|
Indirect
posterior restorations using a new chairside
microhybrid resin composite system
Franklin
R. Tay, Stephen H.Y.Wei
Abstract
A
plethora of choices is available as potential
tooth-colored restoratives for the posterior
dentition. Advances in adhesive technology
and aesthetic chairside microhybrid composite
resins have permitted clinicians to perform
inlay/onlay restorations. The use of adhesive
indirect procedures offers advantages such
as better control of polymerization shrinkage
and anatomical form, when compared to conventional,
direct restorative techniques. This article
describes the use of a new chairside microhybrid
composite system as an indirect restorative
material, using semi-direct and indirect
techniques that can be accomplished within
the realms of a dental operatory.
Introduction
There
is an impressive array of tooth-colored,
restorative materials that are being marketed
as potential amalgam alternatives for the
posterior dentition over the past few years.42
On the glass ionomer side of the product
spectrum, high strength glass ionomer cements
have been advocated for use in the atraumatic
restorative technique17
because of their chemical bonding and fluoride
releasing potential. Resin-modified glass
ionomer cements have similarly been employed
in the primary dentition.40
On the composite side of the spectrum, new
materials like ormocer32
and giomer4 have recently
been introduced. Because of their limited
clinical track records, it will take some
time before their value as posterior restorative
materials can be assessed. Compomers have
gained rapid acceptance since their introduction,
especially in the European market, because
of their ease of use and aesthetic qualities.1
With the adjunctive use of etchants and
resin adhesive systems on enamel and dentin,10,50
the manufacturers' indications for the current
generation of compomers are currently expanding
from non-stress bearing restorations to
unrestricted use in posterior teeth.8
However, the rapid alteration in flexural
properties23 on water
sorption33 undermines
the usefulness of compomers as serious alternatives
to resin composites for extensive, posterior
permanent restorations.
Packable
composites have also enjoyed considerable
popularity, at least among clinicians in
North America, because of their improved
handling characteristics and increased depth
of cure.24 In terms
of mechanical properties, they do not represent
substantial improvements over universal
hybrid or microhybrid composites.29
Likewise, their purported bulk-curing potential
has not been substantiated.59
Wear
resistance of contemporary resin composites
has significantly improved, and good proximal
contacts can be consistently achieved using
the appropriate armamentarium.56
However, the technique sensitivity associated
with controlling polymerization shrinkage
still remains the biggest challenge in direct
composite restorations.7
Cavities that exhibit high configuration
factors are particularly prone to the detrimental
effects of polymerization shrinkage stresses.15
This may result in loss of adhesion from
cavity walls, post-operative pain caused
by cuspal deflection, and fracture of enamel
prisms adjacent to cavosurface margins.
These stresses can be extremely taxing on
currently available adhesive systems, since
there is a substantial difference between
early bond strengths and those obtained
after 24-hour aging.6
Development of shrinkage stresses during
the initial setting stage are directly related
to the viscoelastic properties of tooth-colored
restorative materials.9
These parameters are inherent material properties
that cannot be controlled by the operator.
