Capabilities of an “Expanded-Indication” Flowable
Versatility, easy dispensing, flow control, and the expanded range of use makes Shofu’s new flowable restorative a valuable addition to the clinical armamentarium.
Lou Graham, DDS
Flowables have long been a significant part of a general dentist’s arsenal of direct materials.( The evolution of these flowables has been dramatic over the last 15 years with advances such as low-stress, high-filler content, and low-shrinkage. Now there is a new category of flowables emerging that possesses the physical properties suitable for expanded use. This article will address the last category and the clinical options they offer.
These new flowable restoratives are extremely versatile in their capabilities, having literally become mainstays in many dental practices, including the author’s. Current uses include small and even large Class 1 restorations (Figure 1, Figure 2, Figure 3, and Figure 4) Class 2 restorations (Figure 5) Class 5 restorations (Figure 6 and Figure 7), repairs to existing restorations (Figure 8 and Figure 9), and crown build-ups where a wall or an undercut from recurrent decay needs to be rebuilt, often as a temporary repair to a fractured cusp (all too often it is not temporary). Other colleagues have reported use in both Class 3 and Class 4 restorations.
Figure 1, Figure 2, Figure 3, and Figure 4 show various Class 1 restorations. This classification can present the practitioner with a variety of clinical issues that can include shallow to deep preparations, narrow to wide configurations, different types of dentin, occlusal–functional issues, and C-factor issues. This author uses glass ionomer and resin ionomers in moderate-to-deep restorations but in the cases presented, these materials were not required.
The key steps in these restorations include:
- Preparing beveled occlusals to enhance enamel bonding.
- A total-etch approach using 2% chlorhexidine after rinsing to enhance long-term bond strengths.
- Use of “air”-only syringes and proper air-drying protocols to remove excess solvent before light-curing the hybrid layer.
- Placement of an initial layer of BEAUTIFIL® Flow Plus F03 Low Flow (Shofu Dental Corporation, www.shofu.com) over the dentin floor and proper light-cure (depth- and color-dependent).
- Two final layers of BEAUTIFIL Flow Plus F00 Zero Flow, A2 color, one on the buccal of the occlusal and the other on the lingual of the occlusal. Light-curing can be dual-directional.
Figure 5 showcases the “all-flowable” Class 2. This technique employs the same etching and bonding steps from the previous cases but then follows several additional key steps. First is proper light-curing for the hybrid layer. The deeper the Class 2, the more absolute is the requirement for longer curing times. Routinely, this requires 20 seconds of curing time to establish a well-cured hybrid layer. Lights with weaker strengths or non-collumination require even longer curing times because the most critical area to minimize microleakage is in the gingival box.
Placing Surefil® SDR® (DENTSPLY Caulk, www.dentsply.com) as a low-stress flowable with exceptional marginal adaptability and self-leveling is an excellent option in this area. The technique involves placing the compule tip to the base of the box and injecting slowly, keeping the tip immersed in the material. The next step is critical, where the practitioner waits 5 to 8 seconds to allow the material to self-level. Then, bulk fill up to 4 mm of the universal color. Proper light-curing again is essential.
The restoration is completed by placement of 2 mm of BEAUTIFIL Flow Plus F03 Low Flow A2 and cured from the buccal, lingual, and occlusal directions. The BEAUTIFIL Flow Plus F03 Low Flow formulation allows the practitioner to slightly manipulate the material in order to place the ideal amount and, again, minimize the time for finishing and polishing. After the matrix band is removed, the restoration is again cured from the buccal-lingual directions for 20 seconds.
Figure 6 and Figure 7 show another common class of restorations—the Class 5. These restorations often involve both enamel and dentin and, as such, a total-etch approach is taken with the same steps from above.In these restorations, the essential steps include:
- Placement of the retraction cord to minimize gingival crevicular fluid.
- Beveling the coronal enamel margin to enhance enamel bond strengths.
