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DIRECT APPLICATIONS OF A NANOCOMPOSITERESIN SYSTEM: PART 2PROCEDURES FOR

ANTERIOR RESTORATIONSDouglas A. Terry, DDS*

Pract Proced Aesthet Dent 2004;16(9):677-684 677

Nanocomposite resins allow clinicians to create restorations with improved

biocompatibility, function, and aesthetics. By ensuring that the patients condition

is clearly and thoroughly evaluated preoperatively, the clinician can develop nat-

ural, harmonious integration of the restorative material with the patients natural

tooth structures. The critical information captured during the initial visit can also

be used to ensure development of natural contours, light refraction, and charac-

terization. This article describes two anterior applications of a contemporary restora-

tive material for optimal results.

Learning Objectives:This article presents the restorative procedure for the restoration of Class III andClass IV defects. Upon reading this article, the reader should:

Recognize the clinical procedures involved in the direct restoration of anterior defects.

Understand the treatment rationale associated with nanocomposite systems.

Key Words: nanocomposite, anterior, resin, direct

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*Faculty member, UCLA Center for Esthetic Dentistry, Los Angeles, CA; private practice,Houston, Texas.

Douglas A. Terry, DDS, 12050 Beamer, Houston, TX 77089Tel: 281-481-3470 Fax: 281-481-0953 E-mail: [email protected]

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Preoperative considerations during the diagnostic and treatment planning phase are essential for the development of optimal functional and aestheticrestorations. This article presents two preoperative clinical protocols that should be considered before any restorative treatment is initiated. The first protocolis to define the color orientation, by which a preoper-ative selection of composite resins for the artificialdentin and artificial enamel shade and orientation isrecorded. Shade selection should be accomplished prior to rubber dam placement to prevent improper color matching as a result of dehydration and elevatedvalues.1 When teeth dehydrate, the air replaces thewater between the enamel rods and changes the refractive index, which makes the enamel appearopaque and white.2

The second protocol is to establish the occlusal confines, where the preoperative lingual contact zoneand excursive guiding ridges are recorded with articu-lation paper and transferred to a hand-drawn occlusaldiagram, recorded on an intraoral or digital camera, orindicated and reviewed on a stone model. The initialregistration is valuable in preparation design, when deter-mining placement of centric stops beyond or within theconfines of the restoration, and in minimizing finishingprocedures.3 In addition, since anatomical form definescolor, this occlusal evaluation can provide a more accu-rate anatomical morphological placement of the restora-tive material within the confines of the occlusalparameters, and thus reduce the finishing proceduresand increase the longevity of these directly placed composite restorations.

Restoration of Class IV FracturesA comprehensive clinical and radiographic examinationis first performed (Figure 1), and all goals for the treat-ment are determined. Once the patients expectationshave been discussed and a diagnosis has been reached,a definitive treatment plan is identified. When direct resinsare to be used for the restorations, composite shades areselected prior to rubber dam placement to preventimproper shade matching via tooth dehydration. Onceanesthesia is administered to the patient, the teeth areisolated to ensure adequate field control and protectionagainst contamination.4,5

Figure 2A. A 0.3-mmdeep, 2-mmlong chamfer was placed aroundthe entire margin. 2B. A scalloped bevel was placed on the chamferto break up its straight line.

Figure 3. Once the adhesive protocol was accomplished, the dentinlayer was built up with an A1-shaded nanoparticle hybrid compositeresin and a long-bladed composite instrument.

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Practical Procedures & AESTHETIC DENTISTRY

Figure 1. Case 1. Preoperative facial view of a fracture to a pre-existing Class IV composite restoration on the patients mandibularleft central incisor.

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For a Class IV fracture, a chamfer preparation(approximately 0.3 mm in depth) is placed around theentire margin to increase the enamel-adhesive surfaceand provide a sufficient bulk of material at the margins.6

Using a long, tapered diamond bur, a scalloped bevelshould be placed on the chamfer to break up the straightchamfer line. If the margin is confined to the enamel surface, a bevel of 0.5 mm should be placed on the gingival margin to reduce microleakage (Figure 2).7

The lingual aspect of the chamfer is extended 2 mm tothe lingual surface. The margin should not end on theocclusal contact area unless the operator is relocating itto a contact-free area that would require excessive reduc-tion of healthy tooth structure. The preparation is com-pleted with a finishing disk and polished with rubbercups that contain a premixed slurry of pumice and 2%chlorhexidine. The preparation is rinsed and lightly air-dried, and a soft metal strip is placed interproximally toisolate the prepared tooth from the adjacent dentition.

