Addressing Composite Wear Rates- By Thomas W. Mitchell, DDS, FAGD

Introduction: 

This is #30 DO replacing a 10 year old completely worn out Heliomolar composite with a chip and decay at the distal marginal ridge. It's not beyond my imagination that this really needs a crown, but we've been discussing wear rates of composites so this will give us some info. I used Heliomolar for a long time prior to using Exquisite Restoration by Apex Dental Materials. Heliomolar is a microfill and for many years was the "gold standard" for wear rates of composites. All companies compared their products wear rates to Heliomolar, and rarely came close. Exquisite Restoration exceeds that.

Thomas W. Mitchell, DDS, FAGD
This is #30 opposing a PFM. The composite is Heliomolar bonded with Simplicity. We know there's some old arrested decay on the distal surface under the DMR and there's that chip on the DMR, so I want to intervene. Really this should be a crown, but Dr. Kanca and I have been having a great time with all the "arts and crafts" involved in rebuilding these. These procedures go pretty quickly and since we've been trying this for several years we both have confidence in a long term outcome. Obviously the wear rate is the issue, and we know that Exquisite will wear better than Heliomolar, so we are confident you can do this successfully.
Thomas W. Mitchell, DDS, FAGD
Yup it's a big wide prep with not much dentin backing the lingual (aka frequently fractured off) cusps. No indication of cracks across the pulpal floor. Still we really are relying on bond strength to hold this tooth together, that’s why I use Surpass Universal Adhesive. We've done this same procedure, as you may have seen, multiple times with success.
Thomas W. Mitchell, DDS, FAGD
With no distal tooth I placed a simple Toffelmeyer matrix. Then Clean and Boost dentin and enamel cleanser is applied for 15-20 sec. to clean and etch the enamel and dentin. Rinse and dry that and then re-wet the dentin with Bondsaver D (bond degradation preventer) to fluff up the smear layer. This allows access for the dentin bonding agent (Surpass 2) to penetrate the dentinal tubules. The solvent in Surpass 2 is designed to displace the water in the smear layer and open tubules, in doing so it pulls the resin in Surpass 2 down thru the smear layer and into those tubules. Then when we dry (to remove the solvent) it leaves just the primer penetrated into the tooth. A layer of pure resin (Surpass 3) is placed on top and air thinned. Finally a thin layer of Titan flowable composite is placed and it all is co-cured together. I have my Valo curing light turned up to “Xtra Power” so I'm only curing for 3 seconds. There's a lot going on in this step and we need to understand the what's and why’s, but it goes fairly quickly.
Thomas W. Mitchell, DDS, FAGD
With Exquisite Restoration we have bulk filled these preps up to 4 mm's deep since it is such a low shrink material, with no resulting white lines. I'm not a bulk fill fan because I'm an old anatomy professor, so I prefer to layer. My first layer is the distal marginal ridge. This then allows me to get rid of the matrix and I am left with just an occlusal filling to complete.
Thomas W. Mitchell, DDS, FAGD
With the matrix off, I layer Exquisite for the lingual triangular ridges. I use lots of Seamfree wetting resin and pressure to condense the composite and shape it with a flat bladded instrument and an acorn-shaped carver.
Thomas W. Mitchell, DDS, FAGD
Then the last layer completes the buccal triangular ridges. This technique is clearly shown at Jason Smithson's course on DentalTown. If you've yet to take it, it's really good and it's a chance to see some really beautiful dentistry.
Thomas W. Mitchell, DDS, FAGD
I had to adjust the occlusion at the distal 1/2 of the DL cusp triangular ridge. Then I quickly glazed/sealed the restoration with a quick application of Surpass 2 and 3. Final cure with the Valo light on “Xtra Power” is for 3 seconds from each direction.

Conclusion: 

I'm really happy that we're being bold enough to do these huge composites rather than place crowns on everything. Thanks goes to the guys at Apex Dental Materials for developing these great materials that are effective, easy to use and don't cost an arm and a leg. Hope you all get to try these procedures.

Case by: 

Thomas W. Mitchell, DDS, FAGD