Real World Dentistry with the Bioclear 360 Veneer System

The New Bioclear 360° Veneer Matrix
The Bioclear Matrix System was launched in 2007 and became available in 2008 in Canada through early adoption by Clinical Research Dental (Toronto, Ontario). The Bioclear Matrix is popular for Class III composites, diastema closures, treating peg laterals, and black triangle elimination because of its myriad fully anatomic shapes. Additionally, its ultra-thin width (50 microns) allows a tight contact without heavy wedging pressure. Today the latest evolution is the Bioclear 360° Veneer Matrix System. It utilizes two (mesial and distal) anatomic matrices that literally snap into place and cling to the tooth. The Cling-Fit technology allows the matrix to slide deeply into the sulcus without bleeding, due to patent pending interproximal scallop (Fig. 1). It also features significantly stiffer polyester matrix (75 microns) that can surpass Stainless Steel matrices in terms of strength and stiffness. It can do things that metal cannot, such as glassy smooth surfaces and fully anatomic shapes, and light transmission for curing the composite. When the contacts are lightly sanded, a matrix placed on the mesial and the distal surrounds the tooth and for the first time allows true injection over-molding to not just veneer, but to completely surround the anterior tooth. It is not a replacement for the Bioclear matrix, but a new modality when the entire tooth needs to be reconstructed like a crown, without all of the grinding away of precious tooth structure and the lab costs of porcelain.

How can every day practices begin to do more esthetic dentistry?
Unlike most of the lecturers that show and perform a large number of esthetic cases, my practice is more of a blue-collar office. Only a small percentage of my local clientele arrives at my office asking for esthetic dentistry. I do have a large number dentists and patients who have done internet searches for the Bioclear method that fly into my west coast–Tacoma WA USA–office for esthetic dentistry but that is a subject I will cover in future articles. This case demonstrates how a new practice philosophy can allow dentists in every day “normal” practices to dramatically expand the role of esthetic dentistry in their practice without the cost and possible negative perceptions of a dentist who labels his or her practice as a “Cosmetic Dentistry Office”. In this case, the patient scheduled a new patient examination because her daughter Sarah is a new hygienist in my office. She simply wanted a cleaning, examination and a conscientious dentist. Esthetic reconstruction was not part of her perceived needs.

There are four requirements that we believe essential for every day practices that wish to integrate comprehensive esthetics into their routine:

1. Photography of every new patient. This doesn’t need to be a deal killer if you currently are not taking photographs. Most offices don’t do this because the doctor is busy. At the Bioclear Learning Center, we teach the staff and the doctors the basics of dental photography. I have finally relinquished control and my staff is taking most of the photographs. The auxiliary photos aren’t always perfect, but if I don’t give them a chance to practice, I will never free up my time by doing things the staff can’t do. In the case of Sarah’s mother, the photographs led to a conversation, which led to self-discovery. One tooth leads to two, and then to four, and suddenly we are talking about changing her smile, her face and her life.

2.  Learn the new role of composite overmolding using the Bioclear Matrix System and the new Bioclear 360° veneer/crown system. The system is only available as complete kit and after taking a necessary one-day course (Clinical Research Dental).

3. Train yourself by reading and doing, or take hands-on courses the Bioclear Learning Center in Tacoma or now in Toronto.

4. Adopt new language and that can lead to better patient decisions. And if your own teeth look beat up, it’s high time to fix that!

Case Presentation: (Figs. 2-28)
Sarah’s mom presented with the typical hodgepodge of natural teeth and an assortment of different vintage porcelain crowns. During her consultation, which in my office follows one week after her New Patient Examination, the patient had the opportunity to review her photographs, digital radiographs, and a short video captured through the Global dental microscope. We have found that patients are far more comfortable discussing their smile by pointing at images on a screen as opposed to pointing at their own teeth while holding a mirror. That patient phenomenon is described as emotional compartmentalization. Discussing unsightly teeth that are stained, worn, crowded, with crumbling fillings is embarrassing to most patients. In reality, seeing the photos on the screen is a reality-check that they can no longer pretend that their teeth are “ok”. Invariably the patients say, “I had no idea my teeth were so… (fill in the blank-dark, worn, ugly, mismatched filled, etc.)” This is the self-discovery part. I don’t aggressively “sell” esthetics. I don’t have to be pushy or appear anxious to extract money from their wallet. I am simply there to be their coach and facilitator. At first Sarah’s mom just wanted her old fillings on two incisors replaced. Eventually she realized that a comprehensive approach using the Bioclear method was her best choice. Porcelain and Pre-Prosthetic orthodontics were discussed. My fee for the Bioclear 360°Veneers is exactly half of my porcelain fee. The patient chose to skip orthodontics because it didn’t make sense to spend two to three years in orthodontics and then turn around and completely restore the teeth anyway. Porcelain and ortho were completely out of the question for financial reasons, as was replacing the crowns on 22 and 23. Doing the Bioclear veneers was just barely within her budget. A final note on adult orthodontics, I am advocating it less often than I have in the past for adults unless the patient specifically requests it once they arrive at 50 years of age. The morbidity of black triangles, recession, and mobility are definite negatives that are rarely a problem in adolescents. In truth, adult ortho is almost unrelated to adolescent ortho.