The total-etch technique is utilized for such fracturesdue to its ability to minimize the potential of micro-leakage and enhance bond strength to dentin andenamel.8-10 The preparation is etched for 15 secondswith 37.5% phosphoric acid semi-gel (eg, GEL-Etchant,Kerr/Sybron, Orange, CA), rinsed for 5 seconds, andgently air-dried for 5 seconds. A hydrophilic adhesiveagent (ie, Optibond Solo Plus, Kerr/Sybron, Orange,CA) is then applied for 20 seconds with a disposableapplicator using continuous motion, and excess resin isremoved prior to polymerization.

A small amount of glycerin is applied to the mesialsurface of the adjacent tooth with unwaxed floss. Thisproximal adaptation technique allows the author to opti-mally adapt composite resin to the adjacent tooth with-out using a mylar plastic strip interproximally. Althoughthe literature has indicated that a smooth surface canbe attained with a mylar strip,11 improper proximal adap-tation can result in inadequate contact, improper anatom-ical form and shape, or surface defects. The firstlayerthe artificial dentin bodyof nanoparticle hybridresin (eg, Premise, Kerr/Sybron, Orange CA; FiltekSupreme, 3M Espe, St. Paul, MN) is applied, adapted,and contoured to the proximal surface of the adjacentincisor with a long-bladed composite instrument andsmoothed with a sable brush (Figure 3). Each increment

Figure 4A. An elliptically shaped increment was added inciso-lingually and contoured. 4B. Vertical and horizontal invaginationswere placed, and the restoration was light cured.

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Figure 5. A diluted white tint was placed on specific regions of thetooth for chromatic integration.

Figure 6. A diluted gray tint was placed in the vertical invaginationsto create an illusion of translucency.

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is polymerized for 40 seconds, which allows place-ment of subsequent increments without fear of deformingthe underlying composite layer.

An elliptical-shaped increment of a nanoparticlehybrid composite is then placed from the incisolingualaspect and contoured to form an incisal matrix prior topolymerization from the facial and lingual aspect (Figure4). Since surface irregularities can interfere with the place-ment of tints required for internal characterization, thisstep is crucial. In order to prevent overbuilding of the arti-ficial dentin layer, it is imperative to monitor the com-posite from the incisal aspect to provide adequate spacefor the final artificial enamel layer.

A thin layer of resin can be applied and cured tocreate a light-diffusion layer and provide an illusion ofdepth for restorations of limited thickness. This translucentlayer will cause an internal diffusion of light and controlluminosity within the internal aspect of the restoration.12

As directed by the color map of the contralateral tooth,tints are placed along the fracture line and on specificregions in the vertical invaginations and light cured for40 seconds (Figures 5 and 6). This internal characteri-zation technique utilizes color variation to emphasize thetooth form and to instill the restoration with a three-dimensional effect. To re-create the natural translucencyof the enamel, the final enamel layer of composite resinis applied and contoured (Figure 7). A precut mylarstrip is placed and adapted over the facial surface andlight cured from the facial and the lingual aspects for 40-second intervals, respectively (Figure 8A).

The initial contouring is performed with a series offinishing burs in order to replicate natural form and tex-ture.13 The facial contouring is initiated with 30-fluted, needle-shaped burs (eg, 7714 BlueWHITE Diamond,Kerr/Sybron, Orange, CA; T & F Needle, Midwest Burs,Cedar Rapids, IA) (Figure 8B). The lingual surfaces arecontoured with 30-fluted football-shaped burs. Finishingthe proximal, facial, and incisal angles is performed withaluminum oxide disks and finishing strips. These are usedsequentially according to grit and range from coarse to extra fine. Finishing burs, diamonds, rubber wheels,and points are used to create indentations, lobes, andridges (Figure 9). A soft goat-hair brush is used with com-posite polishing paste to impart a high luster for the

Figure 8A. A precut mylar strip was placed and adapted over thefacial surface and light cured. 8B. Facial contouring was performedwith fluted, needle-shaped finishing burs.

