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K. William Mopper, DDS, MS,explains his protocols forchoosing anterior andposterior composite resinmaterials in aestheticrestorative dentistry

K. William Buddy Mopper, DDS, MS, is in private practice in

Winnetka, Illinois, where he has been involved with creating

dental aesthetics for 42 years. He is an internationally

renowned lecturer in aesthetic dentistry with an emphasis on

composite bonding using direct application techniques. He

co-authored,A Complete Guide to Dental

Bonding, which was the first definitive

book for the dental profession describing

bonding techniques. He is a member of

the Academy of Esthetic Dentistry, and a

fellow of the American Academy of

Cosmetic Dentistry, diplomat of the

American Board of Pediatric Dentistry,and a fellow of the American College of Dentists. He taught

direct resin bonding at many major Universities including the

University of Minnesota, State University of Iowa, the

University of Nebraska, Louisiana State University, the

University of Illinois and the University of Kentucky. He is the

recipient from the American Academy of Cosmetic Dentistry

of an award for Lifelong Commitment to Providing Excellence

in Continuing Education in Cosmetic Dentistry and an award

for Outstanding Contribution to Cosmetic Dentistry. He

received the New York University College of Dentistry Irwin

Smigel Prize in Aesthetic Dentistry, and the Lifetime

Achievement Award from GenR8TNext seminars. He is

director of education for the Center for Esthetic Excellence

(Chicago) and is co-founder and chairman of Cosmedent, Inc.,

where he is responsible for its educational programs and

product development. Buddy Mopper will be speaking at the

World Aesthetic Congress on Friday 12 Saturday 13 June

2009 in London. For further information and to book your

places, please call Independent Seminars on 0800 371652 orvisit www.independentseminars.com/wac.

www.dentis try. co.uk

Correct use of composite resins

Aesthetics: When done properly, one of the most aestheticrestorations attainable

Timesaving: Placed in one practice visit

Control: Aesthetic and functional results are in your hands

Minimally invasive: The most conservative restorativematerial choice available, helping to ensure long-term health ofthe tooth

Biologically compatible: Extremely compatible with thegingival tissue, when properly placed and polished

Wear: Will not wear the opposing dentition

Handling properties: Easy to handle, manipulate, andcontrol

Creative: Maximum creativity according to choice, technicaland artistic abilities

Reparability: Easy to repair and can also be used for all-ceramic and PFM repairs

Long-lasting/high strength: Modern chemistry(research on particle size and filler content) has increased thestrength and longevity of composite restorations.

Table 1: Advantages of direct composite restorations

Figure 1: Maxillary anterior composite restorations at 22.5 years

postoperatively. Only minimal chipping and slight recession can

be seen. Note the highly polished surface of the microfill

composite resin material (Renamel Microfill, Cosmedent)

Figure 2: Microfills are exceptionally color stable and wear

resistant. Note the excellent color match of the restoration to

the shade tab (VITA Classical, Vident) after 22.5 years

Figures 3a and 3b: A shallow labial prep is placed ranging

from 0.8 mm at the incisal to 0.4 mm at the gingival. The

gingival margin is placed 0.3 mm below the free margin for

aesthetics. The application of Complete (Cosmedent) bonding

adhesive after a total-etch technique was performed

Figures 4a and 4b: Lingual surface of tooth six is reduced

about 0.5 mm across the entire incisal third, allowing a

complete labial-lingual wrap of incisal edge, creating better

fracture resistance/retention form. The first application of

Renamel NANO A2 is placed lingually to establish canine rise.

(Note this materials no-slump, no-stick properties allow easy

sculpting/shaping of the incisal tip)

Clinical

Today, in an attempt to replicate lifelike tooth structureaesthetically, there are a multitude of anterior andposterior composite resin materials from which tochoose.

As a result, dentists face a dilemma in deciding whatproduct to use, and when. This article will explain theprotocol that I follow and will also help readers identifyand utilise the ideal product for a specific use that theymay have in mind.

In my experience, there is no other dental material asversatile and useful as this category of restorativeproducts. There are many advantages to understandingand using direct composite resins regularly in yourpractice (Table 1).