Shrinkage stresses and marginal gap reduction
were reported using light-activation techniques
that attempt to alter the kinetics of the
rate of polymerization.25,27,34
However, the advantages of these alternate
curing modes have not been demonstrated
in recent studies.3,18
Moreover, controversy still exists regarding
whether the degree of conversion is compromised
when resins are photo-activated using these
novel techniques.44,49
Maximizing
the degree of conversion and minimizing
shrinkage stresses are opposing goals, a
consortium of which is difficult to achieve
with direct composite restorations. Thus,
the overall benefits derived from the use
of techniques that involve the acquisition
of new curing-units have to be further substantiated
in controlled clinical studies, in alliance
with the current philosophy of evidence-based
treatment in dentistry.41
Indirect
posterior composite restorations
Laboratory-processed
indirect composite inlays were first introduced
in Europe almost two decades ago, primarily
to overcome the problems of wear resistance,
proximal contacts and polymerization shrinkage
that prevailed with the clinical techniques
and materials available in that era.35,51
Indirect luted restorations have since been
augmented to include semi-direct, intraoral
and extraoral chairside techniques.31
They allow clinicians the financial advantages
of utilizing their chairside composite systems
without acute compromise in results, as
well as finishing the restorations in a
single appointment.12
Direct composite restorations are incontestably
more conservative and economical. They also
compare favorably with direct composite
inlays in small to medium preparations.47,56
Nevertheless, indirect composite restorations
do have a place in the contemporary restorative
arsenal. They may find wider applications
in more extensively involved cavity preparations
due to their improved control over anatomical
form and interproximal contour.5
With the adjunctive use of fiber reinforcement,
their applications have been further extended
to semi-permanent prosthetic rehabilitation
such as bonded inlay fixed partial dentures.20
Limiting
intraoral polymerization shrinkage to thin
films of luting composites still entice
a competitive edge when cavosurface margins
inevitably involve bonding to exposed cervical
dentin.53 Post-cure
heat treatment of resin composites does
not accrue any significant long-term improvement
in physical properties.16,57
However, the increased degree of conversion
achieved38 may result
in more biocompatible restorations that
are less susceptible to leaching of unreacted
monomers during hydrolytic or enzymatic
degradation of the polymerized resin matrices.2,46
Laboratory
vs. chairside composites for indirect restorations
The
current generation of laboratory-processed
microhybrid composites with increased filler/resin
ratios represents a significant improvement
in mechanical properties over the earlier
microfilled systems.52
They are activated using a combination of
curing modes, including heat, pressure or
light; and are comparable with contemporary
chairside composites in terms of wear resistance
and the degree of conversion.26
Indirect composite systems are available
with an elaborate assortment of shades and
opacities, and include high chroma color
modifiers. These systems enable the skilled
technician to produce highly aesthetic posterior
restorations that approach the life-like
characteristics of dental ceramics. However,
the handling of these composites necessitates
the acquisition of proprietary laboratory
equipment, and in terms of cost-effectiveness,
may deter their potential chairside applications
by even the most demanding clinician.
A
microhybrid, universal chairside composite
system (Esthet•X,
Dentsply DeTrey, Konstanz, Germany) has
been introduced recently. Although this
system does not represent a quantum leap
in technological advancement, it offers
an optimal combination of polishability,
strength, wear resistance and radiopacity
that renders it an important addition to
the contemporary universal microhybrid ensemble.
What makes this system unique is its comprehensive
shade selection that rivals current laboratory
composite systems. Using
an innovative shade management technique,
an incremental combination of opaque dentin,
regular body, and translucent enamel shades
are blended into the most common shade designations.
This eliminates much of the guesswork that
a clinician has to undergo in order to achieve
the required aesthetic results. With a filler/resin
ratio (ca. 60 volume % inorganic fillers)
and flexural strength (ca. 150 MPa) that
are similar to most of the second-generation
laboratory composites,52
this system is also indicated for indirect
fabrication of inlays, onlays, overlays
and veneers.14 The
use of an improved formulation of light-activated,
chairside composite that utilizes a "recipe"
concept in shade matching may not be in
the best interest of a veteran artisan or
a master technician. Nonetheless, it does
provide an alternative, albeit systematic
means of achieving clinically predictable,
aesthetically pleasing restorations. This
will be illustrated with a few clinical
examples using the semi-direct intraoral
and extraoral chairside techniques, as well
as the indirect technique of posterior inlay/onlay
fabrication.
Intraoral
chairside technique
This
technique is by far the most accurate,37
and economical means of fabricating a composite
inlay. As, the prepared tooth also serves
as the working die, no impression or model
is required. Such a technique is better
reserved for one- and two-surface restorations
due to the difficulty experienced in removing
the inlays from complex, multiple-surface
cavities. It is particularly useful for
composite restoration of medium-sized, class
II cavities in high caries risk individuals,
with gingival margins that are placed completely
in dentin,53 or in
cervical areas with reduced enamel thickness
[Figure 1-1 and 1-2].11 To facilitate easy
retrieval of the inlay after polymerization,
cavity walls were rendered undercut-free,
and prepared with more occlusal divergence
(15 to 20 degrees) than indirect inlay preparations.55
The cavity was also well lubricated (liquid
separator, E-Z Temp, Cosmodent, Inc., Chicago,
IL, USA) prior to composite placement. Similar
to direct composite placement, a contact
retaining ring (BiTine ring, Darway, Inc.,
San Mateo, CA, USA) was used to achieve
the appropriate proximal contact [Figure
1-3].
