Dentsply Sirona’s Complete Signature Workflow for Direct Restorations

Contents:

• Diagnosing class II carious lesions
• Planning and communicating the need for class II restorations with patients
• Prepping and restoring class II carious lesions
• Monitoring and supporting class II restorations 

Class II composite restorations are the bread-and-butter for all dental practices, yet they also can cause anxiety in even the best dentists. Below, we’ll discuss techniques in diagnosis, treatment planning, preparation, restoration, and supportive follow-up to make class II restorations pain-free for both the practitioner and the patient.  

Diagnosing class II carious lesions

The first step in completing a class II composite restoration is diagnosing the need for it. Schick^® intraoral sensors come in a variety of sizes in order to fit all patients, even pediatric patients. In addition, they deliver premium image quality with a high resolution. This minimizes the need for re-taking radiographs, thus limiting radiation exposure to a level that is “as low as reasonably achievable” (the ALARA principle). Having intraoral images also allows for less-invasive image-taking in the future, such as using an Axeos extraoral imaging device for check-ups and to help detect caries.

In patients with a gag reflex who cannot tolerate intraoral radiographs, extraoral panoramic bitewings with an Axeos extraoral imaging device can help diagnose proximal carious lesions that may otherwise progress undetected. 

As an adjunct aid in diagnosing approximal caries, transillumination could be helpful. With the modular LED-curing light SmartLite^® Pro, use the Illuminate tip to identify proximal areas of demineralization. This also allows you to identify cracks in case of larger and undermining caries lesions which could influence the prep design.

Planning and communicating the need for class II restorations with patients

Treatment plan acceptance can often be tricky. But, a picture is worth a thousand words, and the use of X-ray imaging software such as Sidexis^® can help communicate the need for restorations with patients.

Sidexis^® software’s lightbox feature allows the simultaneous display of X-rays and intraoral photos, demonstrating to patients the condition of their teeth, including any carious lesions. 

The online storage platform DS Core^® also allows for complex treatment planning beyond the routine direct restoration workflows. It allows for HIPAA-compliant collaboration with other dentists, specialists, and laboratories. By storing all patient X-rays and intraoral scans in the cloud, DS Core^® allows you to access patient data from anywhere, even the comfort of your home, and can be vital in planning the course of complex treatment.

An additional advantage in using one platform (i.e. DS Core^®) is the increasing importance of understanding the development of various aspects over time. The same size of a caries lesion may lead in one patient to immediate action, whereas in another patient having this lesion for years without progression may simply lead to continuing prophylaxis measures without the need to intervene.

Furthermore, although it is not possible for patients to realistically assess the clinical quality of a dentist’s work, patients may judge their dentist based on the technology that is visible to them. The use of modern software such as Sidexis^® and DS Core^® can help deliver a positive perception to patients, thus maximizing treatment acceptance. 

Prepping and restoring class II carious lesions

The restorative field can be properly isolated with an Ash rubber dam and steel clamps. This minimizes the risk of aspiration of instruments such as burs and also reduces the chances of salivary contamination of the restoration, thus maximizing the success of the restoration.

Once the tooth is anesthetized and isolated, the preparation can be initiated. Midwest Once^® carbide and diamond burs can be used for precision preparation with exceptional cutting. A round carbide bur can be used to begin the preparation on those difficult-to-reach second molars. The proximal box can be prepared using a straight flat-end carbide bur. Finally, an interproximal or tapered carbide bur can be used to obtain gingival clearance and remove any unsupported enamel at the gingival floor, which will facilitate matrix placement. 

A handpiece that can fit into the tight corners of the patient’s mouth with a high light output can help with access to and visualization of the carious lesion. The Midwest Stylus^® is one option that has a mid-size head and fusion-optics. It also features a unique air-flow design that reduces noise level by 10 decibels, which is advantageous for both the dentist and the patient. A mini version is also available for pediatric patients or patients with limited mouth opening. 

A matrix system should be used to create tight, natural contacts without requiring excessive interproximal finishing of the completed restoration. The Palodent^® matrix system comes with stackable rings to allow the restoration of multiple teeth at once, maximizing efficiency. It also includes a WedgeGuard that lets you prepare teeth significantly faster without worrying about damaging the adjacent teeth and gingiva. In addition, the guard can be detached after preparation, leaving the wedge in place, thus serving two functions. The matrix bands themselves have a pin-tweezer hole that allows easy placement and removal. They are also available in multiple sizes, including several bands that have a gingival apron for those tricky subgingival preparations. 