Figure 9. The final polish was initiated with silicone rubber points toeliminate surface defects while accentuating developmental lobes inthe definitive restoration.

Figure 7. A layer of clear, translucent-shaded hybrid composite(Premise, Kerr/Sybron, Orange, CA) was applied and contouredwith a long-bladed composite instrument.

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restoration while maintaining its existing texture and surface anatomy. The final surface gloss is achieved witha dry cotton buff using an intermittent staccato motionapplied at conventional speed (Figure 10).

Performing a Class III RestorationAs with any restorative procedure, the Class III restora-tion is initiated after the completion of all preoperativeevaluations, diagnosis, and treatment planning (Figure11). Once occlusal evaluation and shade determinationare performed and anesthesia is administered, the treat-ment site is isolated. Any defective restorations or cariesare removed, and a bevel preparation is completed tofacilitate resin adaptation (Figure 12). The outline form

should be as conservative as possible without removinghealthy tooth structure unless dictated by caries. Theocclusal outline is extended to include carious enamel,provide access to the carious dentin, remove any resid-ual staining, and provide access for the application ofrestorative materials. Sufficient composite retention will beachieved primarily by micromechanical adhesion to thesurrounding enamel and underlying dentin, and it is notnecessary to produce an undercut in the preparation.14

An enamel bevel is used to increase the surfacearea available for etching of the enamel rods, thus result-ing in a stronger enamel-to-resin bond and increasingthe retention of the restoration, reducing marginal leak-age, and limiting marginal discoloration.14-16 While place-ment of a cavosurface bevel improves the aestheticintegration of restorative material with the colors of thesurrounding tooth structure,14 the cavosurface should notbe beveled if little or no enamel is present or access isdifficult for finishing procedures. A gingival bevel is notrecommended if the preparation extends gingivally toroot structure or is of poor enamel quality. In addition,bevels are not placed on lingual surface margins thatare in areas of centric contact or subjected to heavyocclusal forces, because composite has a lower wearresistance than enamel for withstanding heavy occlusalforces.14 Thus, beveling should be restricted to the gingival and proximal margins, where there is enamelpresent to increase the potential for bonding. Thisincreases the fracture resistance by increasing the bulkof the restoration, increasing the bonding surface

Figure 11. Case 2. Lingual appearance of a defective composite resinrestoration with discoloration and recurrent caries. Note the cavitysilhouette of this Class III restoration.

Figure 12. The cavosurface bevel is placed in enamel to increasefracture resistance and bonding surface area while reducing mar-ginal leakage and discoloration.

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Figure 10. Postoperative appearance of the restoration revealed thecontinuity that can be achieved between natural tooth structure anda nanoparticle hybrid resin.


area, and decreasing microleakage and marginal discoloration17 by exposing the enamel rods for etch-ing.16-18 The completed preparation is cleaned with a 2%chlorhexidine solution, rinsed, and lightly air-dried.

Treating a Class III restoration requires the illusionof light reflection since composites do not have hydroxy-apatite crystals, enamel rods, and dentinal tubules.Therefore, in recreating the proximal surface, a similarorientation of enamel and dentin is required. Since a sil-houette of the cavity form is highlighted by the darknessof the oral cavity (often described as shine through),an opacious dentin replacement with a higher color saturation should be selected so when light strikes theoptically denser dentin with more color saturation, more

light is reflected. To reproduce the optical effects of theenamel, a translucent composite encapsulates the innerdentin core and alters the quantity and quality of the lightas it is reflected.

The restoration of the proximal surface of the ante-rior tooth depends on the surfaces involved; if three sur-faces are involved, the access requires a facial approach.A two-surface restoration, however, generally allows alingual approach. This situation can often be treated uti-lizing the proximal adaptation technique as describedpreviously. This technique replaces tooth structure from theperiphery toward the center of the cavity and should beutilized when the gingival margins terminate in enamel.19,20

After glycerin is applied with unwaxed floss, an initial increment of nanoparticle hybrid resin is placedin the proximal region and shaped (Figure 13A). Eachincrement is individually light-cured from the gingivo-lingual and the gingivo-facial aspect for 40 seconds.Since the first increment is light-cured toward the gingi-val aspect, the restorative material will shrink towardthe cervical margin, improving marginal adaptation.Successive increments of microhybrid composite resinare placed, shaped, and smoothed against the proxi-mal surface of the adjacent central incisor from the gin-gival floor to the marginal ridge, creating a three-dimensional translucent envelope while each incrementis individually light-cured from the facial and lingualaspects (Figure 13B). This translucent envelope layer doesnot contact the pulpoaxial walls and polymerization isnot conducted from the occlusal direction, therefore there

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Figure 13A. A nanoparticle hybrid composite is adapted to the mar-gins and light cured. 13B. Successive increments are placed to createa three-dimensional envelope.

