I see some patients who desire a beautiful smile and others who are not overly concerned with the appearance of their teeth as long as they are healthy and function well. Some patients are on a tight budget and others don’t have a budget. While many patients have insurance, they are choosing to come to an office that is not on their plan (we are not members of any insurance plans). Despite these circumstances, all of the long-term patients in the practice share a goal of keeping their teeth into old age, something that I call “getting to 90 with your teeth.” This concept is not forced on patients, but it is explored. For patients who value the concept, we know that we should address their current treatment needs as well as keep an eye to the future, offering them more proactive care and strong preventive concepts.
Getting to 90 with our teeth starts with a comprehensive examination to determine the condition of the teeth, occlusion, soft tissues, periodontum and TMJ. I am evaluating the patients existing condition as well as looking for warning signs of future problems. Esthetics also becomes part of the dialogue with the patient. Does he or she like their smile? If we have treatment needs in the esthetic zone, has the patient ever thought about whitening? I feel that a crown or composite restoration should be natural and esthetic looking regardless of whether we are using B1 or A5.
When I see signs that reflect a long-term risk to a patient, I ask myself if there is anything we or the patient can do to change their likely future. For someone with early periodontal disease, it may be scaling and root planning followed by a shorter cleaning interval and homecare coaching. For new decay, it may be diet counseling, higher fluoride toothpaste, in-office fluoride treatments and the use of xylitol chewing gum. For broken teeth we may explore the condition of intact teeth to evaluate their risk. Always, we need to think about the etiology of the problem and we need to have a full grasp of preventive products as well as restorative dental techniques and materials. When given the opportunity, many patients will make intelligent choices to avoid certain problems that they are prone to. Still, not every patient chooses proactive care. For those patients, a failure can cause them to reevaluate their choices.
In this particular case, a 64-year-old female visited my practice after fracturing off a piece of incisal edge from no. 11 while eating (Figure 1). She had been a patient for more than 23 years and had been seen by four different periodontists during that time. While she had no health complications, her dental health history indicated issues that contributed to the incisal edge fracture. Her teeth exhibited many superficial enamel craze lines and cracking, excessive wear on the incisal edges, lingual incisal exposed dentin, thin facial incisal enamel and a weakened incisal edge. Additionally, she had a tight class I occlusion with a deep overbite, as well as crowding of the lower front teeth. The fractured tooth was lingually positioned, resulting in early and excessive contact when the patient advanced their jaw or chewed food.
Over a 20 year period, two different periodontists and I had recommended bite splint therapy, as well as orthodontic treatment, all of which the patient chose against. She was happy overall with her teeth but did have concerns about their rough edges. We explained that the edges were due to her tight bite and that while we could smooth them or do veneers, orthodontic treatment to realign her bite would be a better long term solution.
When the chip on no. 11 occurred, I discussed the various treatment options available to her. These included bonding to move the incisal edge to the facial, creating a similar result using porcelain veneers, or simply repairing the damage but also implementing orthodontic treatment. This treatment was the ideal option when paired with the use of a night guard to reduce the impact of the bite and recontour the edges. In the end, the patient opted for the simple composite repair, along with an orthodontic referral. The fracture helped the patient see her future and she didn’t like it. Getting to 90 was still 26 years away and she realized that her teeth needed a little more attention if she wanted them to stay healthy and attractive.
To begin the bonding procedure, a quick prep with a Brassler 8875K red stripe diamond was done to create a bevel on enamel and removal of enamel with microfractures along the edge of the fracture. The bevel enhances bond strength and makes it easier to blend the composite with the tooth. I reviewed the shade guide and chose the new 3M™ ESPE™ Filtek™ Supreme Ultra Universal Restorative shades A1 Body and A2 Body to accommodate for the variance in color of the tooth (Figure 2). Next, enamel margins were etched for 10 seconds, rinsed and dried lightly (Figure 3). The enamel etch was extended beyond the bevels, but did not extend onto the dentin, since Easy Bond achieves optimum bond strength to dentin without a supplemental etch. 3M™ ESPE™ Adper™ Easy Bond Self-Etch Adhesive was then applied for 20 seconds (Figures 4a and 4b respectively), air thinned for 5 seconds and then light cured for 5 seconds with the 3M™ ESPE™ Elipar™ S10 Curing Light (Figure 5). We chose Easy Bond because it’s very simple, very quick and develops excellent bond strength.
