Dr. Parag R. Kachalia

Abstract

During the past 15 years, numerous technologies have come into the dental office, allowing forms of imaging ranging from a simple periapical radiograph to a 3D full-color facial scan. These technologies provide valuable data that can be used to synthesize a proper treatment plan; however, until recently each of these data sources typically resided in a different area and was accessible only by utilizing a multitude of software platforms. For one to examine the digital image gathering in a new patient’s journey, it is very likely extraoral photography will occur, an intraoral scan will be taken, a low-dose CBCT will be captured, still images may be taken within the mouth with an intraoral camera, digital intraoral radiographs may be captured with sensors or phosphor plates, and one may even gather near-infrared images as well as facial scans.

Once all these data are gathered, they may be stored in multiple areas including a standalone computer tied to a CBCT and an individual gaming laptop paired with an intraoral scanner. Photographs may be unlabeled on SD cards, and facial scans may be on a separate storage device. In addition, intraoral radiographs and images may be organized in 2D imaging software tied to a server.

With the many imaging technologies in a practice today, a clinician often must jump back and forth between multiple windows and computers in different rooms to view and study all data that have been captured. This can be inefficient and does not allow the ability to bring all the information together in 1 place or to merge data sets. Furthermore, sharing all the data with colleagues for comprehensive treatment planning can be complicated; third-party file sharing services need to be utilized, and each piece of the acquired data set needs to be uploaded separately.

Equally problematic is that the patient cannot view all their information in 1 place, and an educational opportunity is lost if they are forced to follow a clinician jumping between various software platforms. The solution would be a software platform that allows all 2D and 3D data acquired in a dental office to be stored and utilized in a singular hub.

Historically, dental imaging software was simply a place where 2D images were stored, and some platforms allowed 3D volumes to be viewed by launching an additional module. These platforms offered very little functionality beyond simple annotation of images.

The ideal platform for managing clinical dental images would offer improvements in the following areas: accuracy and efficiency; flexible viewing and storage of data; smart features to aid workflow; leveraging data for accurate diagnosis and planning; and collaboration with patients and colleagues.

In years past, imaging for a patient was straightforward. Most patients simply had bitewing, periapical, and orthopantomogram radiographs taken at regular intervals or as symptoms are detected. Today the recommended imaging could also include intraoral surface scans, specific intraoral and extraoral photographs, and 3D CBCT images.

The traditional workflow communicating the need for these images may be simple verbal communication or a handwritten note. This can work, but there is risk of error.

An ideal software platform would allow the dentist to prescribe specific 2D imaging requests down to a particular tooth on a patient as well as the type of device that should be used to acquire an image. In terms of CBCT imaging, the digital prescription should include the region of interest, the field of view requested, and the appropriate resolution.

In today’s world of multiple imaging devices, these scan requests become important for minimizing confusion between team members and for making sure the patient is having the appropriate imaging captured. Furthermore, the prescribed imaging requests should transfer to the hardware being used to acquire the imaging (

A key challenge with using multiple imaging devices involves storing and being able to view imaging data in an organized, customized manner. Clinicians should have the ability to view all data in 1 spot without having to flip between devices or access computers in different rooms.

In addition, one should not be forced to choose either a Windows PC or macOS ecosystem. Traditionally, dentistry was forced to be primarily PC based. However, today we have intraoral scanners, cameras, and digital sensors that can all work natively in a macOS ecosystem. The flexibility should exist for going back and forth between computer platforms and accessing all data from any computer in the office. All images acquired should automatically transfer and be housed in 1 software ecosystem.

As clinicians view these acquired images, they should be able to set up various layouts pertinent to proper diagnosis and treatment planning. In addition, they should have the ability to present these layouts to a patient in an organized manner, so patients can be properly educated on their treatment needs.

Platforms should allow extraoral photos, intraoral scans, CBCT, and 2D imaging to be displayed simultaneously. The flexibility should be present so that multiple diagnostics layouts for the patient can be created. When a patient has multiple needs, the software should be able to create organized workspaces, with an area having all the corresponding images for a tooth on the upper right side with a problem vs another workspace for the lower left (

If one looks at software development outside dentistry, there has been much focus on the user interface and how the end user interacts with data. Although simple functionality of drag-and-drop features has been available in basic consumer software packages for years, this has been missing from many dentistry-specific imaging platforms.

Dental software needs to be intuitive and automated so that basic things such as tooth anatomy can be recognized and used for organizing all images tied to a specific tooth. This automated image management should be able to complete proper sorting of radiographs as they are imported or taken.

Importing 2D radiographs and extraoral images can be laborious in many software platforms. To bring radiographs and photographs into many imaging platforms, images must be imported individually, utilizing multiple clicks. This is far less efficient than simply dragging images from a file into the system. With most dental image management platforms today, each individually imported image must be oriented and labeled to appear properly in the database. In addition, when a radiographic image is acquired, the software must be told on the front end which zone is being captured so that the digital image is “mounted” properly for viewing the full set of images.

An intuitive sorting feature would allow the teeth to be recognized by anatomical landmarks and be placed appropriately into the database to display in the correct sequence when viewed on screen. As software learns to recognize teeth, a focus feature should be available, so that with a simple click on a tooth, the clinician can access all the data available for that tooth. Today, this can be complex and often requires clicking through numerous menus.

An ability of the software to recognize landmarks should also allow the software to merge data sets from different image sources and technologies. If the patient has had a surface intraoral scan and CBCT image taken with adequate overlapping data, a fusion of these data sets should occur in a near-automatic fashion. This fusion allows proper planning for prosthetic, periodontal, and implant therapies (

Leveraging Data for Accurate Diagnosis and Planning

We live in a world where the GPS systems in our cars guide travel and at times automatically update to offer a different route when there is traffic or an accident. In addition, we can tell the GPS our preferences, such as avoiding toll roads or basing a route on time vs distance. As drivers, we are still responsible for navigating the route we believe is best, and the GPS does not replace the driver. Rather, it acts as an aid. Dental image management software today should have a similar guidance ability based on basic parameters we set up within the software.