- Layering BEAUTIFIL Flow Plus F03 Low Flow in increments that can begin within the dentin and/or gingival area, and then proceed up to the coronal enamel margin. This minimizes marginal gaps from forming to different tooth interfaces, and allows careful placement of this material. Subsequently, finishing and polishing are far more efficient.
All too often, patients present to the office who require extensive oral rehabilitation and simply cannot afford it or the only solution may not be appropriate based on their health or age. The case shown in Figure 8 and Figure 9 involved such a patient where the bicuspid presented with a fractured buccal cusp and there was little anatomical tooth remaining. The treatment options included a crown build-up and crown or, as seen, a bondable repair. After retentive grooves were created, the remainder of the tooth was micro-etched. With no enamel present, a self-etch approach was applied and subsequently followed with layering BEAUTIFIL Flow Plus F03 Low Flow in various colors. The layering followed the previous Class 5 approach and subsequent finishing and polishing revealed a beautifully restored upper bicuspid.
Beautifil Flow Plus offers two viscosities with identical physical properties that allow the practitioner to either flow or not to flow as desired to suit the indication. Their “F00” and “F03” viscosities are so named for the millimeters of movement noted after placement on a glass slide and held upright for 1 minute at room temperature. Truly, the F00 does not flow, allowing a very precise placement. It will stay absolutely anywhere it is placed without dripping or slumping. This can be fantastic when rebuilding a Class 1 preparation if the desire is to minimize any cuspal pull forces because it allows cusp-by-cusp rebuilding. By contrast, the F03 viscosity allows for just enough movement to not have to use instruments extensively to manipulate the material. It happens all too often that dentists unwittingly destabilize their own progress and increase the potential for voids with increased and unwarranted instrumentation.
Easy Dispensing and Flow Control
The level of innovation that is put into the product can readily seen though a simple observation of the syringe itself. When extruded, the material flows in a well-controlled stream that will immediately stop flowing and cleanly separate from the needle tip once pressure is released. This feature is greatly appreciated when it comes time to clean up and there is no product waste on the surgical tray. Other innovations in the design include a rotating finger grip that allows the syringe to be rotated easily in a gloved hand without needing to loosen one’s grip to reposition the syringe. Small details like this can have a big impact on performance and can either make or break office productivity.
Fluoride Recharge and Cariostatic Activity
Beautifil Flow Plus is a “giomer” material providing sustained fluoride release based on its ability to actually recharge and release fluoride at levels substantially higher than non-giomer filler particles.2 While it has not been well established how much fluoride release is required for clinical efficacy, long-term clinical studies have demonstrated that restoratives containing giomer fillers have remarkable durability, and more interestingly, they seem to indicate resistance to secondary caries even at 8 years and beyond.3
Numerous clinical cases exist in which “all-indication” flowables such as Beautifil Flow Plus F00 and F03 can be used to augment routine direct restorative procedures. This new category of material allows clinical benefits such as a simplified delivery system, and reduced need for material instrumentation, both of which may help improve the long-term stability of our restorations. When selecting from among the many commercially available products, it is advisable to consider which properties are desirable for the specific classification being restored. This article has demonstrated that certain benefits of Beautifil Flow Plus, such as viscosity selection, handling, delivery system, and cariostatic properties, can be useful in restoring different classes of cavities.
Dr. Graham has received an honorarium from Shofu Dental Corporation for writing this article.
1. Graham L. Advances in Tooth-Colored Restoratives. December 2010. Available at: www.ineedce.com.
2. Naoum S, Ellakwa A, Martin F, Swain M. Fluoride release, recharge and mechanical property stability of various fluoride-containing resin composites. Oper Dent. 2011;
3. Gordan VV, Mondragon E, Watson RE, et al. A clinical evaluation of a self-etching primer and a giomer restorative material: results at eight years. J Am Dent Assoc. 2007;138(5):
About the Author
Lou Graham, DDS