FIGURE 1. Bioclear 360° veneer matrix in several views. It is ideal for Maxillary Incisors and Canines. Note the notched gingival portion that will allow that matrix to seat up to 4 mm deeper than an ordinary piece of Mylar.

 
FIGURE 2. Pre-operative view of patient taken during the New Patient Examination Appointment.

FIGURE 3. Before and after view of the case. The Bioclear 360° Degree Veneer method and matrix system was used for teeth #’s 13, 12, 11 and 21. The heated composite used in this patient was Filtek Supreme Ultra Body Shade B-1 flowable and paste composite. It is truly monolithic, in other words no layering is needed or wanted in the modern esthetic composite overmolded tooth.

FIGURE 4. Smile pose reveals multiple esthetic dilemmas. “Slapping composite” on the facial of the tooth is a temporary partial fix that rarely serves the patient in a permanent, predictable and healthy way.

FIGURE 5. Oblique view highlights both the darkness and malposed dentition.

FIGURE 6. Side view is very telling in terms of the disharmony of the tooth position.

FIGURE 7. Left side view shows the existing porcelain crowns that had been recently placed by the patient’s previous dentist. The patient will eventually have these replaced as her budget allows, to match the B-1 Bioclear veneers to improve the esthetics.

FIGURE 8. Retracted pre-operative view.

FIGURE 9. Retracted pre-operative view with approximately 5mm of opening.

FIGURE 10. Occlusal view demonstrates that the Maxillary incisors will need significant addition to the facial aspect. Other than removal of old composite, blasting to remove Biofilm, and mild rounding of incisal edges to eliminate internal stresses in the composite, no tooth reduction is necessary there. The lateral incisor will need minor cutback only on the mesial half of the tooth.

The preoperative, mid treatment, and two-week post-operative photographs paint a partial picture of the Bioclear method. Details of the treatment: the best way to understand the process is to watch a four-minute video of the technique. It is posted on YouTube under Bioclearmatrix 360° Veneer. That video shows start to finish technique of a patient’s tooth #22 (left lateral incisor). In short, the grinding and sculpting of the intentional excess of composite in the injection zones (Mid facial, mid lingual and incisal) is relatively quick, safe and easy. The Bioclear Zone of smooth composite in the interproximal, line angles, and subgingival areas will require almost no finishing. The three-step polish technique is also on YouTube as Dr. Clark’s Three Step Composite Polish Technique and pre polish (See Table 1).

 Table  1. Injection Overmolded Composite Versus Freehand Layerred Composite

Composite Overmolding versus Porcelain
Composites have historically been considered inferior to porcelain veneering of teeth when significant portions of the tooth require reconstruction or augmentation. For reconstruction, we will define this term for purposes of the series of composite articles appearing in Oral Health Journal, as the removal of caries and defective restorations involving significant portions of the tooth. This may or may not include adding volume to a tooth to offset wear or to fill in areas to provide instant ortho or simply to bring the tooth forward for enhanced esthetics. Additive dentistry is a new term that clinicians should add to their lexicon and skill set. Injection overmolded composite with infinity edge margins typically have better soft tissue response than porcelain. Note that the patient’s marginal tissue health is pink and pretty compared to the puffy red margins around her crowns on 1-2 and 1-3.

FIGURE 11. Simple shade matching is done by placing the B-1 paste on the facial with at least 1mm of thickness, light cured and evaluated, then discarded.

FIGURE 12. It is critical to constantly hydrate the teeth during the shade match process so that dehydration driven lightening of the teeth does not occur. That artificial and temporary increase in the value (brightness) of the teeth will confuse both the doctor and patient.

FIGURE 13. The canine was restored first for logistical reasons. For the Direct 360° veneer method, each tooth is overmolded individually, and then reduced as needed in the loading (injection) zones with the coarse diamond and then the coarse disc. The teeth are left extra full (1mm) and extra-long (2mm) so they can be disked together in a comprehensive and careful way, similar to the way a ceramist will disk multiple crowns in the lab.

FIGURE 14. The mesial of the lateral has been reduced with the coarse diamond bur using copious water to protect overheating of the pulp. Once a small island of dentin is exposed, it is time to stop cutting the tooth, and plan to leave a slightly prominent mesial in the restoration. It will be barely noticeable and spares insult to the pulp, and an over-reliance on dentin bonding which is never an ideal long term interface.