If we take CBCT technology into consideration, it is incredibly useful in aiding the practitioner in coming to a proper diagnosis for many clinical situations. However, preparing the proper views and slices can be very time consuming. Software today should aid dentists in setting up proper views for common studies of the temporomandibular joint, airway, mandibular canal, and endodontic regions.

Ideally, artificial intelligence would detect all these areas. But at the simplest level, once the clinician identifies a few basic landmarks, the software would then do the rest (

Another key area for leveraging data for accurate diagnosis and planning would involve the identification of edentulous areas and a proposal for virtual tooth replacement. A significant portion of the population is missing 1 or more teeth, and many wish to have these areas restored with dental implants.

For more than 10 years, there has been a focus on having the prosthetic requirements guide the details of the implant placement. However, this is easier said than done.

In traditional workflows, a digital or physical impression would be taken to create a model. The model would then have a wax-up done upon it and this would lead to a model-based surgical guide that would not consider the true bony anatomy.

Designing Software That Meets Dental Professionals’ Needs

In more advanced workflows, an intraoral scan could be combined with CBCT images and planning could commence. However, this often requires sending the data from both imaging technologies to a third party for merging of the data sets, or at least exporting the data into a third-party design software. By having this capability built into imaging software, the clinician could easily show the patient a proposed placement of an implant-supported replacement for a missing tooth or multiple teeth by having it virtually placed into an intraoral scan and properly oriented with the CBCT. This allows the clinician to determine whether implant placement is feasible and what specific implant may be utilized for the procedure (

Collaboration With Patients and Colleagues

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One significant issue with dental imaging software has been the ability to share acquired data and collaborate on cases. Clinicians have had to go through the cumbersome task of exporting data sets to various third-party software platforms and then reimporting these images into an individual clinician’s dental imaging software.

Ideally, a simple workflow should allow the referring dentist to decide which data need to be shared, and a single secure portal would be established for viewing all the data. This portal should include some basic tools to allow users to study the images and the clinical information they can provide. This is of particular importance in multidisciplinary cases involving dentists in different locations. Everyone must be on the same page for these cases to be successful and completed in a timely manner. When data is transferred improperly, there can be negative consequences for patient care.

Patient experience is what may drive the profitability and long-term success of a practice. In the past, patients simply did what their health care practitioners told them. However, today’s patient may want significantly more information before committing to a treatment plan.

Nearly two-thirds of all individuals learn visually, and clinicians should use the various image-based data sets to communicate with and educate patients. For nearly 30 years intraoral cameras have been present in dentistry, and many practices have used this technology to educate patients.

The challenge today is that photography is simply a subset of the data acquired. Digital software today must be designed so all pertinent data can be presented to the patient on 1 screen, and the patient can easily follow along with the clinician as areas of disease are pointed out and a plan is formulated for proper oral care.

Imaging is central to any dental treatment planning process, and user-friendly software solutions must exist to leverage these data sets. Imaging software must allow one to interact with the data and not simply store and view data.

If software does not evolve, we will face data overload and not be able to effectively use the technologies available for improving patient care. Although these concerns and clinical needs for enhanced imaging software are real, they are not going unnoticed. DTX Studio by DEXIS and other software platforms are addressing the various pain points that have been described, so that clinicians can more effectively diagnose cases and plan treatment.

Articles

Earn up to 1/2 Continuing Education Credit after reading this article about the necessary features to make dental imaging software more efficient and effective for dental practices.

	In the following two cases, learn how many dental products worked together to help two dental patients have their problems solved.

	Included in the products used is a posterior composite, 

. To learn more about predictably placing posterior composites, 

	Patient presented with recurrent caries in the distal box form of tooth No. 13 and new approximal caries on the distal of tooth No. 12. After consultation with the patient, a decision was made to remove the existing restoration and caries and place direct restorations.

	After administering anesthesia, the teeth were isolated utilizing a rubber dam. After complete caries excavation, the teeth were restored one at a time in order to achieve proper anatomical proximal contact. The system used was a sectional matrix (

. The deepest portion of each preparation was then measured, and both were found to be inside of 5mm. This finding allows one increment of the SonicFill A3 composite to be placed. After utilizing a total etch protocol and fifth-generation adhesive (Optibond Solo+), a single increment of SonicFill composite was placed, sculpted and fully cured utilizing a 

	To achieve thorough polymerization, the restoration was initially cured for 20 seconds from the occlusal surface as well as 20 seconds from both the buccal and lingual surfaces after removing the sectional matrices. After removing the rubber dam, minor contouring was completed utilizing a 16-fluted carbide composite finishing bur (

). The restoration was polished utilizing a three-step silicone-impregnated rubber point system (

New product alert: Learn more about Maxcem Elite Chroma

	Patient presented with recurrent caries in the mesial and distal box form of tooth No. 30, and the adjacent teeth presented with clinically acceptable restorations.

	The patient was informed the new restoration would be fairly large in size and the patient should consider an indirect restoration to minimize the chance of cuspal flexure and fracture. Taking into account the risks, benefits and alternatives, the patient decided to have a direct restoration placed. After administering anesthesia, the teeth were isolated utilizing a rubber dam. Upon complete caries excavation, the prepared surfaces were matrixed to allow for a properly contoured restoration to be placed. The system used was the V3 Matrix, the Wave-Wedge wedge and 

	The deepest portion of the preparation was then measured, and both were found to be inside of 5mm. This finding allows one increment of the SonicFill 2 composite to be placed. After utilizing a total-etch protocol and fifth-generation adhesive (Optibond Solo+), a single increment of SonicFill 2 composite was placed, sculpted and then fully cured utilizing a DemiUltra LED curing light.

