Dr. Parag R. Kachalia

	In the following two cases, learn how many dental products worked together to help two dental patients have their problems solved.

	Included in the products used is a posterior composite, 

. To learn more about predictably placing posterior composites, 

	Patient presented with recurrent caries in the distal box form of tooth No. 13 and new approximal caries on the distal of tooth No. 12. After consultation with the patient, a decision was made to remove the existing restoration and caries and place direct restorations.

	After administering anesthesia, the teeth were isolated utilizing a rubber dam. After complete caries excavation, the teeth were restored one at a time in order to achieve proper anatomical proximal contact. The system used was a sectional matrix (

. The deepest portion of each preparation was then measured, and both were found to be inside of 5mm. This finding allows one increment of the SonicFill A3 composite to be placed. After utilizing a total etch protocol and fifth-generation adhesive (Optibond Solo+), a single increment of SonicFill composite was placed, sculpted and fully cured utilizing a 

	To achieve thorough polymerization, the restoration was initially cured for 20 seconds from the occlusal surface as well as 20 seconds from both the buccal and lingual surfaces after removing the sectional matrices. After removing the rubber dam, minor contouring was completed utilizing a 16-fluted carbide composite finishing bur (

). The restoration was polished utilizing a three-step silicone-impregnated rubber point system (

New product alert: Learn more about Maxcem Elite Chroma

	Patient presented with recurrent caries in the mesial and distal box form of tooth No. 30, and the adjacent teeth presented with clinically acceptable restorations.

	The patient was informed the new restoration would be fairly large in size and the patient should consider an indirect restoration to minimize the chance of cuspal flexure and fracture. Taking into account the risks, benefits and alternatives, the patient decided to have a direct restoration placed. After administering anesthesia, the teeth were isolated utilizing a rubber dam. Upon complete caries excavation, the prepared surfaces were matrixed to allow for a properly contoured restoration to be placed. The system used was the V3 Matrix, the Wave-Wedge wedge and 

	The deepest portion of the preparation was then measured, and both were found to be inside of 5mm. This finding allows one increment of the SonicFill 2 composite to be placed. After utilizing a total-etch protocol and fifth-generation adhesive (Optibond Solo+), a single increment of SonicFill 2 composite was placed, sculpted and then fully cured utilizing a DemiUltra LED curing light.

	To predictably achieve thorough polymerization, the restoration was initially cured for 20 seconds from the occlusal surface as well as 20 seconds from both the buccal and lingual surfaces after removing the sectional matrices. After removing the rubber dam, minor contouring was completed utilizing a 16-fluted carbide composite finishing bur (ET Series [Brasseler USA]). The restoration was polished utilizing a three-step silicone-impregnated rubber point system, Ultradent’s Jiffy Polishers.

Related reading: Why you should consider Kerr's Demi Ultra curing light

	Watch the technique video below for more information...

Articles

In this how-to dental technique, Dr. Parag Kachalia shows dentists in video and text form how he used posterior composites to help two patients.

Technique: How posterior composites made a difference in two cases

	In the days of G.V. Black dentistry, the watch-and-wait approach actually had a tremendous amount of merit. Clinicians, at times, were able to diagnose caries at an early stage; however, preparation form for amalgam restorations did not lend itself to conservative dentistry.

	Even if caries was diagnosed at an early stage, a significant amount of tooth structure would need to be removed simply to retain these restorations. In the last decade, numerous technologies have come to market, allowing practitioners to discover caries at the early stage, and the practitioner now has the ability to treat this disease through remineralization protocols or minimally invasive surgical intervention.

More from Microcopy: How to extract teeth as atraumatically as possible

	If a practitioner chooses to remove the caries surgically from the tooth, he or she must focus on creating a conservative preparation form and maintaining as much tooth structure as possible. Resin restorations do not require specific preparation parameters, and the goal with these restorations is simply to remove the decay. In the past, the bur of choice for operative preparations was a 557 or 330 bur. While decay can most definitely be removed with these burs, unfortunately an extensive amount of healthy tooth structure is also unnecessarily removed due to the relative large size of these burs. In this day and age, one must consider using the smallest instrument possible. Hard-tissue lasers and air-abrasion units can offer a conservative means for caries removal; however, these devices require a large-to-moderate investment in equipment, and the workflow can become more complicated than necessary. 

