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The Next Step in Restorative Technology
New flowable composite offers promising possibilities.
Martin B. Goldstein, DMD
What dentist has not longed for a modern-day restorative material bearing the simplicity of amalgam placement with the benefits of today’s bondable resins? Would this not be the dental “holy grail”? While a self-etching, self-bonding composite paste is not quite ready for prime time, a flowable composite is and seems to possess some remarkable attributes.
Vertise Flow, Kerr Corporation’s (kerrdental.com) self-adhering flowable composite, would appear to be pushing the envelope toward that end. Moreover, the material packs specifications that make it a legitimate contender to take over a variety of tasks formerly relegated to other materials that require multi-step application. How is this possible? As explained to the author by Kerr’s vice president of research and development, David Tobia, Vertise Flow bonds in two ways: primarily through the chemical bond between the phosphate functional groups of a glycerol phosphate dimethacrylate monomer and calcium ions of the tooth (personal communication, 2009), and, secondarily, through a micromechanical bond as a result of an inter-penetrating network formed between the polymerized monomers of Vertise Flow and collagen fibers (as well as the smear layer) of dentin. Vertise Flow is powered by the same adhesive technology as Kerr’s OptiBond.
Comparative manufacturer evaluations find Vertise Flow to possess bonding strengths in the 21 MPa to 24 MPa range on both cut dentin and enamel, while mechanical properties promise a durable restoration when used appropriately.1-4 Ongoing university-based in vitro studies being conducted in both the United States and abroad hope to confirm Vertis Flow’s restorative virtues.5-8 On paper, as determined by a company that is no stranger to composite technology (eg, Herculite, Prodigy, Point 4, Premise), Vertise Flow would look to be a comer that is pointing in the direction of the future. This author had the pleasure of taking Vertise Flow for a clinical spin to see if in fact it would do what Kerr said it would. The manufacturer recommends the usage of Vertise Flow in the same circumstances in which a clinician might use any highly filled flowable (Vertise Flow features a 70% filler content).
Such applications might include small Class I restorations; liners or bases for Class I and II restorations; pit-and-fissure sealant; repair of enamel defects; porcelain repairs; blocking out of undercuts; and even small build-ups within the context of a needy crown preparation. The porcelain repair technique is especially convenient as there is no longer a need to apply hydrofluoric acid or silane primer when using Vertise Flow to repair porcelain. Hydrofluoric acid tends to be very aggressive on tissues, so bypassing this step makes the procedure much more patient-friendly and easy for the dentist.
Usage requirements are to simply brush Vertise Flow as a thin base layer (< 0.5 mm) for 15 to 20 seconds and light-cure. No phosphoric etch-and-rinse or primer or bonding resin needs be applied. Vertise Flow does it all in one step. After the initial brushing step, the restoration should be built in 2-mm increments, finishing with restorative sculpting and light-curing. This author found the non-slumping, gel-like handling characteristics of Vertise Flow easy to manipulate. It seemed to “know” what shape was intended for the restoration, requiring minimal instrumentation for it to reach its intended shape. Conversely, when used as a base, this flowable “understood” its intended use and readily spread out and evenly coated its dentin and enamel tooth surface.
In Figure 1, Figure 2, Figure 3 and Figure 4, Vertise Flow is being applied as a base liner for the composite restoration to follow. As it is a self-adhering flowable, it can be applied directly to the floor of the cavity preparation.
In Figure 5, Figure 6, Figure 7, Vertise Flow is being applied to perfect the shape of a crown preparation in which an old composite resin had popped out during tooth instrumentation. This is a dependable and convenient way to repair the defect. Carry that concept further to blocking out undercuts in both crown and onlay or inlay preparations. This application might be ideal for those not ready to take the leap of faith that would occur when using Vertise Flow as an all-in-one cavity liner under Class I and II restorations. It affords the opportunity to observe how Vertise Flow bonds, handles, cuts, polishes, etc, in a non-critical application that will be covered by an indirect restoration. Certainly the time savings is immense, and there is the added benefit of not sloshing phosphoric acid or the bonding agent on surfaces of the tooth with which those materials should not come in contact. In the author’s opinion, Vertise Flow might provide the most focused application of a bonding agent available in the industry. It only bonds where the clinician wants it to bond. Any clinician who has ever inadvertently bonded a resin temporary to a tooth that had been unknowingly covered with bonding agent will understand the benefits of focused bonding.
