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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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