	To predictably achieve thorough polymerization, the restoration was initially cured for 20 seconds from the occlusal surface as well as 20 seconds from both the buccal and lingual surfaces after removing the sectional matrices. After removing the rubber dam, minor contouring was completed utilizing a 16-fluted carbide composite finishing bur (ET Series [Brasseler USA]). The restoration was polished utilizing a three-step silicone-impregnated rubber point system, Ultradent’s Jiffy Polishers.

Related reading: Why you should consider Kerr's Demi Ultra curing light

	Watch the technique video below for more information...

In this how-to dental technique, Dr. Parag Kachalia shows dentists in video and text form how he used posterior composites to help two patients.

Technique: How posterior composites made a difference in two cases

	In the days of G.V. Black dentistry, the watch-and-wait approach actually had a tremendous amount of merit. Clinicians, at times, were able to diagnose caries at an early stage; however, preparation form for amalgam restorations did not lend itself to conservative dentistry.

	Even if caries was diagnosed at an early stage, a significant amount of tooth structure would need to be removed simply to retain these restorations. In the last decade, numerous technologies have come to market, allowing practitioners to discover caries at the early stage, and the practitioner now has the ability to treat this disease through remineralization protocols or minimally invasive surgical intervention.

More from Microcopy: How to extract teeth as atraumatically as possible

	If a practitioner chooses to remove the caries surgically from the tooth, he or she must focus on creating a conservative preparation form and maintaining as much tooth structure as possible. Resin restorations do not require specific preparation parameters, and the goal with these restorations is simply to remove the decay. In the past, the bur of choice for operative preparations was a 557 or 330 bur. While decay can most definitely be removed with these burs, unfortunately an extensive amount of healthy tooth structure is also unnecessarily removed due to the relative large size of these burs. In this day and age, one must consider using the smallest instrument possible. Hard-tissue lasers and air-abrasion units can offer a conservative means for caries removal; however, these devices require a large-to-moderate investment in equipment, and the workflow can become more complicated than necessary. 

	A simpler solution may be to simply opt for innovative and cost-efficient smaller burs that have been designed for conservative restorations. These burs tend to have appropriate cutting efficiency yet they are nearly 70 percent smaller than traditional operative burs.  

	One particular bur that accomplishes this task is the 1300 FS bur by 

. It is a diamond-coated bur with a tapering cutting surface. This shape allows for conservative excavation of a carious lesion at the tip of the bur while creating a funnel effect as caries is removed with deeper bur penetration. 

	The small tip diameter allows for minimal preparations to occur many times without the need for pulpal anesthesia.  In addition, the funneling effect allows proper visualization while creating a path for proper adhesive and flowable resin placement. Flowable composites have improved drastically in the last few years, and many flowable composites now have physical properties that rival traditional hybrid composites just a few years ago.

More from Microcopy: Microcopy introduces NeoDrys "Pink to Make You Think" campaign

	In the clinical case depicted, the patient presented with occlusal caries on the lower left second bicuspid. The primary carious lesion was centered in the distal pit with early caries present in the mesial pit (

	The decay is removed in both the distal pit and the mesial pit areas with no anesthesia while utilizing a 1300 FS bur. 

	After caries removal and proper isolation (Isolite Systems), the tooth is restored with a highly filled flowable composite (G-aenial Universal Flow, 

		The patient was happy the carious tooth was restored in an efficient manner with zero discomfort and that a vast majority of healthy tooth structure was maintained (

		The combination of innovations in rotary instrumentation and resin materials allows clinicians to provide minimal intervention with maximum effectiveness.

In the days of G.V. Black dentistry, the watch-and-wait approach actually had a tremendous amount of merit. Clinicians, at times, were able to diagnose caries at an early stage; however, preparation form for amalgam restorations did not lend itself to conservative dentistry.

How to use minimal intervention for maximum effectiveness

	Over the last decade many new technologies have been incorporated into dental practices, including digital impression systems, diode lasers, digital radiography, LED curing lights and caries detection devices yet many individuals are using the exact same handpiece they have always used.

	Most likely this is an air-driven handpiece with a high pitched whistle and a moderate amount of torque.

	The whistle and vibration of these handpieces tend to cause a fair amount of anxiety in our patients, and the soothing environment clinicians try to provide in their offices is destroyed the moment they step on the rheostat. 

Related reading: 5 reasons to switch to electric handpieces

	The question must be asked whether handpieces have evolved beyond these issues.

	The Borden highspeed air-driven handpiece debuted in 1957, and this introduction revolutionized dentistry; however, only incremental changes have occurred in the air handpiece arena since this time. Air-driven handpieces today are certainly lighter, smaller and somewhat quieter then they once were; however, these advancements are still relatively minor. Practitioners continue to battle the fact that air-driven handpieces tend to lose their cutting efficiency with dense materials and patients continue to have anxiety based on the noise and vibration associated with these handpieces.

	The solution to these issues resides with electric handpieces. Electric handpieces have been available to the marketplace for many years, and while Europeans and Asians would not think about going back to air-driven handpieces, the penetration rate in the United States is still relatively low. Practitioners in the United States have been slow to adopt this technology because traditional electric handpieces tended to be heavy, bulky, difficult to maintain and somewhat confusing to use.

More on handpieces: 5 reasons to consider an air-driven handpiece

	The marketplace was clearly aware of the fact that electric handpieces have a tremendous amount torque leading to cutting efficiency; however, in many peoples eyes the bulkiness of the product and warnings related to potentially burning patients was not worth the benefit.