When one truly understands how to properly usethese materials, long-lasting, truly aesthetic results areeasily achievable. Composite resin can help you produceinvisible aesthetic restorations of all types. I know this

from my personal, long-time clinical experiences withthis class of dental materials and their associatedtechniques.

I have been using light-activated direct compositeresin restoratively for more than 35 years , and for the past20 years my practice has been limited to producing

Article reprinted by permission ofDentistry Today, 2008 Dentistry Today. Mopper KW. Lets talk composites! Dent TodayOctober 2008;27:118-122.

K. William Mopper, DDS, MS,explains his protocols forchoosing anterior andposterior composite resinmaterials in aestheticrestorative dentistry

K.William Buddy Mopper, DDS, MS, is in private practice in

Winnetka, Illinois, where he has been involved with creating

dental aesthetics for 42 years. He is an internationally

renowned lecturer in aesthetic dentistry with an emphasis on

composite bonding using direct application techniques. He

co-authored, A Complete Guide to Dental

Bonding, which was the first defini tive

book for the dental profession describing

bonding techniques. He is a member of

the Academy of Esthetic Dentistry, and a

fel low of the American Academy of

Cosmetic Dentistry, diplomat of the

American Board of Pediatric Dentistry,and a fellow of the American College of Dentists. He taught

direct resin bonding at many major Universities including the

University of Minnesota, State University of Iowa, the

University of Nebraska, Louisiana State University, the

Universityof Illinois and the Universityof Kentucky. He is the

recipient from theAmericanAcademy of Cosmetic Dentistry

of an award forLifelong Commitmentto Providing Excellence

in ContinuingEducation in Cosmetic Dentistry and an award

for Outstanding Contribution to Cosmetic Dentistry. He

received the NewYork University College of Dentistry Irwin

Smige l Prize in Aesthet ic Dent istry, and the Lifetime

Achievement Award from GenR8TNext seminars. He is

director of education for the Center for Esthetic Excellence

(Chicago) andis co-founderand chairman of Cosmedent,Inc.,

where he is responsible for its educational programs and

product development.Buddy Mopper will be speaking at the

World Aesthetic Congress on Friday 12 Saturday 13 June

2009 in London. For further information and to book your

places, please call Independent Seminars on 0800 371652 orvisit www.independentseminars.com/wac.

Aesthetics: When done properly, one of the most aestheticrestorations attainable

Timesaving: Placed in one practice visit

Control: Aesthetic and functional results are in your hands

Minimally invasive: The most conservative restorativematerial choice available,helping to ensure long-term health ofthe tooth

Biologically compatible: Extremely compatible with thegingival tissue,when properly placed and polished

Wear: Will not wear the opposing dentition

Handling properties: Easy to handle,manipulate, andcontrol

Creative: Maximum creativity according to choice, technicaland artistic abilities

Reparability: Easyto repairand can alsobe usedfor all-ceramic and PFM repairs

Long-lasting/high strength: Modern chemistry(research on particle size and filler content) has increased thestrength and longevity of composite restorations.

Table 1:Advantages of direct composite restorations

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aesthetic changes using only composite resin. Althoughmy practice is all encompassing, with my partners doingindirect restorations of all kinds, I have limited my

practice to direct placement restorative techniques.Procedures that I use direct composite resins for include: Class I restorations Class II restorations Class III restorations Class IV restorations Class V restorations Tooth shaping Tooth alignment Diastema closure Repair of intraoral defects Veneering for colour change Veneering mutilated dentitions Tooth lengthening Incisal edge reinforcement Composite and porcelain repairs.

Composition of composite resinsWhat categories of composite resin materials are availableto us for use in our clinical armamentarium? Letsexamine them by discussing their properties and seeingwhere they fit into our clinical techniques.

MicrofillsMicrofills are important if you want to create trulyaesthetic, life-like restorations. This class of compositeresins offers the highest level of aesthetics because theymost closely simulate the actual enamel surface of atooth. Since microfills have the smallest average particlesize (0.04 microns) of direct composite resins, theypolish to a higher lustre than any other material on themarket. They also hold their polish over time andexhibit better wear characteristics than other types ofcomposite resins. Microfills are also more stain andplaque resistant, making them more biologicallycompatible with the gingival tissue. In addition, theyhave the highest refractive and reflective index of anycomposite resin category, producing the most realistictranslucency.