For
the Esthet•X
system, shade matching is simplified by
referring to the three sequential composite
shades that are used to create the corresponding
shade designation in the TruMatchTM shade
guide. The selected opaque dentin, regular
body and translucent enamel shades were
inserted incrementally and light-cured separately.
Chairside occlusal anatomy development was
performed using a bur set (Raptor composite
finishing burs, Bisco, Schamburg, IL, USA)
that is designed for creating the pits and
fissures, cuspal inclines and marginal ridges
in a stepwise and systematic manner [Figure
1-4].
Following
removal from the prepared cavity, the completed
inlay was postcured to enhance the degree
of conversion as well as dimensional stability.
The latter, in particular, prevents the
generation of shrinkage stresses after inlay
cementation. Post-curing was performed with
an inlay processing unit (Ivomat IP3, Ivoclar,
Schaan, Liechtenstein) that allows raising
of the curing temperature up to at least
110 C.38
Heat-tempering ovens or light-heat units
may be used when available. For economical
reasons, an autoclave that is universally
present in every dental operatory can serve
as an interim substitute, provided that
the time it takes to reach the desired temperature
is not a crucial issue for both the patient
and the practitioner.
As
it is difficult to achieve good bonding
to post-cured composite surfaces,42
the seating surface of the post-cured inlay
was gently sandblasted and treated with
a methacrylate surfactant (Composite activator,
Bisco) to enhance its bonding to composite
cements. Contamination of the subsequently
bonded surfaces was minimized using an adhesive
placement tip (True-Grip, Clinician's Choice
Dental Products Inc., London, Ontario, Canada)
[Figure 1-5]. Placement of a matrix band
prior to total-etching prevents inadvertent
etching of the enamel of the adjacent tooth,
and facilitates subsequent removal of the
cured cement from interproximal areas [Figure
1-6].30 A dual-cured
version of a simplified-step adhesive (Prime&Bond
NT Dual Cure, Dentsply DeTrey) that contains
sodium p-toulenesulphinate as an alternative
accelerator/reducing agent was used for
bonding.21 The use
of this dual-cured version, as recommended
by the manufacturer, is due to the fact
that some acidic, single-bottle adhesives
bond poorly to chemically-cured or dual-cured
composites.45 Inlay
cementation was accomplished using a dual-cured
resin composite cement (Calibra, Dentsply
DeTrey). The completed restoration is shown
in Figure 1-7. Radiopacity of the bonded
composite inlay was comparable to that of
amalgam in the post-operative radiograph
[Figure 1-8]. The absence of residual luting
composite overhang along the gingival margin
is also evident.36
Fig.1
Intraoral chairside composite inlay.
 |
|
|
| 1-1
Pre-operative
radiograph shows an upper first bicuspid
with a fractured amalgam and extensive
recurrent caries. |
|
1-2
Initial clinical view showing the extent
of recurrent caries. |
 |
|
|
| 1-3
The
finished preparation was lubricated
with a water-soluble separator and is
shown with a BiTine ring in place. The
opacious dentin shade of a microhybrid
composite (EsthetoX, Denstply) was used
as the initial increment. This was followed
by incremental placement and light-activation
of the regular body and translucent
enamel shades. |
|
1-4
The occlusal and proximal surfaces of
the restoration were anatomically finished.
A tight proximal contact could be seen
on removal of the matrix band. |
 |
|
|
| 1-5
The
inlay was removed for post-curing. A
methacrylate surfactant was applied
to the gently sandblasted seating surface
of the composite inlay to enhance its
bonding with the resin cement. |
|
1-6
The cavity was total-etched with a matrix
band in place to facilitate subsequent
cleanup of the polymerized resin cement
in the interproximal area. |
 |
|
|
| 1-7
Following
final occlusal adjustment, the polished
restoration and cavity margins were
sealed with a filled composite surface
sealant. |
|
1-8
Post-operative radiograph showing the
completed inlay restoration. |
Extraoral
chairside technique
Composite
inlays may also be fabricated in a single
appointment using a flexible silicone model.