	In an air-driven handpiece, the speed is a function of the amount of pressurized air that can flow through the turbine. Unfortunately, as rotary cutting instruments meet resistance, the speed at which it can turn decreases and cutting efficiency is lost. In addition, air handpieces tend to have a fair amount of vibration, and the concentricity of rotary instruments decreases.

	In an electric handpiece, air only plays the role of speed regulation as the air approaches a sensor. When a bur meets resistance an electric motor is able to output more energy and continue cutting at essentially the same speed.

More on handpieces: What do women look for in a handpiece?

	Historically large motors with intricate carbon brushes were needed to maintain this torque level. Equally important, electric handpieces are able to cut more concentrically, leading to highly refined preparation.

	Advancements in electric handpieces today allow them to me be lighter, smaller, quieter, easier to maintain and more simple to operate compared to the earlier generations. In addition these benefits have come without sacrificing the tremendous torque and precision cutting ability of electric handpieces.


	The size and weight of electric handpieces has dropped significantly in the last couple of years. Manufacturers such as 

 now offer short motors which are nearly 30 to 40 percent lighter and shorter than motors offered only a few years ago. In addition,  companies like Kavo and NSK now have ultra-small head designs so electric handpieces can be used for people with smaller openings.

Related reading: 7 tips to extend the life of your dental handpieces


	The noise level of traditional air-driven dental handpiece has been a nuisance to patients and can damage the hearing of clinicians over the course of a career. Manufacturers today have electric hanpieces that operate at nearly 20 decibels less than traditional air handpieces. It is estimated that human ear senses a reduction of 10 decibels as almost a 50 percent decrease in loudness.


	In years past, electric handpieces contained carbon brushes that needed to be changed periodically to maintain ideal performance. Today’s handpieces are brushless, and many manufactures have created simple plugin cleaning units to help maintain the precision performance of the handpiece.

Related reading: 5 common misconceptions about electric handpieces


	In years past, many felt electric handpieces were confusing to use because of all the adjustments that could be made. Manufacturers today have integrated simplicity into their handpieces by integrating simple-to-use touch panels and preprogrammability. Manufacturers like Bien-Air have integrated an iPad into its surgical handpiece line, and KaVo has created a product called COMFORTdrive that is a simple plug-and-play electric handpiece that does not need any adjustments.

	A new generation of electric handpieces are available to the profession, and practitioners should consider an upgrade to these highly precise instruments. This upgrade will immediately be noticeable to patients in terms of increased comfort. In addition, it will lead to a positive return on investment in terms of practice efficiency and precision. 

Products, trends and reviews: Your guide to the latest in dental handpieces

Over the last decade many new technologies have been incorporated into dental practices, including digital impression systems, diode lasers, digital radiography, LED curing lights and caries detection devices yet many individuals are using the exact same handpiece they have always used.

Electric handpieces solve many problems

	Practitioners have been placing composite resin restorations for more than 60 years, and during this time, practitioners have gone from a world where only anterior teeth were restored with composite resin to a world where composite resin is used to restore essentially any tooth in the oral cavity.

	Over this time, the physical properties of the material have improved a great deal; however, the improved physical properties alone do not equate to successful restorations. This is particularly true in the posterior aspect of the mouth where many practitioners have struggled to predictably achieve composite restorations that have proper form and function and do not cause postoperative sensitivity. The placement of a successful composite restoration is multi-factorial and must take into account proper adhesion, material placement and polymerization. No single area can be ignored if the goal is to achieve long-term success.

	The world of adhesion has evolved greatly since the time that Buoncore introduced acid etching enamel in 1955. During the late 1970s, enamel etching became fairly predictable as most fourth-generation adhesive systems recommended a 32- to 40-percent phosphoric acid etch for 15 seconds. During this time, the phosphoric acid dissolves away hydroxyapatite crystals from enamel, creating a roughened enamel surface for resin to penetrate. The relative homogeneity found in enamel allows for fairly predictable enamel adhesion to occur.

Dentin, on the other hand, is composed of collagen, hydroxyapatite and water, and the concentration of each of these changes depends on proximity to the pulp. During the late 1980s, dentin bonding started to gain popularity, and, as clinicians placed phosphoric acid etchant onto the dentition, the goal was to gain exposure to the collagen network and mechanically lock resin into this network to achieve high bond strengths. Unlike enamel bonding, dentin bonding proved to be much more complicated because of heterogenous structure. Dentin bonding at this time became achievable; however, true success was based on methodical technique.

	Fourth-generation adhesive protocol consisted of three independent chemical components steps. The first step was to etch the dentin and enamel, followed by a rinsing and drying step. The next was to place a primer that would be soaked up by the collagen, and the third step was to apply the adhesive. To this day, fourth-generation adhesives, such as Optibond FL by Kerr, are still considered to be the gold standard and have shown tremendous long-term success, with studies showing a 94-percent retention rate at 13 years.

	This generation of adhesives perform very well; however, they tend to be technique-sensitive and have a high film thickness, which can be challenging when adhesively bonding indirect restorations. To minimize the number of steps in the adhesion process, fifth-generation adhesives then came to market. The clinician was still required to etch both dentin and enamel; however, the primer and adhesive were put into the same bottle to allow for a single application after the etchant was rinsed off. Products like Prime and Bond NT by DENTSPLY, Adper Single by 3M ESPE and Optibond Solo+ by Kerr have been the primary adhesive for many clinicians for the last 15 years.

	Being that the primer and adhesive are combined into one step, the proper treatment of dentin after etching becomes critically important, and many clinicians have reported the patient can experience post-op dentin sensitivity issues. In many cases, this may be tied to the dentin being overly dried after etching and the collagen network collapsing. This can lead to lower bond strengths and exposed dental tubules.