The A2 Body was placed in most of the defect, as well as on the lingual and incisal edge. I take the time to carefully adapt and sculpt the composite before I cure it. This time translates into less finishing time later. The A2 layer was left slightly undercontoured on the facial, leaving room a layer of A1 body. It was then cured for 5 seconds using the Elipar S10. I like to do multiple layers, so being able to do a quick 5 second cure and knowing I’m giving adequate light for thin layers is a great benefit to me. The S10 curing light facilitates this technique by offering a more powerful cure than the Freelight 2. After the A2 Body increment, A1 Body was used to establish the correct shade and contour. The Elipar S10 was used for 10 seconds followed by 3M™ ESPE™ Sof-Lex™ Contouring and Polishing Discs. Finally, a Cosmedent felt backed flexibuff disk with polishing paste was used to finish the restoration (Figure 6). The patient was amazed that her tooth could be made to look undamaged in such a short amount of time.
The final restoration was successful and gave the patient a pleasing outcome with use of the new Filtek™ Supreme Ultra Universal Restorative as the composite to repair her fracture. Prior to introduction of the entire Filtek line of restoratives, I used six different brands of composite to get the mix of the properties and shades that I wanted to utilize in my practice. Once Filtek Supreme was introduced, I discontinued using all of my previous composites. I have successfully used this product line to accommodate even the most demanding clinical restorations.
As a longtime user of this material, I have become very familiar with its properties, and the most recent advances have made it more clinically useful and beneficial to patients than ever before. This is a simple product to use and offers improved handling characteristics, improved fluorescence and improved polish. I have been an advocate of using multiple shades of composite for many years and the Supreme line of composites can handle the most complex situations. The included shade wheel is designed to help dentists choose the best formulas for 2 or 4 shade layering of supported and unsupported restorations. On the other hand, I have found myself doing more single shade restorations with Supreme Ultra and the results are stunning.
d of Difference
Clinical experience has shown that the use of nanoparticles in a composite does not automatically guarantee a strong performance from the restorative. The manner in which the nanoparticles are incorporated into the product plays a significant role in how the material performs, both in the office and over time in the patient’s mouth. As the only true nanocomposites available, 3M ESPE’s Filtek Supreme line of restoratives are created using both individual nanoparticles and clusters of these particles, termed nanoclusters-a combination that gives the material several unique characteristics. The restorative’s nanoclusters are lightly sintered, allowing them to cleave during the wear process. This property allows the restoration to retain its polish over time, since individual nanometer sized particles can cleave off the clusters without affecting the overall appearance of the restoration. Hybrid restoratives, on the other hand, use both hybrid filler particles with nanoparticles or fumed silica. When these materials are subjected to wear, large particles can be plucked from the matrix, dulling the restoration’s polish (Figures 7a and 7b).
As an alternative to hybrid restoratives, microfill composites are also known for their polish retention, but are often compromised in terms of strength. The bond between a microfill’s resin matrix and the prepolymerized “organic filler” matrix creates a weak link for these materials. Evidence shows that microfills are subject to fracture under stress and fatigue along lines between these particles.1 They have also been shown to break down marginally under occlusal loading more than hybrid composites.2
A nanocomposite material is able to offer both the polish of a microfill with the strength of a hybrid. No prepolymerized filler is used in this material, and its filler loading is higher than that of typical microfills, which results in greater strength. The material’s high filler loading and advanced resin matrix enables outstanding compressive strength, flexural strength, diametral strength and fracture toughness. Delivering the strength required in posterior regions combined with the esthetics desired for anterior treatments are what truly makes the product truly universal. The result is a product that offers the strength of a hybrid, polish that is better than a microfill, 5-year wear that approaches enamel, and enough shades and opacity/translucency choices to satisfy every situation.
My advice to other professionals is to look beyond the immediate needs of your patients -all the way to 90 years-and then give your best possible recommendations on maintaining and improving their oral health. Patients will not always accept your treatment counsel, but still strive to see the signs present for needed treatment, and recommend preventive measures that may reduce the need for future treatment, make future treatment less extensive, or increase their odds of remaining healthy. Patients appreciate it when we try to help them avoid costly damage to their teeth, which translate into healthy referrals. And if these patients do need your skill to restore a tooth, a quadrant or an entire mouth, they are much more likely to trust your recommendations.
Dr. Grant Chyz graduated from University of Michigan in 1983. He has maintained a private practice in downtown Seattle since 1986. He can be reached at drchyz@chyz.com.
Oral Health welcomes this original article.
1. Drummond, JL, “Cyclic fatigue of composite restorative materials,” J Oral Rehab, 16, 509-20(1989).
2. Ferracane JL, Condon JR, “In vitro evaluation of the marginal degradation of dental composites under simulated occlusal loading,” Dent Mat, 15, 262-7(1999).
