Re-treating Failed Anterior Direct Composite Restorations
Strong, bioactive composite provides protection against recurrent caries
Paiman Lalla, DDS
When placing composite restorations in the anterior region, it can be challenging to make them both esthetically pleasing and beneficial for your patient. The contraction of the composite after light curing and the film thickness of the bonding agent can result in microleakage and marginal stain lines, which can also lead to cariogenic bacteria, postoperative sensitivity, and secondary decay.1,2 Today, clinicians have numerous direct restorative products to choose from, many of which have similar clinical characteristics. Selecting a material that can release and recharge beneficial ions, such as the one used in the following case (Beautifil Flow Plus® X, Shofu), can help to protect restorations that are susceptible to recurrent caries and restorative failure.3
A 56-year-old man presented to the practice with failed composite restorations on his maxillary left central incisor, lateral incisor, and canine as well as a receding gum line. His main complaint was the composite failure. Preoperative clinical photography was performed with a digital dental camera (EyeSpecial, Shofu) to improve treatment planning and shade matching (Figure 1 and Figure 2). After discussing possible treatment options, the patient decided against having the canine cervical lesion restored but provided informed consent for a treatment plan to restore the failed composite restorations.
Following administration of an anesthetic (Septocaine®, Septodont), coarse and fine diamond burs (Robot® Diamonds, Shofu) were used to remove the old composite restorations from teeth Nos. 9 through 11 and to slightly bevel the enamel margin of the preparations in a starburst pattern. The enamel surfaces of the preparations were then selectively etched with a 38% phosphoric acid solution (Etch-Rite™, Pulpdent) for 15 seconds and then thoroughly rinsed with water. Next, a universal bonding agent (BeautiBond®, Shofu) was applied to all of the surfaces of the preparations with a microbrush in one generous coat. It was left undisturbed for 10 seconds, air-dried for 3 to 5 seconds, and then light cured for 5 seconds with an LED curing light.
After the bonding agent was placed and cured, a mylar strip was placed to begin with the central incisor. Using a composite plastic instrument to hold the palatal aspect of the strip in place, a 2-mm increment of the high viscosity formulation of the flowable nanohybrid composite (Beautifil Flow Plus X [F00 A3], Shofu) was placed into the bonded cavity to develop the lingual aspect of the restoration and then light cured. This flowable nanohybrid composite was selected because it incorporates Shofu's Giomer Technology, which releases and recharges six beneficial ions that have been clinically proven to inhibit plaque, neutralize acid, and greatly reduce secondary decay. Furthermore, this bioactive composite demonstrates excellent flexural and compressive strength, maintains exceptional color stability before and after curing, and possesses patented nanofiller particles (400 nm) that provide enhanced mechanical properties and effortless polishing. The composite was then placed in 2-mm increments to restore the remaining facial surface of the cavity while using the "mylar pull" technique developed by Corky Willhite, DDS. This technique uses the mylar strip as an instrument rather than as a matrix. Before the composite is cured, the mylar strip is pulled to the lingual aspect, allowing for contouring of the proximal edges of the restoration. Each 2-mm increment of composite was cured for 5 seconds with an LED curing light. After an ultrafine diamond bur and 16-fluted carbide bur were used to complete the contouring, the lateral incisor and canine were restored in the same manner.
The patient's pronunciation of the letter "S" and his anterior guidance were checked to ensure proper lingual contours of the teeth, and then the final polishing was accomplished with a 32-fluted carbide bur and an 8-mm polishing disc system (Super-Snap®, Shofu). The restorative material blended perfectly with the surrounding tooth structure and attained an exceptionally high luster (Figure 3 through Figure 6).
The direct restoration of anterior teeth can be one of the most challenging procedures in dentistry. Due to the nature of direct restorative materials, their placement can cause complications in the anterior region. Selecting a composite that provides bioactive properties to protect against recurrent decay and restorative failure is one way to make these procedures more predictable, and another way is by utilizing a universal bonding agent that helps to avoid postoperative sensitivity. With premium products at an affordable price, successful and profitable outcomes are very likely.
About the Author
Paiman Lalla, DDS
International Congress of Oral Implantologists
San Fernando, Trinidad and Tobago
1. Lowe RA. "Smart" Class V preparation design for direct composites. Dent Today. 2015;34(2):137-141.
2. Swanson TK, Feigal RJ, Tantbirojn D, Hodges JS. Effect of adhesive systems and bevel on enamel margin integrity in primary and permanent teeth. Pediatr Dent. 2008;30(2):134-140.
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):621-627.