	To combat the issue of sensitivity, self-etch adhesives have entered the marketplace. Two-bottle self-etch systems are generally referred to as sixth-generation adhesives. In this generation, the etchant and primer are combined into one bottle and the adhesive is in a second bottle.

	Throughout the last several years, clinicians and researchers have reported very good success in this area in terms of minimal dentin sensitivity and very high dentin bond strengths. The only negative aspect seen with some sixth-generation adhesives is a lower enamel bond strength as the acid and primers combination tends not to create as effective of an enamel etch pattern as that seen with phosphoric acid. To combat this issue, many practitioners have opted to etch the enamel only with phosphoric acid (selective-etch technique) prior to applying the sixth-generation primer and adhesive system. Two sixth-generation adhesives that have shown favorable results both in terms of dentin and enamel etching are Optibond XTR by Kerr and Clearfil SE by Kuraray.

	The newest generation of adhesives are commonly referred to as universal adhesives. These combine all components into one bottle and can be used both in a total-etch and self-etch technique. Generally speaking, products like Scotchbond Universal by 3M ESPE, All-Bond Universal by BISCO and Futurabond U by VOCO America are showing favorable initial results; however, the body of long-term success is limited at this time.
	Regardless of which adhesive technique is used by the practitioner, success must be achieved at this point to have a successful final composite restoration.

	For many years, practitioners have been told that to achieve a successful composite restoration, the material must be placed in increments that are less than 2mm to achieve proper polymerization of the material, as well as to prevent polymerization shrinkage stresses that can be distributed to the cusps. Generally speaking, practitioners that have used an incremental layering technique have achieved success; however, incremental layering can be very time-consuming and technique-sensitive.

	Most individuals would agree that if resin can be developed to allow for a bulk placement, posterior composite restorations could be placed more predictably and efficiently. To this end, over the last five years, numerous products have come to market to address these issues. Products like SureFil SDR flow by DENTSPLY Caulk and Xtra Base by VOCO allow the practitioner to place an initial base layer of resin 4-5 mm in depth. Once polymerized, the base layer is capped with a traditional layer of composite. This technique offers very good adaptation of the material because of the initial low viscosity layer that is placed followed by a more filled capping layer that can withstand the forces of mastication. The initial studies of these materials show favorable results.

	Another category of products that have come to market is one in which a single increment of composite resin is placed in a 4-5 mm increment to fill a cavity preparation in entirety. The clear benefit of this technique is further conservation of time; however proper adaptation of a 4-5 mm increment of composite may be difficult to achieve. Products in this category include Tetric EvoCeram Bulk by Ivoclar, X-tra fil by VOCO, Beautifil Bulk by Shofu and many others.

	The ideal bulk fill composite would be one that can adapt nicely to all the walls of a cavity floor yet have enough body to easily anatomically blend the restoration into the adjacent unprepared tooth surface and withstand occlusal forces. To this end, the SonicFill system by Kerr addresses each of these issues. The system essentially allows for sonic energy to be delivered to a highly filled composite via a handpiece. As this energy is applied, the viscosity of the material drops by more than 80 percent, allowing it to nicely adapt to all walls of the preparation. As energy is removed, the composite resin starts to regain its viscosity over ample working time.

	During this time, the proprietary resin can easily be sculpted so that it can be properly contoured and anatomical harmony can be achieved. The material can be placed in a single increment of up to 5mm before it needs to be polymerized. After polymerization, a standard polishing regimen can commence. SonicFill 2 will be introduced by Kerr soon, and improvements have been made to the resin to allow for easier polishing.

	Patient presented with recurrent caries in the distal box form of tooth No. 13 and new approximal caries on the distal of tooth No. 12. After consultation with the patient, a decision was made to remove the existing restoration and caries and place direct restorations. After administering anesthesia, the teeth were isolated utilizing a rubber dam.  After complete caries excavation, the teeth were restored one at a time in order to achieve proper anatomical proximal contact. The system used was a sectional matrix (V3 Matrix) and wedge (Wave-Wedge), and ring (V3 Universal Ring) from Triodent. The deepest portion of each preparation was then measured, and both were found to be inside of 5mm. This finding allows one increment of the SonicFill A3 composite to be placed. After utilizing a total etch protocol and fifth-generation adhesive (Optibond Solo+), a single increment of SonicFill composite was placed, sculpted and fully cured utilizing a DemiUltra LED curing light. To achieve thorough polymerization, the restoration was initially cured for 20 seconds from the occlusal surface as well as 20 seconds from both the buccal and lingual surfaces after removing the sectional matrices. After removing the rubber dam, minor contouring was completed utilizing a 16-fluted carbide composite finishing bur (ET Series [Brasseler USA]). The restoration was polished utilizing a three-step silicone-impregnated rubber point system (Jiffy Polishers [Ultradent Products]).

	The patient was informed the new restoration would be fairly large in size and the patient should consider an indirect restoration to minimize the chance of cuspal flexure and fracture. Taking into account the risks, benefits and alternatives, the patient decided to have a direct restoration placed. After administering anesthesia, the teeth were isolated utilizing a rubber dam. Upon complete caries excavation, the prepared surfaces were matrixed to allow for a properly contoured restoration to be placed. The system used was the V3 Matrix, the Wave-Wedge wedge and the Palodent Plus ring by DENTSPLY.

	Watch the video below to see pictures of Cases 1 and 2:

	It is incredibly important to realize that to be considered a successful composite resin restoration, the material must be fully polymerized. All curing lights are not created equal, and just because a blue light is being emitted from the tip of a light does not mean the composite is being fully cured. The physical properties of light-cured composite resin can only be achieved when the composite receives the right amount of energy at a specific wavelength.   