FIGURE 15. The old composite has been removed from the right central incisor. The residual incisal edge, although it will eventually be buried deep inside of the composite, must be rounded to eliminate stresses inside of the yet to be injected composite.

FIGURE 16. The two Bioclear 360° veneers are fully seated after the contacts are lightly sanded (sanding not shown). The incisal tab has been trimmed away to allow better access to the mesial tab, which will allow the operator to gently leverage the mesial incisal embrasure toward left central incisor to achieve an appropriate long contact.

FIGURE 17. Once the 37 percent phosphoric acid is placed (20 seconds before rinsing) the fit and shape of these matrices can be fully appreciated.

FIGURE 18. Incisal view of the facial and lingual “vestiges (or affectionately referred to as belly buttons) are visible. This is certainly a new sight for dentistry, but a welcome one.

FIGURE 19. Facial view of the injection vestige. The instructions in the complete kit specify not to remove the vestiges before light curing. That could disturb the body of the composite with resultant. It is quickly chopped off with the diamond bur after light curing.

FIGURE 20. Lingual view of the injection vestige. It will be necessary to create a palatal concavity with the egg shaped 12-blade carbide bur.

Why Heated Composite is a Must, and Why it is so Safe
The dental world needs to wake up to the science of warmed, injectable paste composite paired with warmed flowable composite. First things first, is it safe to the pulp? The standard for heated composite is 155°F. At your next opportunity, take some heated composite and squirt it on your fingernail or your fingertip. It feels fine. That is because composite, unlike metal, is a poor conductor of heat. Conversely, steel or aluminum heated to 155°F will blister the skin with prolonged exposure. Next, take a high intensity LED curing light and hold it next to your skin. In three seconds, you will feel intense pain. That is why we must blow air between the light tip and the tooth after two seconds. Multiple studies have confirmed that heated composite is safe to the pulp. On the other hand, curing lights, polishing cups and points, and diamond burs impart ferociously high heat on the tooth and pulp. Worry about these three issues, not heated composite.

FIGURE 21. Rough sculpting and finishing is quickly finished before moving to the next tooth. The left central incisor is ready for disassembly of old composite and then over molding. One tooth at a time is the optimal approach so that landmarks are not lost and the case does not get out of control.

FIGURE 22. Two-week postoperative view. Like other traditional modalities such as porcelain laminates, a comprehensive approach yields a life changing transformation. We can fix some teeth, or if we go the distance we can alter the smile and the face and the life of our patients.

FIGURE 23. Oblique postoperative view. The restorations meet the fundamentals of Smile Design that are taught in our Bioclear Learning Center Courses.

FIGURE 24. Retracted postoperative view. The beauty of pink and white is readily apparent to the human eye. Note that the composite teeth have tissue that is healthier, pinker, and prettier.

FIGURE 25. Incisal thickness of overmolded composite that replace the incisal edge can be no thinner than 2 mm. At 2 mm, we are tracking hundreds of cases at five years and they are rivaling porcelain restorations for fracture resistance, as long as the restoration is monolithic without the gaps and seams of hand-stacked composite.

FIGURE 26. Full Face view of the completed case.

FIGURE 27. The Bioclear Heat Sync composite warmer. Liquefaction of paste and flowable composite is the heart of injection over molding.

Now, the why of heated composite: Once you have injected a creamy, heated nanofill composite such as Filtek Supreme Ultra into a Bioclear Matrix, you won’t go back to old fashioned composite. Composite manufacturers heat the composite to 190°F when they load the compule and syringes. Why? Because they don’t want voids. Do you want voids in your fillings? More than that, injecting a small amount of flowable, chased by injected heated paste into fully anatomic matrices is a complete game changer for many dentists. It’s hard to imagine how well it actually works until you try it for yourself.

Moreover, there was recent research showing that the Bioclear Method was significantly faster than the ‘Mylar Pull Technique and resulted in 100 percent of the samples with an ideal contact, versus only 80 percent with the Teflon technique.1

As the realities of current dental practice including insurance and patient’s financial restraints become paramount, the choices and results that can be officered by the Bioclear Matrix system will have a increasingly significant place in dentistry. Being competent in this technique will make the practitioner more in demand by the ever increasingly savvy consumer.

Disclosure

Dr. Clark is the creator of the Bioclear Matrix system and has a financial interest in this product.

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Dr. Clark founded the Academy of Microscope Enhanced Dentistry. He is a course director at the Newport Coast Oral Facial Institute and the Director of the Bioclear Learning Center in Tacoma WA.

Oral Health welcomes this original article.

References:

1. Kwon SR, Oyoyo U, Li Y. Influence of application techniques on contact formation and voids in anterior restorations. Oper Dent 2014 Mar-Apr;39(2):213-20

2. Clark DJ, Kim J. Optimizing gingival esthetics; a microscopic perspective. Oral Health 2005;116-126