	A simpler solution may be to simply opt for innovative and cost-efficient smaller burs that have been designed for conservative restorations. These burs tend to have appropriate cutting efficiency yet they are nearly 70 percent smaller than traditional operative burs.  

	One particular bur that accomplishes this task is the 1300 FS bur by 

. It is a diamond-coated bur with a tapering cutting surface. This shape allows for conservative excavation of a carious lesion at the tip of the bur while creating a funnel effect as caries is removed with deeper bur penetration. 

	The small tip diameter allows for minimal preparations to occur many times without the need for pulpal anesthesia.  In addition, the funneling effect allows proper visualization while creating a path for proper adhesive and flowable resin placement. Flowable composites have improved drastically in the last few years, and many flowable composites now have physical properties that rival traditional hybrid composites just a few years ago.

More from Microcopy: Microcopy introduces NeoDrys "Pink to Make You Think" campaign

	In the clinical case depicted, the patient presented with occlusal caries on the lower left second bicuspid. The primary carious lesion was centered in the distal pit with early caries present in the mesial pit (

	The decay is removed in both the distal pit and the mesial pit areas with no anesthesia while utilizing a 1300 FS bur. 

	After caries removal and proper isolation (Isolite Systems), the tooth is restored with a highly filled flowable composite (G-aenial Universal Flow, 

		The patient was happy the carious tooth was restored in an efficient manner with zero discomfort and that a vast majority of healthy tooth structure was maintained (

		The combination of innovations in rotary instrumentation and resin materials allows clinicians to provide minimal intervention with maximum effectiveness.

In the days of G.V. Black dentistry, the watch-and-wait approach actually had a tremendous amount of merit. Clinicians, at times, were able to diagnose caries at an early stage; however, preparation form for amalgam restorations did not lend itself to conservative dentistry.

How to use minimal intervention for maximum effectiveness

	Over the last decade many new technologies have been incorporated into dental practices, including digital impression systems, diode lasers, digital radiography, LED curing lights and caries detection devices yet many individuals are using the exact same handpiece they have always used.

	Most likely this is an air-driven handpiece with a high pitched whistle and a moderate amount of torque.

	The whistle and vibration of these handpieces tend to cause a fair amount of anxiety in our patients, and the soothing environment clinicians try to provide in their offices is destroyed the moment they step on the rheostat. 

Related reading: 5 reasons to switch to electric handpieces

	The question must be asked whether handpieces have evolved beyond these issues.

	The Borden highspeed air-driven handpiece debuted in 1957, and this introduction revolutionized dentistry; however, only incremental changes have occurred in the air handpiece arena since this time. Air-driven handpieces today are certainly lighter, smaller and somewhat quieter then they once were; however, these advancements are still relatively minor. Practitioners continue to battle the fact that air-driven handpieces tend to lose their cutting efficiency with dense materials and patients continue to have anxiety based on the noise and vibration associated with these handpieces.

	The solution to these issues resides with electric handpieces. Electric handpieces have been available to the marketplace for many years, and while Europeans and Asians would not think about going back to air-driven handpieces, the penetration rate in the United States is still relatively low. Practitioners in the United States have been slow to adopt this technology because traditional electric handpieces tended to be heavy, bulky, difficult to maintain and somewhat confusing to use.

More on handpieces: 5 reasons to consider an air-driven handpiece

	The marketplace was clearly aware of the fact that electric handpieces have a tremendous amount torque leading to cutting efficiency; however, in many peoples eyes the bulkiness of the product and warnings related to potentially burning patients was not worth the benefit.

	In an air-driven handpiece, the speed is a function of the amount of pressurized air that can flow through the turbine. Unfortunately, as rotary cutting instruments meet resistance, the speed at which it can turn decreases and cutting efficiency is lost. In addition, air handpieces tend to have a fair amount of vibration, and the concentricity of rotary instruments decreases.

	In an electric handpiece, air only plays the role of speed regulation as the air approaches a sensor. When a bur meets resistance an electric motor is able to output more energy and continue cutting at essentially the same speed.

More on handpieces: What do women look for in a handpiece?

	Historically large motors with intricate carbon brushes were needed to maintain this torque level. Equally important, electric handpieces are able to cut more concentrically, leading to highly refined preparation.