However, microfills are less filled than othercomposite resins. As a result, they will not exhibit thesame strength-properties as microhybrid or nanofillcomposites. Because of this, I use a layering techniqueplacing an enamel layer of microfill composite resin(Renamel Microfill, Cosmedent) over a stronger, dentinelayer composite. For the dentine layer(s) I use either amicrohybrid or nanofill composite (Renamel Microhybridor Renamel NANO, Cosmedent). Restorations built inthis way exhibit optimal aesthetics and wear resistancedue to their outer microfill enamel layer.

MicrohybridsMicrohybrids are able to most closely simulate thedentine of natural tooth structure. Because of theirhigher strength and greater opacity, microhybrids areperfect for supporting the microfill enamel layer.Microhybrids have a larger particle size than the nanofilland the microfill composites, resulting in higher-strength

properties. Since microhybrids are the most opaque ofthe three composite types, they are also great for maskingout unwanted colour and achieving extreme colour changes.

Microhybrids are also less polishable, more difficult tomarginate, and will wear faster than microfill resins. Asmicrohybrids most closely simulate the dentine of toothstructure, they will not obtain the same aesthetic resultsfor an enamel layer as a microfill resin. In my practice, Iuse microhybrids as the substructure under microfills inareas that require high strength.

NanofillsThe incorporation of nanofill technology into compositeresins is an important advancement in the field ofaesthetic dentistry. Nanofill composites combineconventional-filler technology with nano particles toachieve both strength and aesthetics in one material.Currently, there are two distinct types of nanofillcomposites in the marketplace: completely nanofilled

resins and nano-hybrids (i.e. Renamel NANO,Cosmedent). Completely nanofilled resins containnanometer-sized particles throughout the resin matrix.Nano-hybrids, on the other hand, consist of largerparticles surrounded by nanometer-sized particles.

Although these nanofill materials vary in composition,the goal is the same, creating a universal dental composite.

As prev iously mentioned, nano-hybr ids conta innanometer particles combined with more conventional

filler technology. These large particles provide similarstrength properties to hybrid materials while exhibitinghigher polishability, as seen with the microfill resins.Unlike microhybrids, nanofill composites have a lifelikeopacious translucency that is very natural in appearance.It is important to note that these materials will not holdtheir polish as long as microfill resins and, as a result,may be more susceptible to plaque and staining overtime. However, when compared with conventionalmicrohybrids, nanofill composite resins will maintainbetter surface smoothness and are thus great for the

single-product user.Where should you use nanofill composites? Althoughyou can really use nanofill materials to create cosmeticdental restorations of all kinds, I have identified a few keyareas where nanofill composites fit into my dentalpractice. They are as follows: Posterior restorations Veneering lower anteriors Building up incisal edges

Clinicalwww.dentis try.co. uk

The classic class IV restoration When restoring or increasing cuspid rise.

They can also be used when the dentist wants to useonly one material, instead of layering a microfill over amicrohybrid; as a support material for Class IVrestorations; any tooth lengthening; adding cusps toworn molars or bicuspids; and for veneering mandibularanterior teeth (when strength is a concern); and posteriorrestorations.

Opaquers and tints

Opaquers and tints are key ingredients to creatingbeautiful invisible restorations. During the restorationprocedure, opaquers allow you to block-out unwantedcolour while tints help you bring the desired colour backinto the tooth. The use of both is where your creativity asa dentist can really shine! However, opaquers and tintsshould always be used sparingly. Also, be careful whenchoosing them as some manufacturers make thesematerials too opaque. Lets examine the difference

Figures 5a and 5b: After polymerisation of the incisal tip,

Renamel NANO (Cosmedent) was used on the mesial

proximal to add to the width of the cuspid to match the

other side of the mouth. Note the space between cuspid and

laterals is not fully closed because it would have delivered a

disharmony in size. Proper morphology of each tooth is

completed making finishing and polishing much easier

Figures 6a and 6b: Addition of facial NANO A2 and the use

gloved finger (no powder and clean and dry) to manipulate

material into place. Apply light pressure with a tapping

motion to allow for rapid and easy placement and pre-

contouring

Figures 7a and 7b: Use of titanium-coated instruments ensures

easy placement of nanofills without sticking. Similar to buttering

bread, the composite is spread and thinned simultaneously. A G3

instrument (Cosmedent) allows for easy placement on facial

surfaces. An IPC Carver (Cosmedent) cleaves excess material

interproximally and at gingival margins. Morphology andcontours are achieved, but the material has not yet been