	In addition, enough of this energy should be delivered to the composite resin restoration without causing a significant temperature change to the pulpal tissue. Successful polymerization requires proper equipment and training. In a recent study by the ADA that looked at eight LED curing lights currently in the marketplace, only three lights showed the ability to have depth-of-cure measurements that were equivalent to or better then a standard halogen curing light. These lights were the DemiUltra by Kerr, Elipar S10 by 3M ESPE and the VALO by Ultradent.

	In terms of operator technique, it is critically important that the team member who is responsible for curing is properly trained and that the patient is put into an ideal position so the tip of the light can get as close to the restoration as possible. The effective energy of all lights drops off as the light source moves away from the surface to be cured, and just because a restoration has a top surface that is hard does not mean the restoration is fully polymerized. Clinically, this can be a big issue in Class II restorations with a deep gingival box form.  

	It is very common for a light to float 3-4 mm off a tooth surface when it is activated, and this can mean a gingival box form is now 8-9 mm away from where the light is being emitted and gingival failure can become more likely. In terms of bulk fill resins, they tend to be slightly more translucent than traditional composites, and this is one of the primary reasons they can be cured in bulk. Based on the author’s experience, it is advisable to cure all resin-based restorations from the buccal and lingual surfaces in addition to the occlusal surface to maximize polymerization possibilities. Team members should also make sure curing tips are not damaged or covered with dental material that could inhibit proper curing. In addition, batteries and charging bases should be maintained to allow for optimal performance. One interesting point about Kerr’s DemiUltra is that it actually does not contain a battery at all. The light operates based on an ultra capacitor technology that allows it to fully charge in just 40 seconds. In addition, the light output is modulated every second through a process called periodic level shifting that allows the optimization of power while minimizing heat that may get to the pulpal tissue.

	Posterior composite restorations are one of the most prevalent procedures that occur in dental practices today.  When a practitioner blends proper technique with the advancements in technologies and material, these procedures can also become some of the most predictable. Efficiently placing natural-looking direct restorations that do not produce any post-operative sensitivity is very feasible today and should be considered the norm versus the exception.

Kerr SonicFill is a unique bulk fill system comprised of a specially designed handpiece and new composite material in Unidose tips. SonicFill’s composite incorporates a highly filled proprietary resin designed with special modifiers that react to sonic energy. As sonic energy is applied through the handpiece, the modifier causes the viscosity to drop (up to 87 percent), increasing the flowability of the composite and enabling quick placement and precise adaptation to the cavity walls. When the sonic energy is stopped, the composite returns to a more viscous, non-slumping state that is said to be perfect for carving and contouring.
	

	Building upon the award-winning performance of its predecessor, SonicFill 2 is designed to transform tedious, repetitive posterior restorations into easy and reliable SingleFill placement, filling cavities up to 5mm in depth in a single increment with a single material and no liner or capping layer. The upgraded composite of SonicFill 2 was engineered using a new proprietary resin-infused zirkonsil filler system. Composed of nano-scale zirconium oxide and silica oxide particles, the improved composite reportedly imparts excellent gloss, wear resistance and strength to make bulk filling even easier and more reliable. SonicFill 2 is said to dramatically lower the viscosity of the composite during placement to ensure intimate adaption with the cavity surface. With its low shrinkage stress, high depth of cure and excellent mechanical and esthetic properties, SonicFill 2 is designed to meet the key requirements of a successful bulk fill procedure as you’ve come to expect from this market-leading product.
	

3M™ ESPE™ Filtek™ Bulk Fill Posterior Restorative

3M™ ESPE™ Filtek™ Bulk Fill Posterior Restorative reportedly gives dentists the ability to place up to 5 mm in one increment while offering excellent wear resistance and stress relief. By eliminating additional layers and multiple steps, Filtek Bulk Fill posterior restorative is designed to outshine competitors to give dentists a fast and easy option for direct posterior restorations. With this “one-and-done” option, dentists reportedly can save valuable chairtime and improve productivity. Designed for durability, Filtek Bulk Fill posterior restorative utilizes the same true nanofiller technology of other Filtek restoratives, which is said to enable high strength, wear resistance, surface smoothness and gloss retention.

	With more than 20 years of clinical excellence, Renamel Microhybrid reportedly is strong and opaque just like dentin. Because of its wetting properties, Renamel Microhybrid is said to be easy to place and manipulate in thin layers. The product offers SuperBrite shades for bleached teeth and includes shades A1, A2, A3, A3.5, A4, B1, B2, B3, B4, C1, C2, C3, C4, D2, D3, D4, CO, LI, MI, MWO, W, SB1, SB2 and SB3. Renamel Microhybrid is said to adapt well to underlying tooth structure and block unwanted undercolor.
	

“I’ve been using Renamel Microhybrid since 1994 in cases large and small. Its ability to adapt to underlying tooth or composite layer is the best I’ve experienced. The chance of trapping air bubbles or having an open margin is reduced because of its viscosity.”
	– Corky Willhite, DDS, FAACD

 Universal Composite is designed to provide the handling preference of choice with TPH Spectra LV (low viscosity) and TPH Spectra HV (high viscosity) that is spreadable or packable. The new shading system for the composite offers seven VITA-based shades that cover the entire VITA shade system. This reduction in shades allows for carrying fewer inventories in the office and is said to provide confidence that the chameleon shading ability of the composite will blend it in to the surrounding tooth structure making the restoration indistinguishable.
	

DENTSPLY Caulk
	800-532-2855  |  tphspectra.com

“TPH Spectra has taken all the attributes most practitioners would like in a direct composite resin - good handling, shade simplification, solid physical properties and ease of finish and polish and combined them into one product. It might be DENTSPLY Caulk's best composite ever!”
	- Dr. Doug Lambert

Venus Diamond is designed to embody a true balance of science and esthetics based on a patented cross-linked polymer matrix. With more than five years of extensive composite research that produced a patented chemistry, Venus Diamond is said to be the ideal choice for both anterior and posterior restorations. Offering a firmer, more packable consistency, Venus Diamond reportedly leads the industry in color adaptability with a patented formula that is designed to provide an outstanding natural look-replicating nature and mimicking tooth anatomy. Just one shade is said to save time and produces radiant results. The optimal physical properties of Venus Diamond reportedly offer a composite that truly performs in every category with low shrinkage stress, unique handling, exceptional strength and durability and perfect color adaptation.
	