	Advancements in electric handpieces today allow them to me be lighter, smaller, quieter, easier to maintain and more simple to operate compared to the earlier generations. In addition these benefits have come without sacrificing the tremendous torque and precision cutting ability of electric handpieces.


	The size and weight of electric handpieces has dropped significantly in the last couple of years. Manufacturers such as 

 now offer short motors which are nearly 30 to 40 percent lighter and shorter than motors offered only a few years ago. In addition,  companies like Kavo and NSK now have ultra-small head designs so electric handpieces can be used for people with smaller openings.

Related reading: 7 tips to extend the life of your dental handpieces


	The noise level of traditional air-driven dental handpiece has been a nuisance to patients and can damage the hearing of clinicians over the course of a career. Manufacturers today have electric hanpieces that operate at nearly 20 decibels less than traditional air handpieces. It is estimated that human ear senses a reduction of 10 decibels as almost a 50 percent decrease in loudness.


	In years past, electric handpieces contained carbon brushes that needed to be changed periodically to maintain ideal performance. Today’s handpieces are brushless, and many manufactures have created simple plugin cleaning units to help maintain the precision performance of the handpiece.

Related reading: 5 common misconceptions about electric handpieces


	In years past, many felt electric handpieces were confusing to use because of all the adjustments that could be made. Manufacturers today have integrated simplicity into their handpieces by integrating simple-to-use touch panels and preprogrammability. Manufacturers like Bien-Air have integrated an iPad into its surgical handpiece line, and KaVo has created a product called COMFORTdrive that is a simple plug-and-play electric handpiece that does not need any adjustments.

	A new generation of electric handpieces are available to the profession, and practitioners should consider an upgrade to these highly precise instruments. This upgrade will immediately be noticeable to patients in terms of increased comfort. In addition, it will lead to a positive return on investment in terms of practice efficiency and precision. 

Products, trends and reviews: Your guide to the latest in dental handpieces

Over the last decade many new technologies have been incorporated into dental practices, including digital impression systems, diode lasers, digital radiography, LED curing lights and caries detection devices yet many individuals are using the exact same handpiece they have always used.

Electric handpieces solve many problems

	Practitioners have been placing composite resin restorations for more than 60 years, and during this time, practitioners have gone from a world where only anterior teeth were restored with composite resin to a world where composite resin is used to restore essentially any tooth in the oral cavity.

	Over this time, the physical properties of the material have improved a great deal; however, the improved physical properties alone do not equate to successful restorations. This is particularly true in the posterior aspect of the mouth where many practitioners have struggled to predictably achieve composite restorations that have proper form and function and do not cause postoperative sensitivity. The placement of a successful composite restoration is multi-factorial and must take into account proper adhesion, material placement and polymerization. No single area can be ignored if the goal is to achieve long-term success.

Related reading: How to eliminate the tackiness between dental instruments and filled composite resin

	The world of adhesion has evolved greatly since the time that Buoncore introduced acid etching enamel in 1955. During the late 1970s, enamel etching became fairly predictable as most fourth-generation adhesive systems recommended a 32- to 40-percent phosphoric acid etch for 15 seconds. During this time, the phosphoric acid dissolves away 

 crystals from enamel, creating a roughened enamel surface for resin to penetrate. The relative homogeneity found in enamel allows for fairly predictable enamel adhesion to occur.

, on the other hand, is composed of collagen, hydroxyapatite and water, and the concentration of each of these changes depends on proximity to the pulp. During the late 1980s, dentin bonding started to gain popularity, and, as clinicians placed phosphoric acid etchant onto the dentition, the goal was to gain exposure to the collagen network and mechanically lock resin into this network to achieve high bond strengths. Unlike enamel bonding, dentin bonding proved to be much more complicated because of heterogenous structure. Dentin bonding at this time became achievable; however, true success was based on methodical technique.

	Fourth-generation adhesive protocol consisted of three independent chemical components steps. The first step was to etch the dentin and enamel, followed by a rinsing and drying step. The next was to place a primer that would be soaked up by the collagen, and the third step was to apply the adhesive. To this day, fourth-generation adhesives, such as 

, are still considered to be the gold standard and have shown tremendous long-term success, with studies showing a 94-percent retention rate at 13 years.

Related reading: Double take: DENTSPLY Caulk Prime&Bond Elect

Continue to page two for more on adhesion...