polymerised

Figures 8a and 8b: After polymerisation of facial surface,

Renamel NANO (Cosmedent) Medium Incisal shade is placed

with a Multipurpose instrument (Cosmedent) into the incisal

areas to enhance the overall lifelike appearance of the

finished veneer (Note colour and translucency of this

material). The G3 instrument is used along with fingerpressure to aggressively compress incisal material into the

pre-formed incisal grooves

Figures 9a and 9b: Incisal material in place and polymerised(note the translucency difference between the incisal edge

and the body material). When gingival margins are involved,

apply a small amount of Renamel Microhybrid (A2)

(Cosmedent) material and sculpt with the IPC instrument to

completely seal gingival and proximal margins

Figures 10a and 10b: The G3 is used to smooth/sculptsubgingivally to completely seal margin. Material application

and morphology is complete (note how much attention is

given to properly sculpted tooth form). Then the material is

light-cured for 60 seconds

Nanofills

The incorporation of nanofill technology into compositeresins is an important advancement in the field ofaesthetic dentistry. Nanofill composites combineconventional-filler technology with nano particles toachieve both strength and aesthetics in one material.Currently, there are two distinct types of nanofillcomposites in the marketplace: completely nanofilledresins and nano-hybrids (i.e. Renamel NANO,Cosmedent). Completely nanofilled resins containnanometer-sized particles throughout the resin matrix.Nano-hybrids, on the other hand, consist of largerparticles surrounded by nanometer-sized particles.Although these nanofill materials vary in composition,the goal is the same, creating a universal dental composite.

As previou sly mention ed, nano-h ybrids conta innanometer particles combined with more conventional

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between these two materials.Opaquers: The main advantage of opaquers is that they

produce opacity and block light transmission. Use them

anywhere you would like to produce opacity in your finalrestoration. Since opaquers increase the value of arestoration, they are great for masking out metals anddark stains.

Tints: Tints are used to help increase the hue andchroma of your restoration. Since tints transmit light,they are great for adding translucency back into yourrestoration. Unlike opaquers, tints decrease value. I usethem to help develop a realistic-looking enamel surfacefrom within.

System advantagesTo excel in direct composite resin techniques, you shouldfind a system that gives reliable and long-lasting results then stick with it! Ask yourself the following question:How many composite materials have I shelved becausesome guru says another product is better only to bedisappointed once you have used it? When you arelooking for a system, you should consider certain criteria(Table 2).

Application techniqueFirst, one should understand that no material in itself willdeliver the ideal restoration. This is because materialselection is only one part of direct resin bonding. Second,one must consider the dentists technical ability. Propertechnique involves many components including thefollowing: proper preparation technique for eachprocedure; method of material placement this involvescomplete understanding of tooth morphology andsculpting techniques necessary to achieve it; knowledgeof layering and how to use various materials incombination to enhance the overall physical, aesthetic,and biologic results of each procedure (i.e. when to usemicrohybrid, nanofill, microfill, tints, and opaquers); andusing the proper finishing and polishing techniques toachieve the most lustrous, plaque resistant, stain resistantand wear resistant finished result. One must understandwhen and how to use finishing burs, discs, rubber

impregnated points, and polishing paste to obtain thedesired result. (Note: knowledge and technical abilities in

all the above-mentioned areas can be greatly enhanced byan excellent hands-on workshop experience. I wouldrecommend that you consider this if you have not alreadydone so.)

Case report:direct composite resin techniqueMany years ago, I placed direct composite resin veneerson my sons maxillary anterior teeth (6 to 11) to closespaces using only a microfill (Renamel Microfill,Cosmedent). Over considerable time, Robert had some

chipping due to aggressive eating habits. These defectswere easily repaired. Photos, taken at 22.5 yearspostoperatively, show minimal chipping of the compositematerial and excellent color stability of the material(Figure 1). As mentioned previously, microfills hold theirpolish long-term better than any other type of compositeresin material, especially when the right dentifrice andtoothbrush are used (Figure 2).