Such a technique is less stressful both
for the patient and the practitioner, as
minor undercuts are tolerable and multiple
restorations may be performed extraorally.
However, more occlusal adjustment is anticipated
in the absence of an antagonist model. Marginal
discrepancies of inlays fabricated using
flexible dies are generally larger than
those fabricated indirectly on stone casts,
and are in the range of 100-150  .39
Compared with direct composite inlays, this
increase in gap dimension may result in
a higher incidence of submargination that
is caused by the lower wear resistance of
the luting resin composites.48,54
A releasing agent has to be used if a vinyl
polysiloxane (VPS) die is poured from an
impression of the same material. The use
of a releasing agent inevitably results
in some loss of surface detail.19
Figures
2-1 and 2-2 show a severely decayed lower
first molar with undermined buccal and lingual
enamel. Both mesiobuccal and mesiolingual
pulp horns were exposed following complete
caries removal [Figure 2-3]. They were capped
with a calcium hydroxide lining (Dycal,
Dentsply DeTrey) [Figure 2-4]. Undercuts
were blocked with a resin-modified glass
ionomer cement base (Vitrebond, 3M Dental
Products, St. Paul, MN, USA) and the preparation
was further refined to yield the required
outline form [Figure 2-5]. The VPS impression
was lubricated with a releasing aerosol
(Silicone mold release, Huron Technologies,
Inc., Ann Arbor, MI, USA) [Figure 2-6].
A high durometer, fast-setting VPS die material
(Mach-2, Parkell, Farmingdale, NY, USA)
was used to produce the flexible model [Figure
2-7] as well as the antagonist model. The
use of a closed-mouth impression technique58
(provides the cinician with the option of
generating a quick antagonist reference
in habitual occlusion with the use of a
disposable articulator. Although the technique
involves the use of additional VPS die material
and is not excessively accurate, it is helpful
for chairside fabrication of inlays/onlays
with partially or completely missing cusps.
This eliminates the frustration of having
to grind down the anatomy that was arduously
produced on the working die, and reduces
the time required for occlusal adjustment
during the try-in stage.
The
composite inlay was constructed with Esthet•X
system, using the layering technique described
previously, with the pits and fissures further
characterized with high chroma resins [Figure
2-8]. As the working die can be easily sectioned
from the flexible model with a razor blade,
better interproximal finishing can be achieved.
The inlay was post-cured following the try-in,
and then bonded using a total-etch adhesive
technique and a dual-cured resin cement.
The completed restoration and the accompanying
post-operative radiograph are shown in Figures
2-9 and 2-10.
Fig.2
Extraoral chairside composite inlay fabricated
with a flexible silicone die
 |
|
|
| 2-1
Pre-operative
micrograph shows a lower first molar
with extensive interproximal caries
and an anticipated pulpal exposure. |
|
2-2
Initial clinical view shows lateral
spread of carious dentin that involves
substantial undermining of buccal and
lingual enamel. |
 |
|
|
| 2-3
Pulp
horns were exposed after complete caries
removal. Undercuts were present along
proximal cavity walls. |
|
2-4
Direct pulp capping using a calcium
hydroxide lining material. |
 |
|
|
| 2-5
Finished
inlay preparation with undercuts blocked
by a resin-modified glass ionomer cement. |
|
2-6
A vinyl polysiloxane impression of the
inlay preparation that was lubricated
with a silicone mold release aerosol
to facilitate separation of the addition
silicone die material. |
 |
|
|
| 2-7
The
working flexible die model was made
with a high durometer die silicone (Mach-2,
Parkell), using a quick-setting, high
viscosity VPS material (Blu-Mousse,
Parkell) as a base. |
|
2-8
The inlay was fabricated using a chairside
microhybrid composite system (Esthet•X,
Denstply). Interproximal contouring
and surface characterization are more
easily accomplished with the extraoral
chairside technique.