	This generation of adhesives perform very well; however, they tend to be technique-sensitive and have a high film thickness, which can be challenging when adhesively bonding indirect restorations. To minimize the number of steps in the adhesion process, fifth-generation adhesives then came to market. The clinician was still required to etch both dentin and enamel; however, the primer and adhesive were put into the same bottle to allow for a single application after the etchant was rinsed off. Products like 

 have been the primary adhesive for many clinicians for the last 15 years.

Related reading: How to use OptiBond XTR as a universal bonding solution

	Being that the primer and adhesive are combined into one step, the proper treatment of dentin after etching becomes critically important, and many clinicians have reported the patient can experience post-op dentin sensitivity issues. In many cases, this may be tied to the dentin being overly dried after etching and the collagen network collapsing. This can lead to lower bond strengths and exposed dental tubules.

	To combat the issue of sensitivity, self-etch adhesives have entered the marketplace. Two-bottle self-etch systems are generally referred to as sixth-generation adhesives. In this generation, the etchant and primer are combined into one bottle and the adhesive is in a second bottle.

	Throughout the last several years, clinicians and researchers have reported very good success in this area in terms of minimal dentin sensitivity and very high dentin bond strengths. The only negative aspect seen with some sixth-generation adhesives is a lower enamel bond strength as the acid and primers combination tends not to create as effective of an enamel etch pattern as that seen with phosphoric acid. To combat this issue, many practitioners have opted to etch the enamel only with phosphoric acid (selective-etch technique) prior to applying the sixth-generation primer and adhesive system. Two sixth-generation adhesives that have shown favorable results both in terms of dentin and enamel etching are 

Related reading: How to simplify Class II restorations with Class II Total Practice Solution from DENTSPLY Caulk

	The newest generation of adhesives are commonly referred to as 

. These combine all components into one bottle and can be used both in a total-etch and self-etch technique. Generally speaking, products like 

 are showing favorable initial results; however, the body of long-term success is limited at this time.
	Regardless of which adhesive technique is used by the practitioner, success must be achieved at this point  to have a successful final composite restoration.

Continue to page three to read about composite resin...

	For many years, practitioners have been told that to achieve a successful composite restoration, the material must be placed in increments that are less than 2mm to achieve proper polymerization of the material, as well as to prevent polymerization shrinkage stresses that can be distributed to the cusps. Generally speaking, practitioners that have used an incremental layering technique have achieved success; however, incremental layering can be very time-consuming and technique-sensitive.

Related reading: How to simplify composite selection, procedures

	Most individuals would agree that if resin can be developed to allow for a bulk placement, posterior composite restorations could be placed more predictably and efficiently. To this end, over the last five years, numerous products have come to market to address these issues. Products like 

 allow the practitioner to place an initial base layer of resin 4-5 mm in depth. Once polymerized, the base layer is capped with a traditional layer of composite. This technique offers very good adaptation of the material because of the initial low viscosity layer that is placed followed by a more filled capping layer that can withstand the forces of mastication. The initial studies of these materials show favorable results.

	Another category of products that have come to market is one in which a single increment of composite resin is placed in a 4-5 mm increment to fill a cavity preparation in entirety. The clear benefit of this technique is further conservation of time; however proper adaptation of a 4-5 mm increment of composite may be difficult to achieve. Products in this category include 

Video: How to create contours with Triodent's new V4 ClearMetal Matrix System™

 would be one that can adapt nicely to all the walls of a cavity floor yet have enough body to easily anatomically blend the restoration into the adjacent unprepared tooth surface and withstand occlusal forces. To this end, the 

 addresses each of these issues. The system essentially allows for sonic energy to be delivered to a highly filled composite via a handpiece. As this energy is applied, the viscosity of the material drops by more than 80 percent, allowing it to nicely adapt to all walls of the preparation. As energy is removed, the composite resin starts to regain its viscosity over ample working time.

	During this time, the proprietary resin can easily be sculpted so that it can be properly contoured and anatomical harmony can be achieved. The material can be placed in a single increment of up to 5mm before it needs to be polymerized. After polymerization, a standard polishing regimen can commence. SonicFill 2 will be introduced by Kerr soon, and improvements have been made to the resin to allow for easier polishing.

