Just Take a Minute

Dental product marketing generally promotes ease, speed and cost savings as an advantage to change but we need to filter that information so that the techniques and products that we choose reflects our patients’ best interests. 

Chair time is the most valuable commodity in the dental office, thus taking time to review treatment protocols makes a lot of sense. However, balance between clinical efficiency and continuing to provide dentistry of the highest quality is critical to any change you consider. Most of us get locked into a technique that we simply accept as “works best in my hands”. If we take a minute to consider the challenges that we experience in our day-to-day dentistry, many can be solved with just a small change in the technique or product we use.

The anterior composite restoration continues to improve in both its esthetic potential and efficiency of placement. Each step of this procedure should be considered, as current research and techniques show capacity for significant improvement; in adhesion, getting the most out of your composite, and the development of a more effective finishing and polishing technique. Just take a minute to break down your anterior composite technique into its component parts. Evaluate each step to determine if there are some changes that can be made to improve both your efficiency and clinical result. 

Start by considering if your choice of phosphoric acid is the optimal strength and viscosity. Runnier H3PO4 gels tend to be more difficult to control during placement, leading to potential sensitivity. As well, many of us turned to self-etch adhesives due to postoperative sensitivity linked to the total-etch adhesive technique and “how wet is wet” dilemma. While there was far less sensitivity, I experienced some esthetic challenges. Occasionally, white lines appeared at the margin after polishing, and the formation of marginal staining was sometimes noted due to the inadequate pH of the self-etch adhesive. In hindsight, the bond strengths of the 4th and 5th generation or total-etch adhesives are considered the highest and most enduring, compared to the later generations. The simple addition of a glutaraldehyde-based desensitizer helps to solve the question of “how wet is wet”, as well as the post-operative sensitivity that is sometimes linked to the total-etch technique. Recent research into MMPs and their bond degrading activity makes it necessary to reconsider the choice of adhesive in its ability to inhibit their effect. The adhesive technique of choice should be easy to apply, universally compatible with all substrates and provide high, predictable bond strengths that are resistant to MMP degradation. Just take a minute and ask yourself if your adhesive choice satisfies these requirements.

Anterior preparations have generally required bevelling to hide the margin and blend the restoration into the surrounding tooth. Despite this, it was always disappointing to go through a strict anterior composite regimen and still see the margin after polishing. Some composite systems today can provide the range of shades and opacities/ translucencies that enable the dentist to more easily blend the restoration into the tooth with less layers. I remember the frustration of having composite stick to my instrument, resulting in pull-back or lifting off of the tooth when trying to thin out the margin of the restoration or adapting it into a preparation. Some of today’s composites allow for easy placement of an infinitely thin margin without any pull-back. Coated instruments, available in many tip forms and thicknesses, allow improved placement, adapting, and sculpting of the composite. Would a change in your composite material and instrumentation improve your technique efficiency and composite restoration? 

Finishing and polishing is one aspect of the technique whose importance is often overlooked. Many of us use discs for gross reduction, refining and final polishing. It is now possible to dispense with the finer grit discs and polishers of various shapes. Newer two-step, single shaped polishers produce an ultra high luster in less than a minute without degrading surface anatomy or diminishing the characterization of the restoration. Surface texture can be easily created by reducing the speed of a fine diamond and maintained with the right diamond polish. Take a minute to consider if your polishing regimen provides the efficiency as well as the flexibility to recreate form, texture, and luster of your anterior composites.

In order to desire an alteration in technique, it must be perceived that a change will better serve our patients. By just taking a minute to re-assess each step in your composite technique, perhaps you will discover that what you perceive as a challenge can be solved with just a little alteration to your technique. If not, you can remain confident that your approach is the best for you.

The traditional method of restoring existing Class IV composites, or replacing anterior tooth structure due to trauma, is to place and contour the composite by hand instrumentation.

If the length and lingual contour of the existing restoration is ideal, making a record of this preoperatively and using it as a template can greatly simplify the layering of dentin and enamel composite opacities and dramatically reduce the finishing time. In the case of trauma, simply mocking up the ideal lingual and incisal aspect using old or unwanted composite prior to making this lingual matrix will have the same effect. Fig. 1

Template® Ultra Quick MatrixMaterial from Clinician’s Choice is a silicone material designed to make highly detailed provisionals; however, its fast working and set times (30s and 30s), in addition to its accuracy, make it a perfect choice for this lingual matrix technique. Utilizing the Template lingual matrix technique dramatically reduces procedure time, provides the ideal lingual/embrasure contours, and leaves a pre-polished lingual surface.

Prevention of post-operative sensitivity is determined by the quality of the dentin/adhesive seal. Class I and II restorations are most prone to sensitivity due to the sheer size of the preparation as well as the number of adhesive walls involved. Ensuring your adhesive is properly applied and controlled so that all adhesive walls are sufficiently sealed is crucial. A properly applied adhesive obturates the dentin tubules which eliminates intra-tubular fluid pressure changes, preventing post-operative sensitivity. Utilizing a Glutaraldehyde-based desensitizer takes the guesswork out of dentin bonding by helping to obturate the dentin tubules before adhesive placement.

G5™ from Clinician’s Choice contains 5% Glutaraldehyde, HEMA, and water – the combination of which helps coagulate intra-tubular fluid proteins, resulting in a partial/initial dentin seal. Once G5 is applied, followed with MPa™ Max adhesive, together they create consistently high bond strengths and an ideal dentin seal to ensure the likelihood of postoperative pain is virtually eliminated. The use of G5 is not restricted to posterior restorations; it can be very effective in anterior restorations when dentin is exposed, as well as for desensitizing crown preps.