Figure 14. An infinitesimal amount of flowable composite was injectedand uniformly distributed with a round ball tipped instrument.

Figure 15A. The dentin core is replaced with an opacious nano-particle hybrid composite (Premise, Kerr/Sybron, Orange, CA). 15B. Each increment is condensed and shaped.

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is less propensity for contraction toward this wall andaway from the cervical during polymerization.20-22 Sincethe curing light is directed toward the gingival aspect,the first composite increment shrinks toward the cervicalmargin, enhancing marginal adaptation.22,23 Once theperipheral composite envelope is developed, the prepa-ration can be treated as an occlusal preparation.

A flowable composite is carefully injected into thispreparation and uniformly distributed with a round ball-tipped instrument (Figure 14). This reduces the potential airbubbles and ensures optimal adaptation of the resin mate-rial to the adhesive interface. A small, 1-mm-thick incrementis applied to the gingival floor of the proximal preparationand light cured for 40 seconds.

The cavity preparation is layered using an opaciousnanoparticle hybrid composite and adapted to the underlying resin and tooth structure. Each increment islight cured for 40 seconds. This process is repeated withsuccessive increments of composite to form an internaldentin core (Figure 15). To reduce the possibility of cus-pal flexure, a composite hybrid with a low volumetricpolymerization shrinkage should be selected accord-ingly.24 The potential for cuspal flexure can also be min-imized through the diagonal layering of the resin in 1-mmincrements, which can then be feathered up the cavitywall in a V shape.19,25 Opposing enamel walls shouldnot be contacted by the same increment in order to minimize the wall-to-wall shrinkage and thus reduce intercuspal stress.26,27 The application of the compositein oblique layers results in fewer contraction gaps at

the margins. The resin is then condensed, shaped to replicate the natural anatomy of the dentin layer, andpolymerized for 40 seconds.

The artificial enamel layer is the principal deter-minant of the value of the tooth or the restoration,28 andthis can be varied by the thickness of this layer. A clear-or translucent-shaded hybrid composite is thus selectedand sculpted prior to the placement of a precut mylarstrip. As outlined above, this strip is adapted over thelingual surface and light cured from the facial and thelingual aspects for 40-second intervals, respectively(Figure 16). Developing the restoration in incrementsand considering the occlusal morphology and occlusalstops minimizes finishing procedures and results in

Figure 18. The postoperative view demonstrates the aesthetic resultsachieved by layering artificial dentin and enamel layers similar to theanatomy of the natural tooth.

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Figure 16A. The final translucent layer of composite is placed overthe opacious core and contoured. 16B. A precut mylar strip is placedand adapted over the lingual surface and light cured.

Figure 17A. Finishing is first accomplished with a 30-m egg-shapeddiamond bur. 17B. The definitive polish is accomplished with a sili-cone carbide-impregnated brush.

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a restoration with improved physical and mechanical characteristics and a reduced potential for microfracture.

Once the final layer of composite is placed (andprior to final curing), an oxygen-inhibiting glycerin isapplied in a thin layer to the surface of the restorationand light cured for 60 seconds from the facial and lingual aspect. The restoration is then contoured and finished to proper morphology and luster (Figure 17).29,30

After the initial finishing procedure and before final pol-ishing, the margins and surface defects are sealed. All accessible margins are etched with a 37.5% phos-phoric acid semi-gel, rinsed, and dried. A composite surface sealant is applied and cured to seal any cracksor microscopic porosities that may form during the finishing procedures.

The contact is tested with unwaxed floss to bothensure the absence of sealant in the contact zone andto verify adequate contact. The absence of a gingivaloverhang is also noted, and the margins are inspected.The rubber dam is removed, and the patient is asked toperform closure without force and then centric, protru-sive, and lateral excursions. Any necessary occlusal equilibration is accomplished, and the final polish is rendered (Figure 18).