Continue to page four for two case studies...

	Patient presented with recurrent caries in the distal box form of tooth No. 13 and new approximal caries on the distal of tooth No. 12. After consultation with the patient, a decision was made to remove the existing restoration and caries and place direct restorations. After administering anesthesia, the teeth were isolated utilizing a rubber dam.  After complete caries excavation, the teeth were restored one at a time in order to achieve proper anatomical proximal contact. The system used was a sectional matrix (

. To achieve thorough polymerization, the restoration was initially cured for 20 seconds from the occlusal surface as well as 20 seconds from both the buccal and lingual surfaces after removing the sectional matrices. After removing the rubber dam, minor contouring was completed utilizing a 16-fluted carbide composite finishing bur (

Video: Pride Institute's "Best of Class" 2014: Ultradent VALO curing light is capable of polymerizing all light-cured materials

Continue to page five to watch a video of the two cases...

	Watch the video below to see pictures of Cases 1 and 2:

Innovator profile: How Kerr 's products have become the cornerstones of dental practices

	It is incredibly important to realize that to be considered a successful composite resin restoration, the material must be fully polymerized. All curing lights are not created equal, and just because a blue light is being emitted from the tip of a light does not mean the composite is being fully cured. The physical properties of light-cured composite resin can only be achieved when the composite receives the right amount of energy at a specific wavelength.   

	In addition, enough of this energy should be delivered to the composite resin restoration without causing a significant temperature change to the pulpal tissue. Successful polymerization requires proper equipment and training. In a recent study by the ADA that looked at eight LED curing lights currently in the marketplace, only three lights showed the ability to have depth-of-cure measurements that were equivalent to or better then a standard halogen curing light. These lights were the DemiUltra by Kerr, 

Technique: How to use Kerr SonicFIll™ and SonicFill 2™

	In terms of operator technique, it is critically important that the team member who is responsible for curing is properly trained and that the patient is put into an ideal position so the tip of the light can get as close to the restoration as possible. The effective energy of all lights drops off as the light source moves away from the surface to be cured, and just because a restoration has a top surface that is hard does not mean the restoration is fully polymerized. Clinically, this can be a big issue in 

	It is very common for a light to float 3-4 mm off a tooth surface when it is activated, and this can mean a gingival box form is now 8-9 mm away from where the light is being emitted and gingival failure can become more likely. In terms of bulk fill resins, they tend to be slightly more translucent than traditional composites, and this is one of the primary reasons they can be cured in bulk. Based on the author’s experience, it is advisable to cure all resin-based restorations from the buccal and lingual surfaces in addition to the occlusal surface to maximize polymerization possibilities. Team members should also make sure curing tips are not damaged or covered with dental material that could inhibit proper curing. In addition, batteries and charging bases should be maintained to allow for optimal performance. One interesting point about Kerr’s DemiUltra is that it actually does not contain a battery at all. The light operates based on an ultra capacitor technology that allows it to fully charge in just 40 seconds. In addition, the light output is modulated every second through a process called periodic level shifting that allows the optimization of power while minimizing heat that may get to the pulpal tissue.

	Posterior composite restorations are one of the most prevalent procedures that occur in dental practices today.  When a practitioner blends proper technique with the advancements in technologies and material, these procedures can also become some of the most predictable. Efficiently placing natural-looking direct restorations that do not produce any post-operative sensitivity is very feasible today and should be considered the norm versus the exception.

 is a unique bulk fill system comprised of a specially designed handpiece and new composite material in Unidose tips. SonicFill’s composite incorporates a highly filled proprietary resin designed with special modifiers that react to sonic energy. As sonic energy is applied through the handpiece, the modifier causes the viscosity to drop (up to 87 percent), increasing the flowability of the composite and enabling quick placement and precise adaptation to the cavity walls. When the sonic energy is stopped, the composite returns to a more viscous, non-slumping state that is said to be perfect for carving and contouring.
	