Heraeus Kulzer
	914-219-9000  |  heraeus-kulzer-us.com

“An essential quality of a composite is the ability to create invisible margins by blending with natural tooth structure. Venus Diamond’s color adaptive matrix, combined with easy handling and polishing to a high luster, allows us to restore teeth to their natural beauty in both anterior and posterior restorations.” 
	- Howard S. Glazer, D.D.S., F.A.G.D.

Clearfil Majesty posterior composite is a light-cure, radiopaque restorative composite resin composed of nano-and micro-inorganic filler that is treated with a proprietary surface coating technology. The surface technology is designed to permit larger quantity of nanofiller to be dispersed in the resin matrix, which consists of monomer and microfiller. The resulting resin matrix is reinforced with a filler loading of 92-percent weight (82-percent volume). The product reportedly has an improved surface hardness that is close to that of human enamel, high mechanical strength, durability, high light curing depth and low polymerization shrinkage.
	

Kuraray America, Inc.
	800-423-9762  |  

Simile™ Universal Composite is designed to combine strength and esthetics for both anterior and posterior restorations. With its outstanding physical properties and nano-hybrid formula, Simile is said to have been independently proven to deliver outstanding surface smoothness for an easy polish, superior polish retention and exceptional wear resistance. The reportedly extraordinary shine is visible as soon as you handle the material, and the low wear rates are said to result in a beautiful, long-lasting restoration. The soft, sculptable handling of Simile is designed to ensure the material won’t stick to the instrument at placement. Simile is offered in a convenient 10-shade introductory kit and has a total of 20 VITA shades, available in your choice of single dose or syringe.
	

“We have been restoring anterior and posterior teeth using your Flow-it and Simile composite materials for more than seven years. Simile has proven to be a strong and durable product and is our composite of choice.  It is not sticky and adapts well to the teeth. It is easy to apply and is highly polishable, making it ideal for anterior restorations as well as offering the strength needed for posterior Class II restorations. The shade choices match perfectly with our patient’s teeth. We are very pleased with this product. In combination with the excellent service we receive from Pentron, it is the composite of choice for our office.” 
	- Renee Walcom, RA

Beautifil Bulk Restorative is a conventional packable composite resin designed to incorporate the unique, bioactive benefits of Giomer, a surface prereacted glass filler that is backed by 13 years of clinical success. Beautifil Bulk Restorative has optimum translucency and a high fill ratio, which is said to reduce polymerization shrinkage stress while increasing compressive and flexural strength. With the balance of light diffusion and transmission that ensures complete polymerization at 4mm depth of cure, Beautifil Bulk Restorative has sustained fluoride release and rechargability, which makes it ideal for high caries patients. Indicated for direct posterior restorations, including occlusal surfaces, it is said to have excellent condensability and sculptability with minimized shade difference before and after light curing.
	

“The material is highly esthetic because of the S-PRG filler. This filler allows for an ideal balance of light diffusion to penetrate deeply into the composite, while simultaneously creating an optimal opacity that matches and mimics the surrounding tooth structure quite nicely.”
	– Dr. John Comisi, DDS, MAGD

 Sigma Quick is a supra-nano, 100-percent spherically filled universal composite that is designed to deliver a high-gloss, outstanding polishability and lasting shine on restorations. Its spherical fillers reportedly resist plucking for excellent wear resistance, while a quick curing time is said to allow for minimal volumetric shrinkage at 1.3 percent. Estelite

 Sigma Quick has a creamy consistency and packs well into a variety of spaces, which is said to make it exceptionally versatile and easy to handle. It comes in a total of 20 shades, including variations of opaque and bleach shades. Its superior shade integration-combining up to 10 shades in a “chameleon effect”-reportedly reduces inventory costs without sacrificing esthetics.
	

Tokuyama Dental America
	877-378-3548  |  

“Definitely a great handling material for both anterior and posterior restorations. Great opalescence and translucency allow it to blend very well with surrounding tooth.”
	- Consultants from the Dental Advisor

x-tra fil is an 86-percent filled (by weight) multi-hybrid, universal shade, bulk-fill composite that was developed to offer speed without sacrificing performance quality for posterior restorations. x-tra fil’s ability to cure 4mm layers in 10 seconds reportedly offers practitioners a real solution, especially when combined with Futurabond U or DC as the bonding adhesive. x-tra fil’s high performance quality is based on both its elevated physical characteristics, such as its 1.7-percent shrinkage (by volume), no-stick handling and high radiopacity (330-percent Al) as well as its dentin-like compressive strength, mechanical durability and thermal expansion.
	

"xtrafil allows up to 4mm of material to be placed with only a 10-second cure-a time-saving benefit for many clinicians. Compared to traditional layering techniques, xtrafil offers a more forgiving technique for some clinicians. Esthetically, the blending capabilities of xtrafil's universal shade performs well in most posterior situations requiring less inventory by the clinician."
	- Todd C. Snyder, DDS, AAACD, accredited Member - American Academy of Cosmetic Dentistry

Practitioners have been placing composite resin restorations for more than 60 years, and during this time, practitioners have gone from a world where only anterior teeth were restored with composite resin to a world where composite resin is used to restore essentially any tooth in the oral cavity.

