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February 2023
Volume 44, Issue 2

Dentsply Sirona Products Support Class II Posterior Composite Workflow

For over 30 years, Alan M. Atlas, DMD, has maintained a full-time private practice in Philadelphia dedicated to esthetic and comprehensive restorative dentistry. He's also been a teacher and researcher at Penn Dental Medicine for more than 22 years, focusing on "identifying the etiologies of failures and determining how to avoid them," he says.

Atlas notes that according to systematic reviews and academic studies, posterior composite restorations are failing two times faster than amalgam restorations in adult dentitions, and practice-based studies demonstrate even higher annual failure rates. The good news, he says, is that improving these success rates requires only some minor changes in technique. "You need to prepare the tooth well, put the matrix down correctly, and use the right materials," he asserts. "I'm currently doing research to help us understand how to improve the lifespan of the posterior composite restoration using improved techniques even under less-than-favorable ‘patient-induced' conditions like poor diet and oral hygiene."

The Class II posterior composite workflow, he offers, has five critical steps: tooth preparation, matrix band selection/placement, adhesive strategy/placement, material selection and placement technique, and finishing of the restoration. "Unfortunately, many clinicians have adopted the same philosophy of tooth preparation they followed since dental school using the same carbides implemented for the amalgam restoration," Atlas says. "It's very important for the clinician to move towards finishing preparations with smoother, fine-grit diamonds. This minor tweak in the armamentarium can produce major improvements in reducing discoloration, deterioration, and postoperative sensitivity."

Atlas has been successfully using the Dentsply Sirona Class II solution, comprising a range of the company's restorative products, for over a decade. After preparation, he places the Palodent® Plus sectional matrix system to achieve a strong and smooth contact. "We've been using this system for many years at Penn Dental Medicine because it contains all the items needed to place the matrix band precisely for optimal material adaptation and strong contacts," he says. "This includes the wedge guard to protect adjacent teeth against damage during preparation, sectional matrices of different sizes, tweezers to place and remove the band, and forceps to place and remove the ring. The sectional ring is the key component, as it creates the contact for the final restoration."

Atlas advises clinicians to ensure the ring has proper resistance to extension when placing it on the wedge and also to make sure interproximal margins are closed to prevent material from extending past the band and creating overhangs. A small amount of teflon tape may be used between the ring and matrix band to seal this area, if necessary, he says. He also warns clinicians to avoid burnishing the band, as doing so "will create a terrible irregular contact that will act as a biofilm magnet and exacerbate bacterial colonization and food entrapment."

Bonding strategies, Atlas notes, have evolved into the next generation of "universal" multi-mode adhesive agents. He chooses Prime&Bond elect® as a bonding agent, which he points out has performed well in scientific studies and can be used in a total-etch, self-etch, or selective enamel etch strategy. He notes that the key aspect is at the interproximal enamel and dentinoenamel junction/cementoenamel junction. "Prime&Bond elect enables the clinician to safely etch those areas where both dentin and enamel are present without weakening the bond strength of the dentin. After a short etching time, the area needs to be dried carefully without desiccating the dentin affected by the etch. This is not possible with traditional light-cured self-etch bonding agents," he says.

The next important step in the workflow is material selection and placement. Atlas is passionate about SDR® flow+ bulk-fill flowable composite. "Independent studies showed that this material was by far the most impactful game-changing composite material in dentistry during the past decade," he says. "I utilize SDR flow+ in an ‘open sandwich' technique as a dentin replacement up to 4 mm extending up from the gingival or pulpal floor. Due to its unique chemistry, it relaxes and adapts to the margins seamlessly during light polymerization. The scientific evidence is extensive demonstrating that SDR flow+ has the least polymerization shrinkage stress and contraction stress of any material available on the market."

Atlas typically places a cap layer on top using TPH Spectra® ST, a nanohybrid composite material that "adapts and polishes beautifully, has excellent wear durability and an amazing chameleon effect that allows for its use in the esthetic zone."

"I determine the extent of SDR flow+ I place by the size of the entire preparation," he explains. "I always leave room for at least 2 mm of TPH Spectra at the cavosurface and marginal ridge aspect. This ensures that masticatory stresses and bite forces caused by hard foods or parafunction will not impact the restoration. As an example, if the cavity preparation is 5 mm from the gingival box floor to the cavosurface margin, I will place 3 mm of SDR flow+ and 2 mm of TPH Spectra. SDR flow+ is self-leveling and adapts well inside the preparation."

After minor adjustments, Atlas polishes with the Enhance® Finishing System to smooth and eliminate any unnecessary flash and roughness. He is careful not to over-finish the composite.

Atlas then uses the SmartLite® Pro curing light. "It's been tested to show that at a 10-second interval it achieves a predictable photopolymerization of the composite placed inside the cavity preparation even at a 4 mm to 5 mm depth." The small footprint of the head of the light, he notes, enables easy access inside the oral cavity and for posterior quadrants. Other benefits of the SmartLite Pro, he adds, are a replaceable rechargeable battery, a transillumination tip to detect cracks and caries, and a built-in radiometer.

"The bottom line is that the Dentsply Sirona Class II solution has all the materials in its product portfolio that you need to complete an efficient and proficient restoration," Atlas states. "We owe it to our patients to use the best evidence-based materials available." With the Dentsply Sirona Class II solution, he is creating better restorations for his patients.

Alan M. Atlas, DMD
Clinical Professor, Department of Endodontics and Department of Preventive and Restorative Sciences, and Director of Restorative Microscopy, University of Pennsylvania School of Dental Medicine; Private Practice, Philadelphia, Pennsylvania

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