Related reading: I use that: SonicFIll from Kerr

	Building upon the award-winning performance of its predecessor, 

 is designed to transform tedious, repetitive posterior restorations into easy and reliable SingleFill placement, filling cavities up to 5mm in depth in a single increment with a single material and no liner or capping layer. The upgraded composite of SonicFill 2 was engineered using a new proprietary resin-infused zirkonsil filler system. Composed of nano-scale zirconium oxide and silica oxide particles, the improved composite reportedly imparts excellent gloss, wear resistance and strength to make bulk filling even easier and more reliable. SonicFill 2 is said to dramatically lower the viscosity of the composite during placement to ensure intimate adaption with the cavity surface. With its low shrinkage stress, high depth of cure and excellent mechanical and esthetic properties, SonicFill 2 is designed to meet the key requirements of a successful bulk fill procedure as you’ve come to expect from this market-leading product.
	

Video: Pride Institute's "Best of Class" 2014: SonicFill makes for faster, easier restorations

3M™ ESPE™ Filtek™ Bulk Fill Posterior Restorative

 reportedly gives dentists the ability to place up to 5 mm in one increment while offering excellent wear resistance and stress relief. By eliminating additional layers and multiple steps, Filtek Bulk Fill posterior restorative is designed to outshine competitors to give dentists a fast and easy option for direct posterior restorations. With this “one-and-done” option, dentists reportedly can save valuable chairtime and improve productivity. Designed for durability, Filtek Bulk Fill posterior restorative utilizes the same true nanofiller technology of other Filtek restoratives, which is said to enable high strength, wear resistance, surface smoothness and gloss retention.

Continue to page seven for more products...

	With more than 20 years of clinical excellence, 

 reportedly is strong and opaque just like dentin. Because of its wetting properties, Renamel Microhybrid is said to be easy to place and manipulate in thin layers. The product offers SuperBrite shades for bleached teeth and includes shades A1, A2, A3, A3.5, A4, B1, B2, B3, B4, C1, C2, C3, C4, D2, D3, D4, CO, LI, MI, MWO, W, SB1, SB2 and SB3. Renamel Microhybrid is said to adapt well to underlying tooth structure and block unwanted undercolor.
	

“I’ve been using Renamel Microhybrid since 1994 in cases large and small. Its ability to adapt to underlying tooth or composite layer is the best I’ve experienced. The chance of trapping air bubbles or having an open margin is reduced because of its viscosity.”
	– Corky Willhite, DDS, FAACD

Related reading: Why use DENTSPLY Caulk's TPH composite

 is designed to provide the handling preference of choice with TPH Spectra LV (low viscosity) and TPH Spectra HV (high viscosity) that is spreadable or packable. The new shading system for the composite offers seven VITA-based shades that cover the entire VITA shade system. This reduction in shades allows for carrying fewer inventories in the office and is said to provide confidence that the chameleon shading ability of the composite will blend it in to the surrounding tooth structure making the restoration indistinguishable.
	

“TPH Spectra has taken all the attributes most practitioners would like in a direct composite resin - good handling, shade simplification, solid physical properties and ease of finish and polish and combined them into one product. It might be DENTSPLY Caulk's best composite ever!”
	- Dr. Doug Lambert

 is designed to embody a true balance of science and esthetics based on a patented cross-linked polymer matrix. With more than five years of extensive composite research that produced a patented chemistry, Venus Diamond is said to be the ideal choice for both anterior and posterior restorations. Offering a firmer, more packable consistency, Venus Diamond reportedly leads the industry in color adaptability with a patented formula that is designed to provide an outstanding natural look-replicating nature and mimicking tooth anatomy. Just one shade is said to save time and produces radiant results. The optimal physical properties of Venus Diamond reportedly offer a composite that truly performs in every category with low shrinkage stress, unique handling, exceptional strength and durability and perfect color adaptation.
	

“An essential quality of a composite is the ability to create invisible margins by blending with natural tooth structure. Venus Diamond’s color adaptive matrix, combined with easy handling and polishing to a high luster, allows us to restore teeth to their natural beauty in both anterior and posterior restorations.” 
	- Howard S. Glazer, D.D.S., F.A.G.D.

Technique: Three tips for shade matching in a Class II dental restoration

Practitioners have been placing composite resin restorations for more than 60 years, and during this time, practitioners have gone from a world where only anterior teeth were restored with composite resin to a world where composite resin is used to restore essentially any tooth in the oral cavity.

Author | Dr. Parag R. Kachalia

Articles

Technique: How posterior composites made a difference in two cases

How to use minimal intervention for maximum effectiveness

Electric handpieces solve many problems

Category cruncher: Predictable posterior composites