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Perfect optical and structural toothmimetic with a modern compositeClarence Tam describes a restoration performed using Vocos Grandioso compositeThere is no single key to stress-free aesthetics in restorative dentistry today. Indeed, theingredients leading to the perfect direct composite result are multivariate and may dependto some degree on your artistic tendencies that day. It is no secret that the sine qua non ofcosmetic and restorative dentistry is predictability. Predictable restorative materials embodythe hallmarks of chameleon effect, ease-of-polishability, biomimetic physical properties,ideal texture and handling, minimal polymerisation shrinkage, superior wear resistanceand good radio-opacity. Basically, the more the material works and the less you have to,the better. Prior to this point, one turned to bonded porcelain restorations for strengthand durability. Vocos Grandioso is a cutting-edge nanohybrid composite representing aparadigm shift where direct composite restorations can be placed with such ease, physicaland aesthetic predictability that you will find yourself reaching for it time and again.

BiomimicryBiomimicry of a material is the next best thing to actually reproducing natural enamel anddentin for a restoration. Prior to this point , the numerous resin composites I had previouslytested featured numerous struggles in compromise. On one hand, a product may be reallyoptically-perfect, but a nightmare to handle. It may not stick to your instrument, but it

may not stick to anything. It might be a pleasure to butter and shape, but lack chameleoneffect and radio-opacity. In the development of Grandioso, Voco has strived to exactlyreproduce the optical and physical parameters of natural tooth structure, allowing anydirect restoration to restore the original strength of the tooth long-term.Physical propertiesGrandioso represents the culmination of years of collaboration in research that hasproduced a composite resin with a strikingly high filler weight percentage of 89% (w/w).Correspondingly, a high filler percentage equates with low linear polymerisation shrinkage,previously one of the main struggles of other composite systems. As recurrent caries is thenumber one stated reason for clinical failure, this feature allows for maintained marginalintegrity and optimal long-term success.

lastic modulus and thermal behaviourVoco has utilised two main ingredients that lend strength to Grandioso. They haveincorporated glass ceramics in a bed of resin featuring 60% functionalised nanoparticles(20-40nm). Strength is integral in the design of a composite as restorative materials willbe subjected to the same dynamic and damaging cyclical loads as natural tooth structure.Lending stiffness back to the tooth as well as minimally-disturbing residual tooth structuremust be an uncompromised quality. In my opinion, Grandioso is the most tooth-like direct

composite material available, boasting an elastic modulus over 16.55GPa (dentin range:16.55 to 18.62). The thermal loading figures are equally impressive by showing significantabsolute minimal dimensional change within a 5mm diameter lesion and an 11C variation.This is important to prevent cyclical thermal flexure and fatigue of residual tooth structure,a feature that would in its absence accelerate its demise.

Composite posing as porcelainThe reasons behind the outstanding surface longevity of Grandioso are multifactorial. Firstly,Grandioso boasts a Vickers Micro-Hardness reading in excess of 211 MHV that significantlyis more than two-fold greater than any other tested composite material and approaches thatof human enamel (350-450 MHV). This is significant in the resistance form and feature ofany restoration, and is invaluable for marginal resistance to wear and leakage. Indeed, thecombination of surface hardness, naturomimetic coefficient of thermal expansion and highfiller content make this composite a real alternative to ceramic/porcelain restorations.

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Dr Clarence Tam maintains a private practice in Remuera, Auckland, witha special focus on cosmetic and restorative dentistry. He is vice chairmanof the New Zealand Academy of Cosmetic Dentistry. You can contact

Dr Tam by email at clarence.tam@gmail.com or visit his website, www.cosmeticdental.co.nz.

Compressive and tensile strengthOne of the main factors that biased my attention to using Grandioso in all posterior bondedrestorative applications was its compressive strength. At 439 MPa, it is significant because itis the only composite material tested to date that actually exceeds the compressive strengthof my preferred indirect bonded porcelain material (IPS e-max). In this regard, it behaves likeporcelain, an enviable characteristic for any composite. This is important for the durabilityof posterior restorations because inelastic deformation or permanent set will destroy yourmarginal integrity and marginal bond. Stress under tension is usually the Achilles heel ofany material. Grandioso features a tensile strength value of 72 MPa, nearly twice that ofnatural dentin.

