Patient Demand Is Increasing for Posterior Aesthetics

[Drsumitra]

CASE REPORT
This case illustrates the use of a modern composite resin and bonding agent to restore a mandibular second premolar tooth that had interproximal caries form after the placement of a porcelain veneer. The patient is a dentist who found that he was packing food in the contact area between his second bicuspid and the molar (Figure 1).

Clinical Procedures
The patient was anesthetized and a rubber dam (Hygenic [Coltène Whaledent]) was placed for proper isolation. I have found that rubber dam isolation is desirable when utilizing resin bonding agents and composite resin restorative materials. After the proximal area was prepared and the caries removed, no pulpal exposure was detected (Figure 2). (The dentist and patient did not wish for the stained pits to be included in the preparation.)

A sectional matrix band (Tab Matrix [Triodent]) was applied, and a wedge (V-Wedge [Triodent]) was placed interproximally to seal the matrix against the gingival margin. A separating ring (Triodent) was used to slightly separate the teeth and hold the matrix tight against the unprepared proximal surfaces. The preparation was thoroughly rinsed and left slightly moist for the wet bonding procedure. A self-etching dentin and enamel bonding agent (All-Bond SE [BISCO]) was liberally applied to the moist prepared surfaces (Figure 3) and dried with oil- and water-free air in order to remove the moisture and the solvent carrier in the bonding agent. The bonding agent was then light-cured for 10 seconds with an LED curing light (Bluephase [Ivoclar Vivadent]).

A radiopaque flowable composite resin (N’Durance Dimer Flow [Septodont]) was applied to the dentin surface (Figure 4) and thinned with an explorer before light-curing for 10 seconds (Figure 5). A posterior composite resin material (N’Durance Dimer Flow) was added in approximately 2-mm increments (Figure 6) and condensed with a metal instrument (Plastic Filling DE No. 1 [Hu-Friedy]) (Figure 7). Each layer placed was light-cured for 20 seconds (Figure 8) before adding the next layer.

A carbide finishing bur (ET OS1 [Brasseler USA]) was used to refine the anatomy and to remove any excess composite resin from the margins of the restoration. After the rubber dam was removed and the occlusion adjusted, the final restoration was thoroughly polished using composite polishing cups (ComposiPro [Brasseler USA]).

The final result is shown in Figure 9. Figure 10 shows a radiograph of the restoration in place illustrating the radiopacity of the restorative material and the flowable composite resin. The patient in this case reported no postoperative sensitivity problems and was extremely satisfied with the aesthetic and functional result.

DISCUSSION: COMPOSITE RESIN MATERIALS USED
This particular composite resin restorative material (N’Durance Dimer Flow) is reported to have high conversion (75%) of monomer to polymer, resulting is less free monomer and increased durability. Its nanodimer conversion technology also provides low polymerization shrinkage (1.2%), decreasing the chances of microleakage and bonding failures. It is reported to have optimized nanofillers at 81% by weight designed for high strength, high wear resistance, improved polishability, and high gloss. It is highly radiopaque and can easily be seen on a radiograph for verification of margins and detection of recurrent caries. This composite resin is made with a dimethacrylate based mix of monomers (BIS-GMA free) making it compatible with regular bonding agents. Its special dimer acid formulation is reported to result in more hydrophobicity and better color stability. And it is reported to have zero solubility and thus enhanced functional integrity of the restoration.

CLOSING COMMENTS
In my clinical experience, I have found that a well-placed posterior composite resin can last for many years. I have found that many patients desire tooth-colored, natural looking alternatives to amalgam or gold. A direct composite resin, properly executed, can be a viable option for such patients.