|
 |
|
|
| 2-9
Clinical
view of the complete restoration. |
|
2-10
Post-operative radiograph of the completed
restoration.
|
Indirect
technique
Posterior
resin restorations with extensive caries
involvement that require extracoronal coverage
cannot be easily accomplished in a single
appointment and are more suitable for the
indirect technique. The rationale for choosing
composite or ceramic as materials for these
restorations is exquisitely discussed by
Roulet and Losche,43
Dietschi and Spreafico12
and Inokoshi.22 Fabrication
of serial indirect ceramic restorations
is best handled by experienced ceramists
in well-equipped laboratories. On the other
hand, single unit indirect composite onlays
and overlays, being an extension of the
chairside flexible model technique, require
less arduous protocols and may be adequately
performed in a dental operatory using the
minimal laboratory armamentarium.
Figures
3-1 to 3-3 show a grossly decayed lower
that subsequently required root canal therapy.
Preparations were performed on this tooth,
as well as the second molar, to receive
indirect luted restorations. The impression
was poured up in die stone and mounted using
a precision die system (Accu-Trac, Coltene/Whaledent
Inc., Mahwah, NJ, USA). Undercuts were blocked
with inlay wax and the dies were lubricated
with cold mold seal. Resin composite inlay
and onlay were fabricated using the EsthetoX
microhybrid system [Figure 3-4]. The post-cured
restorations were tried-in prior to cementation
to ensue an acceptable fit and shade matching
[Figure 3-5].
Fig.3
Composite inlay and onlay fabricated using
the indirect technique
 |
|
|
| 3-1
Pre-operative
radiograph of a grossly decayed lower
first molar that requires root canal
therapy. |
|
3-2
Clinical view of the carious lower
first and second molars.
|
 |
|
|
|
3-3
Onlay
preparation in the lower first molar.
|
|
3-4
Completed inlay and onlay fabricated
on a working die stone model using
Esthet•X
microhybrid composites.
|
 |
|
|
|
3-5
Try-in
of the indirect composite restorations
before cementation.
|
|
3-6
Clinical view of the bonded restorations.
|
 |
|
|
3-7
Post-operative
radiograph of the completed restorations.
|
Fig.4
Composite overlay fabricated using the indirect
technique
 |
|
|
|
4-1
A
hypoplastic and decayed lower first
molar that was prepared for a composite
onlay. Enough enamel was present to
allow reliable adhesion for a fully
bonded restoration.
|
|
4-2
The composite overlay was presented
on the second pour dental stone model.
|
 |
|
|
|
4-3
With
proper case selection, the bonded
composite onlay offers a less invasive
option compared with conventional
ceramometal or full ceramic crowns.
|
|
4-4
Post-operative view of the completed
restoration.
|
Staining
of the fissures was not performed as it
was considered unaesthetic by this adolescent
lady patient. The completed restorations
and accompanying post-operative radiograph
are shown in Figures 3-6 and 3-7.
A
composite overlay that was used to restore
a hypoplastic and grossly decayed lower
first molar is also illustrated in Figures
4-1 to 4-4. With proper case selection and
continued improvement in the wear resistance
of contemporary microhybrid composites,26,28
such a procedure represents a more conservative
approach for the rehabilitation of these
extensively involved teeth before resolving
to the more invasive prosthetic procedures.
Conclusion
As
more long-term clinical reports of the clinical
performance of indirect posterior composites
begin to emerge,13,53,56 their potential
as tooth-colored alternatives to amalgam
is increasingly auspicious. In certain aspects
such as fracture resistance, antagonist
wear and repair-potential, contemporary
indirect composite restorations are emulating
the supremacy of the more labor-intensive
and costly ceramic inlays and onlays. This
paper attempted to illustrate, without condescension,
the use of a new chairside microhybrid composite
system as an indirect restorative material.
Although initial aesthetics are promising
with the simplified shade selection technique,
the success of indirect posterior restorations
fabricated with this chairside system must
be further assessed over extended periods,
in terms of mechanical stability, wear and
durability.
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