Stress-free aesthetics: meet the chameleonSculpting direct composite beauty is hard enough. Voco has engineered Grandioso torecognise this by allowing simplicity of not only placement, but also shade selection. Due

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Contact:Clarence Tam, HBSc, DDS cosmetic and general dentistryCosmetic Dental , 126B Remuera Road, Remuera, Auckland1050, New Zealand

(09) 524-2515 (work)(021) 833 543 (mobile)

E-Mail: clarence.tam@gmail.com

www.cosmeticdental.co.nz

to the unique optical properties of Grandioso, often, onlya main single shade is required for a completely invisiblerestoration. If you feel like being ultra-creative and mixingshades, you dont have to. Voco have created two uniqueshades: VCA3.25 and VCA5. In the case shown, A5 wasutilised for the cervical aspect of the MODB subgingivallesion, and VCA3.25 was used for the entire coronalaspect. The polishability of this composite is unmistakablyexceptional.

Simplicity in aesthetics, fortitude in predictability, andpleasure in placement make Voco Grandioso perhaps thesingle key to predictable aesthetics in restorative dentistrytoday. The following clinical case demonstrates the propertiesand advantages of this modern nanohybrid composite.

Clinical case

An 89-year-old female patient exhibited a case of deeprecurrent caries involving the proximocervical surfacesof tooth 24 MODB featuring an old amalgam restorationin situ. After clinical and radiographic analysis of vitality,as well as assessment of residual tooth structure, it wasdecided to replace the amalgam restoration with a directcomposite restoration. It was ascertained that such apolychromatic tooth featuring extensive pulpal sclerosiswould be best-restored with a direct bonded compositeresin restoration due to the need to preserve maximalresidual tooth structure. The premolar was isolated withrubber dam before the old amalgam removed from the tooth

and the caries extirpated by drilling (Figures 1-3). This wasfollowed by the adaptation of two sectional matrices (V-ringsystem, Triodent), which were fixed using the appropriatetensioners and interdental wedges (Figure 4). FuturabondNR (Voco), a light-curing self-etch bond, was selected as the

adhesive. After activation, the adhesive was massaged in for20 seconds. The application was followed by five seconds ofair drying as well as ten seconds of light-curing, according tothe instructions for use (Figures 5 and 6).

The marginal ridge was constructed coronally using thenanohybrid composite Grandioso in shade VCA3.25, whilethe cervical marginal ridge was created in shade VCA5(Figure 7). After finishing the mesial and distal proximalwalls, the remaining occlusal cavity was incrementallyfilled with Grandioso VCA3.25, whereby every layer was

polymerised for 20 seconds. The shade of the restorationprovides an excellent match to the existing dental hardtissue of 24 (Figure 8). Coarse contouring was followed byfinishing of the occlusal surface. Polishing culminated in thecompletion of the restoration (Figures 9 and 10). The post-

Figure 10: Result after occlusal adjustments andfinal polishing with D*Fine Double Diamond(Clinicians Choice Dental Products)

Figure 11: Post-operative PA demonstrating goodradio-opacity of Grandioso and precise adaptationto margins along with natural emergence profile

proximally

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Figure 1: Roeko (Coltene Whaledent) rubber damisolation and mesiobuccal oblique angle view of 24MOD amalgam restoration with proximocervicalrecurrent caries

Figure 4: Adaptation of dual Triodent V3 rings(Triodent Ltd) with sectional matrices and wedgesin place

Figure 7: Marginal ridge construction coronally withVCA3.25 Grandioso (Voco), cervically with VCA5Grandioso

Figure 2: Preparation photo with amalgam andcaries removed: mesiobuccal oblique angle

Figure 5: Activation of primerinto bonding resin of Single DoseFuturabond NR (Voco) and mixingof liquid A and liquid B

Figure 8: Mesiobuccal oblique post-restorativephoto showing close adaptation and shade matchof VCA3.25 Grandioso to slightly dehydrated toothsurface. Colour integration on full rehydrationshould be seamless

Figure 3: Occlusal view of preparation afteramalgam and caries removed

Figure 6: Application of Futurabond NR (Voco)into the preparation overlapping margins (20seconds) slightly before air thinning (5 seconds)and light-curing (10 seconds) as per manufacturersinstructions

Figure 9: Pre-polishing occlusal view after roughcontouring with NTI football and needle-pointdiamonds

operative X-ray image confirms the excellent radiopacityof Grandioso and shows the precise adaptation of therestoration at the margins, as well as a natural proximalemergence profile (Figure 11).