ConclusionAdvancements in dental material research and adhesivetechnology have yielded direct bonding techniques thatallow preservation of remaining tooth structure and con-servation of tooth structure during preparationall whilereinforcing the remaining tooth structure and improving thelongevity and aesthetics of the restoration. In these casepresentations, composite layering techniques are combinedwith accurate anatomical morphological placement ofrestorative materials to minimize the finishing protocoland thus may increase the longevity of these directly placedcomposite restorations. Utilizing these restorative methods,direct composite resin restorations continue to be an effacious means for developing various anterior conditions.

AcknowledgmentPortions of this presentation have been adapted withpermission from Douglas A. Terry, DDS. NaturalAesthetics With Composite Resin. 2004. MontageMedia Corporation.

References1. Fahl N Jr, Denehy GE, Jackson RD. Protocol for predictable restora-

tion of anterior teeth with composite resins. Pract Periodont AesthetDent 1995;7(8):13-21.

2. Winter R. Visualizing the natural dentition. J Esthet Dent1993;5(3):103-116.

3. Liebenberg WH. Successive cusp build-up: An improved place-ment technique for posterior direct resin restorations. J CanadDent Assoc 1996;62(6):501-507.

4. Croll TP. Alternative methods for use of the rubber dam. Quint Int1985;16:387-392.

5. Liebenberg WH. General field isolation and the cementation ofindirect restorations: Part 1. J Dent Assoc South Afr1994;49(7):349-353.

6. Bichacho N. Direct composite resin restorations of the anteriorsingle tooth: Clinical implications and practical applications UnitalCompendi 1996;17(8):796-801.

7. Miller M. The Techniques: Class IV Direct Restorations. In: Reality.Houston, Texas; 13th ed., Reality Publishing;1999: 118.

8. Kanca J III. Improving bond strength through etching of dentinand bonding to wet dentin surfaces. J Am Dent Assoc1992;123:35-43.

9. Nakabayash N, Nakamura M, Yasuda N. Hybrid layer as adentin-bonding mechanism. J Esthet Dent 1991;3(4):133-138.

10. Kanca J III. Resin bonding to wet substrate. II. Bonding to enamel.Quint Int 1992;23(9):625-627.

11. Chung K. Effects of finishing and polishing procedures on sur-face texture of resin composites. Dent Mater 1994;10:325-330.

12. Vanini L. Light and color in anterior composite restorations. PractPeriodont Aesthet Dent 1996;8(7):673-682.

13. Dietschi D. Free-hand composite resin restorations: A key to ante-rior aesthetics. Pract Periodont Aesthet Dent 1995;7(7):15-25.

14. Sturdevant CM. Class III, IV, and V direct composite and othertooth-colored restorations. In: The Art and Science of OperativeDentistry. 4th ed. St. Louis, MI: Mosby 2002:490-536.

15. Oilo G, Jorgenson KD. Effect of beveling on the occurrences offractures in enamel surrounding composite resin fillings. J OralRehab 1977;4:305.

16. Lorton L, Brady J. Criteria for successful composite resin restora-tions. Gen Dent 1981;29(3):234-236.

17. Welk DA, Laswell HR. Rationale for designing cavity prepara-tions in light of current knowledge and technology. Dent ClinNorth Am 1976;20(2):231.

18. Craig RG. Restorative Dental Materials, 11th ed. St. Louis, MO:Mosby, 2001.

19. Eakle WS, Ito RK. Effect of insertion technique on microleakagein mesio-occlusodistal composite resin restorations. Quint Int1990;21(5):369-374.

20. Szep S, Frank H, Kenzel B, et al. Comparative study of com-posite resin placement: Centripetal buildup versus incrementaltechnique. Pract Proced Aesthet Dent 2001;13(3):243-250.

21. Lutz F, Krejei I, Luescher B, Oldenburg TR. Improved proximalmargin adaptation of Class II composite resin restorations byuse of light-reflecting wedges. Quint Int 1986;17(10):659-664.

22. Cheung GS. Reducing marginal leakage of posterior compositeresin restorations: A review of clinical techniques. J Prosthet Dent1990;63(3):286-288.