After the matrix system is securely in place, the preparation is etched (either in a selective enamel etching or total etch technique), rinsed, and air dried (but not desiccated). An adhesive system is applied with a microbrush. Microbrushes can be bent at a 45 degree angle to increase access to difficult-to-reach areas of the preparation. The Prime&Bond^® elect adhesive system has a minimal film thickness, thus preventing the adhesive from pooling into the corners of the proximal box. These pools typically appear radiolucent on X-rays and thus may be mis-diagnosed as a void or recurrent caries, leading to unnecessary replacement. In addition, Prime&Bond^® elect uses acetone to chase away residual water and contains PENTA (dipentaerythritol penta acrylate monophosphate ) that can chemically interact with hard tissue, creating a strong bond with decreased postoperative sensitivity.   

After the adhesive is air dried, it can be light cured. The SmartLite^® Pro curing light has a 10 mm active curing diameter with a homogeneous light output and its low profile LED tip allows correct positioning, which minimizes the risk of uncured adhesive, especially in those hard-to-reach areas.

To use flowable composite as a first layer in the gingival portion of the proximal box is a widely used technique to improve adaptation in this most critical area of a class II cavity. A material such as SDR^® Flow+ can be used to flow easily into every nook and cranny. In addition, its self-leveling properties allow for the placement of gap-free restorations without the need for agitation. Furthermore, due to its proprietary chemistry leading to a highly decreased shrinkage stress compared to convential flowables, it can be used in layers up to 4 mm making the application much less stressful compared to conentionaly flowables that are typically applied in 1-2 mm layers. 

As for the adhesive, proper curing of each increment, is often underestimated. The large active area of SmartLite® Pro’s Cure tip (10 mm diameter), its low profile, and the homogeneous light distribution allows effective curing in an easy way.

After placement of the flowable into the gingival portion of the proximal box, a packable composite can be incrementally placed and light cured. Spectra^® ST universal composite offers optimized handling and esthetics, with five available CLOUD shades. 

Upon removal of the matrix system, the restoration can be finished. If the matrix system was correctly utilized, there should be little to no composite flash; hence, the finishing step should be minimal. After occlusal adjustments are complete, finishing can be initiated. Finishing a new class II restoration is imperative in order to decrease surface roughness. This minimizes plaque accumulation and thus helps prevent recurrent caries. Finishing a restoration is also important for the comfort of the patient, as a sharp edge can cause irritation of the soft tissues, including the buccal mucosa and tongue. The Enhance^® finishing system can accomplish both the gross contouring and fine finishing of a new restoration, which increases efficiency. By applying more pressure, excess composite can be removed, and the restoration can be contoured. By easing off the pressure, the restoration can be smoothly finished. A mini version of this polishing system is also available for smaller restorations, for example, in pediatric patients. 

Monitoring, and supporting class II restorations

At recall appointments, the appropriately sized Schick^® intraoral sensor can be used to take high resolution X-rays to assess the status of previously placed restorations. Primescan^® can be used to take digital impressions of the patient’s existing restorations and can be integrated with DS Core^® to show patients the status of their oral health by using “before” and “after” impressions—and to monitor wear as well as tooth movement over time.

If you’ve placed your class II restoration properly with the techniques discussed above, it is unlikely to be dislodged during a routine prophylaxis, though this may depend on the material used to restore the teeth. A Cavitron^® ultrasonic scaler can be used around restorations with some modifications. For example, a thin insert—such as the Cavitron® Thinsert—with a low power setting and proper angulation of the tip can minimize damage to previously placed restorations. 

A Nupro^® handpiece in combination with a Nupro^® prophy angle can be used to efficiently polish all teeth, even those with composite restorations. While the use of a prophylaxis polishing cup and paste can increase the surface roughness and decrease the gloss of composite restorations, the micro-fine aluminum oxide of Nupro^® Shimmer can restore the luster of previous composite restorations without damaging them. Nupro^® fluoride varnish can be applied at routine prophylaxis appointments in high-risk patients to minimize the risk of recurrent caries under existing class II restorations.¹ This varnish comes in multiple flavors, is gluten-, SLS-, and dye-free, and allows patients to eat and drink just two hours after placement. 

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In conclusion, the use of specific techniques in combination with excellent restorative materials and products can increase the predictability of class II restorations, your productivity, and your patient’s trust in you and your office. Dentsply Sirona offers a variety of solutions tailored to your needs, so contact us now to determine the best products for you.