How to: Place monomer technology composite

February 2010 | Dental Products Report
Clinical 360°: Restorative Technique

How to: Place monomer technology composite

GC America’s Kalore nano composite helps deliver “instant orthodontics.”

by FRANK J. MILNAR, DDS
Information provided by GC America Inc.

• Universal light-cured nano composite for optimal handling
• Proprietary HDR prepolymerized fillers are said to produce easy, sustainable polishability
• Highly sculptable with no slumping

GC America
gcamerica.com  
800-323-7063

Direct composite veneers are among the more minimally invasive treatment modalities clinicians can use to rejuvenate a patient’s smile and/or create the appearance of “instant orthodontics.”  When no removal of tooth structure is required, this modality can be reversible. In other cases, only minimal preparation may be necessary, contributing to the overall conservative nature of the direct composite restorative technique.

Successful direct composite veneer placement requires a clinician to understand a tooth’s natural polychromicity if resulting restorations are to exhibit life-like esthetics. Further, dentists also should be familiar with the inherent structure of natural teeth, including the thickness variations between dentin and enamel in different parts of the tooth. Finally, clinicians should be skilled at layering selected composites within the restoration to specifically manipulate the manner in which hue, chroma and value will affect its appearance.

When creating a direct veneer restoration, clinicians should use a comprehensive restorative system such as Kalore universal light-cured nano composite that provides the necessary shade opacities, translucencies, and dentin and enamel colors.

However, a patient’s long-term satisfaction with his or her restorations is dependent not only on esthetics, but also on the restoration’s overall long-term durability. Of  paramount importance to a restoration’s longevity is the composite’s ability to reduce polymerization shrinkage and therefore, shrinkage stress, while still providing clinicians with beneficial handling properties.

The different light refractive indices of the fillers are what contribute to Kalore’s chameleon effect. These have different light scattering properties, and colors from the surrounding teeth are matched perfectly (i.e., demonstrating a chameleon effect).

This article demonstrates how to easily place this monomer technology composite to create restorations that exhibit the different opacities and translucencies observed in natural teeth. The use of such an esthetic and durable composite lends to patient satisfaction in terms of esthetics and long-term function while simultaneously adhering to the principles of responsible esthetics and minimum intervention dentistry.

Case presentation

• Refer to the slideshow for  figures

A 50-year-old female presented with the desire to have her anterior teeth more visible, with a less dark appearance (Figs. 1-2). She also presented with misaligned tooth Nos. 8 and 9 (Fig. 3), as well as a Class V lesion (abfraction) on tooth No. 11. She had previously seen an orthodontist to determine the feasibility of orthodontic therapy, but she decided this was not an option as this time.

After researching conservative dental procedures, “no-prep veneers,” and minimally invasive dentistry on the Internet, she sought treatment for her anterior teeth that would create “instant orthodontics” without sacrificing tooth structure. However, of primary importance was being treated by a dentist who would place composite using “reversible” techniques.

A thorough examination that included an oral history, radiographs and photographs was performed, and the patient’s occlusion was analyzed. In addition, the morphological, histological and optical characteristics of the teeth were noted. The patient was in good health, and nothing was found to contraindicate direct composite restoration of her anterior maxillary dentition.

Treatment planning

It was decided that a minimal preparation design would be used to treat tooth Nos. 8 and 9, and a composite material demonstrating different opacities and translucencies would be selected to match the adjacent teeth.

Of importance in the creation of polychromatic restorations in this case was the selection and use of a next generation composite available in a variety of opacities and translucencies, as well as one that would demonstrate low shrinkage stress for maximum durability. For this reason, Kalore was chosen. Because the patient declined periodontal grafting procedures to address the sensitivity and exposed root of No. 11, it was recommended that a gingival colored composite be used to restore the Class V abfraction. 

Prior to initiating treatment, the shade was taken using classic and 3D shade guides. Vident’s Vita Class Shade Tabs and Vita 3D Master Shade Tabs were used (vident.com). The accuracy of the composite shades selected (e.g., a B1 dentin shade, a White Translucent Enamel shade for the cervical area, and a Bleach White Enamel shade for the incisal area) were placed on the teeth pre-operatively, before any irreversible tooth reduction was completed. The composite was light cured to enable the dentist and patient to determine if they were the right choices.1,6

An impression was taken with an alginate substitute material, in this case, Clinician’s Choice’s Counter-FIT™ (clinicianschoice.com), for use in creating a diagnostically enhanced model. This model also would be used to fabricate a high-viscosity putty stent with GC America’s Exafast™ Putty (Fig. 4).