If during the course of performing a crown preparation incipient caries is noted on the adjacent proximal surface, Vertise Flow provides a rapid repair as demonstrated in Figure 8 and Figure 9. Again, the ability to confine the etch and bonding agent to the restorative site only limits such inconveniences as peripheral bleeding, often incited by phosphoric acid running onto friable interproximal tissue.
In a similar vein, and in keeping with the concept of minimally invasive dentistry, this author has found Vertise Flow to be a convenient way to restore early Class I carious lesions as detected by laser diagnosis devices such as KaVo’s DIAGNOdent (http://www.kavo.com). Small lesions can be detected, prepared with a minimal preparation cutting instrument without local anesthesia, and restored almost instantly with Vertise Flow. Needless to say, such restorations—which in many respects are the equivalent of a highly filled sealant—are appropriate in low-wear zones of the occlusal table.
To accelerate large Class II restorations, Vertise Flow can be used to provide conveniently placed core material as shown in Figure 10. Keep in mind that while Vertise Flow can be used as its own incorporated bonding agent, it can also be used atop areas that have already been bonded via another method. The self-etching capabilities do not preclude Vertise Flow from being used as a conventional flowable composite.
Vertise Flow is available in an introductory kit form and features refill shades: A1, A2, A3, A3.5, B1, B2, XL, Translucent, and a Universal Opaque shade.
This author had the privilege of working with Vertise Flow since its early development stage and has seen the evolution of the product unfold. Having witnessed the different viscosities and delivery options Kerr was considering for Vertise Flow, this evaluator can clearly see the improvements over the course of time that Kerr has made to the material to reach its optimal characterization today. The comprehensive scientific body of evidence Kerr has put forth with this product illustrates the manufacturer’s commitment to providing a product that has sound clinical data behind it.
The author is a consultant for Kerr Corporation.
1. Bui H, Nguyen TD, Qian X, Tobia D. Bond strength of a new self-adhering flowable composite. Presented at: IADR/AADR/CADR 87th General Session; April 2009; Miami, Florida. Presentation #1804.
2. Nguyen TD, Qian X, Tobia D. Bond strength of Vertise Flow to dentin of varying wetness. Presented at: IADR/AADR/CADR 87th General Session; April 2009; Miami, Florida. Presentation #2331.
3. Nguyen M, Nguyen TD, Qian X, Tobia D. Physical properties of a new self-adhering flowable composite. Presented at: IADR/AADR/CADR 87th General Session; April 2009; Miami, Florida. Presentation #3272.
4.Mine A, Poitevin A, Peumans M, et al. TEM interfacial characterization of an adhesive-free composite bonded to enamel/dentin. Presented at: IADR/AADR/CADR 87th General Session; April 2009; Miami, Florida. Presentation #2961.
5. Nguyen M, Nguyen TD, Qian X, Tobia D. Bond durability of Vertise Flow to tooth structure. Abstract submitted to: 39th Annual Meeting of the AADR; March 2010; Washington, DC.
6. Bui H, Nguyen TD, Qian X, Tobia D. Bond strength of Vertise Flow to porcelain substrate. Abstract submitted to: 39th Annual Meeting of the AADR; March 2010; Washington, DC.
7. Munoz-Viveros CA, Campillo-Funollet M. Shear bond strength of Vertise Flow on dentin and enamel substrates. Abstract submitted to: 39th Annual Meeting of the AADR; March 2010; Washington, DC.
8. Latta M. A laboratory evaluation of the shear bond strength of self-adhering flowable restoratives to dentin and enamel compared to two ‘self-etch’ adhesive systems and their associated conventional flowable restoratives. Unpublished data.
About the Author
Martin B Goldstein, DMD