Completed case at three-week post-op (note the
accurate color match)
porcelain veneers? And, I would ask, why
porcelain veneers? What did we achieve with my son
after 23 years? We achieved long-lasting results with
minimal preparation. We observed only minimal (nonpathologic) recession due to material biocompatibility
(and good oral hygiene habits); total colour stability with
excellent aesthetics; complete and intimate bond of the
composite-to-tooth surface (no cementation); and
easy-to-repair restorations (Figures 17 and 18). Oh, and
by the way —Robert still eats ribs!
9/8/09 8:30:29 PM
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