Composite placement

A reduction guide (i.e., polyvinyl matrix positioned against the lingual aspect of teeth) was invaluable for achieving the conservative tooth reduction the patient desired. In particular, because the incisal length of the patient’s central incisors would be increased by 2.0 mm-as verified by mounting of the models on an articulator-only an ultra-light chamfer preparation was completed (Fig. 5).

To facilitate composite placement, Ivoclar Vivadent’s Contour Strip II mylar matrixes (ivoclarvivadent.com) were placed between tooth Nos. 8 and 9. A single-component, self-etching bonding agent (GC America’s G-Bond) was applied onto the preparations for 10 seconds using a brush (Fig. 6). The bonding agent was air thinned with high pressure, then light cured for 10 seconds per tooth.

The initial dentin replacement layer was placed using Kalore B1, the highest chroma shaded composite for the tooth (Fig. 7). Placement began at the gingival third of the tooth, tapering the composite into the middle third, almost to full contour, to anticipate the future thin enamel resin overlay. This composite layer was then light cured for 20 seconds.

The second dentin replacement layer in the Bleach White shade of composite was applied to the middle third of the tooth and extended into the incisal third. This increment also was cured for 20 seconds. Sufficient room was left on the facial surface for the application of the enamel layer.

At this point, the dentin anatomy of the restoration was complete, resulting in an undulating effect that produced depth of color and enhanced the trapping and scattering of light.

The final White Translucent enamel composite shade (KALORE WT) was placed and sculpted across the entire facial surface of the restoration (Fig. 8). Care was taken to slightly overbuild this layer to accommodate finishing. This increment also was cured for 20 seconds.

Finishing, polishing

After the direct composite veneer restorations were layered and anatomically constructed, the texture and tertiary anatomy were imparted in the restorations. Specifically, the line angles were defined by scribing faint lines on the composite to outline transition line angles. The texture of the restorations then was carried to and beyond the line angles to replicate nature.

To finish and polish the direct composite veneer restorations, a series of discs and points, intermediary diamond polishers, and more refined polishers, were used in a sequential manner. In particular, the tertiary anatomy was created using a fine diamond bur from Brasseler USA (brasselerusa.com). To achieve the appropriate luster and polish, a goat hair brush and high shine points, cups and wheels were employed, along with GC America’s Epitex Strips interproximal polishing strips (Figs. 9-12).

Conclusion

Manufacturers today are responding to clinician demands for predictable and durable restorative options that enable them to deliver minimally invasive, high-quality restorations that replicate the esthetics of nature. Kalore demonstrates a number of desirable characteristics, including high chameleon effects, enhanced polishability, greater flexural strength and better wear resistance. In addition, this direct composite exhibits low shrinkage stress for greater restorative longevity and marginal adaptation. The different light reflective indices of the composite’s fillers contribute to its chameleon effect, enabling clinicians to deliver restorations that truly blend with adjacent natural dentition for a life-like result (Figs. 13-14). 

Dr. Frank J. Milnar, is a graduate of the University of Minnesota, School of Dentistry. He is an accredited member of the American Academy of Cosmetic Dentistry and a Board Examiner for accreditation. He maintains a full-time practice in St. Paul, Minn., emphasizing appearance related dentistry. He has published numerous articles about the direct placement of composites, shade selection and porcelain materials.

Disclosure:  Dr. Milnar received product and financial support from GC America, Inc.

References

1.    LeSage B, Milnar F, Wohlberg J.  Achieving the epitome of composite art: Creating natural tooth esthetics, texture, and anatomy using appropriate preparation and layering techniques. Journal of Cosmetic Dentistry (Special Issue): 132-141, 2008.

2.    Blank JT. Simplified techniques for the placement of stratified polychromatic anterior and posterior direct composite restorations. Compend Contin Educ Dent 24 (2 Suppl): 19-25, 2003.

3.    Irie M, Tamada Y, Maruo Y, et al. Vertical and horizontal setting shrinkages in composite restorations. J Dent Res. 2009; IADR Abstract 2443.

4.    Terry DA, Leinfelder KF, Blatz MB. A comparison of advanced resin monomer technologies. Dent Today. 2009 Jul;28(7):122-3.

5.    Kaga S, Fusejima F, Kumagai T, Sakuma T. Polymerization shrinkage ratio of various resin composites. J Dent Res. 2009; IADR Abstract 2441.

6.    Terry DA, Leinfelder KF. An integration of composite resin with natural tooth structure: The Class IV restoration. Pract Proced Aesthet Dent 16(3):235-42, 2004.