I made the decision to redo Roberts case in autumn

2007. The treatment goals were to achieve greataesthetics while establishing proper disclusion byimproving his canine rise. Therefore, the new aestheticrestorations were done by utilising both nanofill andmicrofill composites.

Let me take you through the reasoning involved in theproper material-selection thought process. I could havedone the entire case using a nanofill and achieved

excellent results, but I wanted the best of both worlds,both strength and aesthetics. I wanted a microfill surfacebecause of its long-term polishability and optimal,life-like aesthetics. I used a nanofill to complete thefunctional portion involving the right and left cuspids.This would give me the strength required on a supporttooth, along with great aesthetics and an excellent colourmatch to the laterals and centrals (the technique is shownin detail in Figures 3-16). Now, many would ask, why not

Clinicalwww.dent ist ry.co.uk

1. How does the material handle?

2. Does the finished material truly match its selected shade

guide?

3. Does the system make colour matching or colour

development easy?

4. Is the finished product colour stable over time? (15 to 20

years?)

5. How easy is it to polish, and will the composite hold the

polish over time?

6. How strong is the restoration?

7. What are the translucency and opacity characteristics of the

material?8. When finished properly, are the composite and the gingival

tissues biocompatible?

9. What material has adequate strength for the purpose of use?

10. What material is more wear resistant? Why?

Table 2: Key questions when selecting a composite

resin system

porcelain veneers? And, I would ask, why

porcelain veneers? What did we achieve with my sonafter 23 years? We achieved long-lasting results withminimal preparation. We observed only minimal (non-pathologic) recession due to material biocompatibility(and good oral hygiene habits); total colour stability withexcellent aesthetics; complete and intimate bond of thecomposite-to-tooth surface (no cementation); andeasy-to-repair restorations (Figures 17 and 18). Oh, andby the way Robert still eats ribs!

Figure 11: Final right cuspid

composite resin veneer

(tooth 6) after finishing and

polishing. (Figures 13-15

demonstrate finishing and

polishing steps on tooth 11)

Figure 12: Upper left cuspid (tooth 11). Composite application

complete and polymerised prior to finish (note the two most

important views when finishing and polishing are from the

incisal and profile. Incisal view: Sets up incisal gingival

contours, mesial distal contours and labial lingual relationships.

It also helps to visualise embrasure space development. Profile

view: Helps to silhouette one tooth against another to establish

the alignment and emergence profile)

Figures 13a and 13b: Use of discs to contour the labial

surfaces and to properly contour line angles and to develop

embrasure surfaces. Note retraction with an 8A instrument to

protect gingival tissue and an 8392-016 diamond (Brasseler,

USA) while trimming and defining the gingival tissue

Figures 14a and 14b: Further define tooth and pre-polish with

a fluted ET6 bur (Brasseler USA). A diamond-impregnated

point (Diamond Polisher Medium, Cosmedent) is used to

form/polish mesial and distal grooves and further develop

central lobe on cuspid

Figure 15: Fine and superfine

disks (FlexiDiscs, Cosmedent)

are used to achieve a high

lustre while maintaining facial

anatomy. This is followed witha buffing procedure (FlexiBuff

and Enamelize polishing paste,

Cosmedent) to achieve

exceptionally smooth surface

and immediate high polish. A

Felt FlexiPoint (Cosmedent)

and Enamelize polishing paste

are used to enhance the

mesial and distal grooves

Figure 16: Note the excellent

colour match of the

completed veneer to an A2

shade tab (Vita Classical,

Vident)

Figure 17: Completed case: tooth numbers 6 and 11 were done

with Renamel NANO A2 Body and Medium Incisal. Tooth

numbers 7 and 8 were done with Renamel NANO and overlaid

with Renamel Microfill A2 Body and Medium Incisal. Tooth 9

was not veneered, but the mesial and distal diastema closures

were done using only Renamel Microfill

Figure 18: Completed case at three-week post-op (note the

accurate color match)

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THE GOLD STANDARD

before

Dentistry and photography by: Newton Fahl, Jr., D.D.S.

after

Why settle for Bronze or Silver when...you can have Gold?

Dentistry and photography by:Bud Mopper, D.D.S.,M.S.

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