Direct resin restorations are the most frequently performed operative treatment in the dental practice of the average general practitioner (GP). With recent advances in both the adhesives and composites now available to the GP, these restorations are becoming easier and more predictable to deliver and are providing improved aesthetics with less time involved in their placement. What follows is a discussion of a new self-etch adhesive and the nanocomposite it was formulated to pair with, in the restoration of a defective composite with recurrent decay.
CASE REPORT
Diagnosis and Treatment Planning
A 69-year-old male patient presented for his regular prophylaxis appointment, and it was noted that the composite on the right lateral maxillary incisor (No. 7) had chipped incisally, and recurrent decay and stained margins were observed (Figure 1). Recommended treatment consisted of replacement of the defective filling with a new composite resin restoration.
Clinical Protocol
A local anesthetic (4% Septocaine with 1:100,000 epi [Septodont]) was administered, and the defective composite was removed using a carbide bur (330M [SS White Burs]) in a high-speed handpiece with ample water. Recurrent decay was noted at the gingival margin, and this area was prepared with a carbide bur. A diamond bur (2858.FG.014 [Komet USA]) was utilized to remove the stain at the mid-facial area and to roughen the enamel margins of the preparation to improve the retention of the planned restoration (Figure 2). To minimize potential sensitivity due to the depth of the preparation, a selective-etch approach was applied with a 40% etching gel (Onyx [Centrix Dental]) applied only to the enamel areas of the tooth for 20 seconds (Figure 3). The tooth was then thoroughly rinsed with water, dried, and cotton roll isolation placed (Figure 4).
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| Figure 1. Defective composite filling with stained margins, recurrent decay, and fracture of the composite. | Figure 2. The old composite restoration along with recurrent caries were removed using carbide and diamond burs. |
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| Figure 3. Selective-etching (enamel only) with a 40% etching gel (Onyx [Centrix Dental]) for 20 seconds. | Figure 4. The acid gel was rinsed off and dried to reveal the enamel with a frosty appearance. |
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| Figure 5. G-Premio BOND (GC America) was applied to all surfaces using a microbrush, then light-cured for 20 seconds. | Figure 6. G-ænial Sculpt (GC America) (shade A3) was applied incrementally, light-curing between layers, to return the tooth to its natural anatomical shape. |
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| Figure 7. The new restoration, prior to finishing and polishing, demonstrating a natural coloration compared with the unrestored canine. | Figure 8. A safe-tipped tapered carbide-finishing bur (Ultimate F&P Kit [GC America]) was utilized to refine the contours of the restoration. |
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| Figure 9. Final polishing was accomplished using a one-step diamond abrasive point (Ultimate F&P Kit) in a slow-speed handpiece. | Figure 10. The completed composite resin restoration with excellent marginal integrity and improved aesthetics. |
G-Premio BOND (GC America), a new universal 8th generation bonding agent, was applied with a microbrush to all enamel and dentin surfaces and left undisturbed for 10 seconds. This was followed by application of a light oil- and water-free air stream for 5 seconds to help evaporate any remaining solvent in the adhesive before light-curing for 20 seconds with an LED curing light (The Light 405 [GC America]) (Figure 5). The dentin, when finished, should have a glossy surface, indicating that ample adhesive is properly coating the surfaces to be bonded. (Should any areas be noted that are not glossy, a second coat of the adhesive is applied using the same protocol as described above.)
G-Premio BOND is compatible with total-etch, self-etch, and selective-etch techniques, providing excellent versatility for whichever technique the situation requires or the GP prefers.
A Mylar strip was placed interproximally on the mesial, and G-ænial Sculpt (GC America) (Shade A3), a compactable universal composite, was applied to form the new contact with the central incisor. The composite was placed from the uni-tip and adapted with a suitable instrument to cover the dentin and contact the Mylar strip (Figure 6). The composite material was then light-cured for 20 seconds. Additional increments were applied and shaped to reform the anatomy and to properly shape the lateral incisor, covering the entire facial surface for aesthetic purposes. Should any staining occur in the future due to the patient’s dietary habits, the margin between the composite and enamel is in a nonvisible area helping to hide any possible future color changes at the margins. Once full contour had been achieved, the Mylar strip was removed and the contact verified with floss to ensure that the new composite was making intimate contact with the adjacent tooth.
G-ænial Sculpt has a high radiopacity (> 300% Al), making identification of recurrent decay on recall radiographs easy. It also provides a strong, wear-resistant finished restoration with beautiful aesthetics. This composite has good body, allowing sculpting of anatomy without slumping prior to light-curing. In addition, the material exhibits very good surface adaption when placed against tooth structure. G-ænial Sculpt has uniform nanofiller dispersion technology providing high wear-resistance and long-term gloss retention. Available in 17 shades with opaque and translucent options, it can meet all aesthetic needs that may present clinically. As illustrated in this case, the “chameleon” effect provided by using a single-shade material allowed a natural blend matching the adjacent unrestored canine (Figure 7).
Finishing and polishing was initiated by minor refinement of the anatomy with a safe-ended, 12-bladed finishing carbide bur (Ultimate F&P Kit [GC America]) in a high-speed handpiece with water and a light touch on the composite material (Figure 8). Once the anatomy had been completed, final polishing was achieved using a one-step diamond-impregnated fine abrasive from the Ultimate F&P Kit in a low-speed handpiece to achieve a high gloss (Figure 9). These one-step polishers are available in a point, cup, and wheel (knife-edge) shape to accommodate whichever area of the tooth is being polished. The author recommends, if available in the practice, to utilize an electric low-speed handpiece with water, as this helps remove debris on the surface from the abrasive point. Furthermore, this suggested technique seems to yield a better gloss as compared to when an air-driven low-speed is used.
The final result for our patient was a natural-looking direct restoration that blended well with the adjacent natural unrestored tooth (Figure 10).
CLOSING COMMENTS
Direct restorations remain a fundamental part of the general restorative practice. With the recent improvements in composite resin systems, it is possible to achieve a consistent and predictable bond to both enamel and dentin. When combined with the newer nanocomposites that have improved handling and polishing characteristics, clinicians can now provide better and higher quality direct composite restorations in less time.
Dr. Kurtzman is in private general practice in Silver Spring, Md, and is a former assistant clinical professor at the University of Maryland, Baltimore School of Dentistry, Department of Endodontics, Prosthetics, and Operative Dentistry. He has lectured internationally on restorative dentistry; endodontics and implant surgery; prosthetics, removable and fixed prosthetics; and periodontics. Dentistry Today has named him one of the Leaders in Continuing Education annually since 2006. He can be reached at dr_kurtzman@maryland-implants.com.
Disclosure: Dr. Kurtzman received an honorarium from GC America for writing this article.
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