23. Lambrechts P, Braem M, Vanherle G. Evaluation of clinical per-formance for posterior composite resins and dentin adhesives.Oper Dent 1987;12(2):53-78.

24. Rees JS, Jacobsen PH. Restoration of posterior teeth with com-posite resin. 1: Direct -placement composite. Dent Update1996;23(10):406-410.

25. Duke ES. Direct posterior composites. IDA J 1993;72(5):35-39.26. Wieczkowski G, Joynt RB, Klockowski R, Davis EL. Effects of incre-

mental versus bulk fill technique on resistance to cuspal fractureof teeth restored with posterior composites. J Prosthet Dent1988;60(3):283-287.

27. Hansen EK. Effect of cavity depth and application technique onmarginal adaptation of resins in dental cavities. J Dent Res1986;65(11):1319-1321.

28. Muia PJ. Esthetic Restorations: Improved Dentist-LaboratoryCommunication. Carol Stream, IL: Quintessence Publishing;1993:86-87.

29. Jefferies SR, Barkmerier M, Gwinnett AJ. Three composite finish-ing systems: A multisite in vitro evaluation. J Esthet Dent1992;4(6):181-185.

30. Goldstein RE. Finishing of composites and laminates. Dent ClinNorth Am 1999;33(2):305-318.

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1. Shade selection should be accomplished prior to rubberdam placement to:a. Allow for proper fit of restorations.b. Prevent improper color matching.c. Achieve adequate fit.d. None of the above.

2. When teeth dehydrate:a. The air replaces the water between the enamel rods.b. The refractive index is changed.c. The enamel appears opaque and white.d. All of the above.

3. In the aforementioned case, the total etch techniquewas used because it has the ability to:a. Minimize the potential of microleakage.b. Enhance bond strength.c. Both a and b.d. Neither a nor b.

4. Monitoring the composite from the incisal aspect to provide adequate space for the final artificial enamellayer is important because it:a. Prevents surface irregularities from interfering with

placement of tints.b. Avoids adverse periodontal sequellae.c. Prevents overbuilding of the dentin layer.d. Controls luminosity.

5. An enamel bevel increases the surface area for end-onetching of enamel rods, resulting in a stronger enamel toresin bond. A stronger enamel to resin bond decreasesthe retention of the restoration, marginal leakage, andmarginal discoloration.a. The first statement is true and the second statement

is false.b. The first statement is false and the second statement

is true.c. Both statements are true.d. Both statements are false.

6. A rubber dam was used in the Class IV restoration forthe following reasons except to:a. Isolate the teeth.b. Prevent dehydration.c. Achieve adequate field control.d. Protect against contamination.

7. The Proximal Adaptation Technique:a. Replaces tooth structure from the periphery toward the

center of the cavity.b. Decreases the number of times microleakage occurs, in

comparison to cementum.c. Should be utilized when the gingival margins terminate

in enamel.d. All of the above.

8. The nanocomposite hybrid used in the Class IIIRestoration had four translucent shades. They includedclear, superclear:a. White, and superwhite.b. White, and pearl.c. Amber, and grey.d. Yellow, and pearl.

9. In the second case presented, an A-3.5 shaded flowablecomposite was injected as the syringe tip was slowlyremoved, and uniformly distributed with a round ball-tipped instrument. This technique:a. Reduces the possibility of cuspal flexure.b. Ensures optimal adaptation of the resin material to the

adhesive interface.c. Replicates natural form and texture.d. All of the above.

10. Initial contouring was performed with a series of finishing burs in order to:a. Replicate natural form and texture.b. Impart a high luster and maintain texture and

surface anatomy.c. Both a and b.d. Neither a nor b.

To submit your CE Exercise answers, please use the answer sheet found within the CE Editorial Section of this issue and complete as follows:

1) Identify the article; 2) Place an X in the appropriate box for each question of each exercise; 3) Clip answer sheet from the page and mail

it to the CE Department at Montage Media Corporation. For further instructions, please refer to the CE Editorial Section.

The 10 multiple-choice questions for this Continuing Education (CE) exercise are based on the article Direct Applications of a Nanocomposite

Resin System: Part 2Procedures for Anterior Restorations by Douglas A. Terry, DDS. This article is on pages 677-684.

CONTINUING EDUCATION(CE) EXERCISE NO. 25

CECONTINUING EDUCATION25

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