Category Cruncher: Predictable Posterior Composites

Learn how 3M ESPE's Scotchbond Universal Adhesive offers options

No dentist wants to stock more products or learn more techniques than necessary. For many years, however, adhesion technology made it necessary for dentists to keep multiple systems in the operatory, and to learn the numerous steps that went with each system.

Whether using a self-etch, total-etch or selective-etch technique, dentists had to carefully weigh the needs of each case in regard to desired bond strength and the risk for post-operative sensitivity.  Over etching dentin or failing to keep dentin moist after etching could result in significant sensitivity and unhappy patients.

Fortunately, new universal adhesive technology has now entered the marketplace and offers dentists more convenience and increased efficiency. For example, 

3M™ ESPE™ Scotchbond™ Universal Adhesive

 can not only be used in self-etch, total-etch or selective-etch modes; direct and indirect procedures; and on dentin or enamel; it can also streamline cementation when used with 

3M™ ESPE™ RelyX™ Ultimate Adhesive Resin Cement

, which has an integrated dark cure activator, eliminating the need for a separate activator.

The adhesive’s chemistry allows it to work effectively for each type of etching situation:

: Phosphorylated monomers in an aqueous solution make this adhesive acidic enough to bond to dentin and cut enamel without a separate phosphoric acid etching step. This enables the most simple adhesive technique and also protects dentin from post-operative sensitivity.

: When applying etchant just to enamel, dentists know they must prevent the etchant from touching dentin or risk sensitivity later, unless the dentin is kept moist. Scotchbond Universal adhesive addresses this issue with a balance of 

This combination lets the adhesive provide high and consistent bonds to etched dentin surfaces, even if the dentin surface is accidentally over dried.

: In the total-etch technique, etchant is used on both dentin and enamel, then rinsed away, completely removing the smear layer. Traditionally, when using fifth generation adhesives, it was very important to keep the dentin moist during this technique. The chemistry of Scotchbond Universal adhesive helps dentists sidestep this technique sensitivity and achieve high bond strengths.

As mentioned, Scotchbond Universal adhesive’s properties make it possible for dentists to use it with both direct and indirect procedures. The product also bonds methacrylate-based restoratives, cement and sealant materials to dentin, enamel, glass ionomer and various indirect restorative substrates (metals, glass ceramics, alumina and zirconia) without an extra primer step.

The cases shown here demonstrate the use of this adhesive for both direct and indirect purposes, in each etching mode.
	
	Case 1: Self-etch

: The patient presented with recurrent decay under an existing crown on tooth No. 30. The tooth was prepared for a lithium disilicate crown and a provisional restoration was placed.

: At the delivery appointment, an Isolite was placed, the provisional was removed and temporary cement was cleaned away (Fig. 1). Anesthesia was not necessary for this procedure.

Figure 1: Crown preparation on tooth No. 30

: Scotchbond Universal adhesive was used in self-etch mode; the adhesive was scrubbed onto the prep for 20 seconds. The tooth was then lightly air dried (Fig. 2).
	
	

Figure 2: The prep after application of adhesive and air drying

Scotchbond Universal adhesive also was applied to intaglio surface of the restoration after it was etched with hydrofluoric acid. RelyX Ultimate cement was dispensed into the crown and the crown was seated onto the preparation (Fig. 3).

Figure 3: Excess cement was light-cured to reach a gel state, then removed

: A brief light cure was performed to get the cement into a gel state. Excess cement was then easily removed and final polishing was performed (Fig. 4).

: The patient presented with decay on tooth Nos. 29 and 30. Decay was removed and the teeth were prepared for composite restorations.

: Because of the amounts of dentin on the molar and enamel on the bicuspid, it was determined to perform a selective etch on No. 30 and a total etch on No. 29. 

3M™ ESPE™ Scotchbond™ Universal Etchant

 was applied to the enamel periphery of No. 30 and the entire prepared area on No. 29 (Fig. 5). The etchant was left in place for 15 seconds, then rinsed thoroughly with water. The teeth were then gently dried.

Figure 5: Scotchbond Universal etchant was applied and allowed to sit for 15 seconds

: Adhesive was then applied to both teeth and scrubbed for 20 seconds. After a five second air-drying step, the teeth were cured with an LED light (Fig. 6).

Figure 6: Adhesive was applied and polymerized

3M™ ESPE™ Filtek™ Supreme Ultra Universal Restorative

 in shade B3 was applied and light cured in incremental layers (Fig. 7).

Figure 7: A single shade of Filtek Supreme Ultra Universal Restorative was used for the restorations

: The restorations were then adjusted and polished (Fig. 8).

Figure 8: The completed restorations after contouring and polishing

These cases show the same adhesive being used in three different ways, illustrating its versatile properties. The fact the adhesive works with RelyX Ultimate cement, as well as the fact that it needs no additional primer for many substrates, also highlights the versatility it provides in the operatory.

In the past, dentists have had to switch adhesive products, sometimes within the same case, to get the properties they wanted for each tooth. Now, it is possible to take advantage of a simplified process to work with maximum efficiency and effectiveness. 

 3M™ ESPE™ Scotchbond™ Universal Adhesive  Features

		Combined total-etch, self-etch and selective-etch adhesive

		Consistent bond strength to both moist and dry etched dentin

		One-step, one-coat adhesive application

Other products featured in this article...

Vitrebond™ Light Cure Glass Ionomer Liner/Base

Filtek™ Supreme Ultra Universal Restorative

How to maximize versatility with a universal adhesive [VIDEO]

Over the last decade many new technologies have been incorporated into dental practices including digital impression systems, diode lasers, digital radiography, LED curing lights, and caries detection devices, yet many individuals are using the exact same handpiece they have always used. Most likely this is an air-driven handpiece with a high pitched whistle and a moderate amount of torque.

The whistle and vibration of these handpieces tend to cause a fair amount of anxiety in our patients and the soothing environment clinicians try to provide in their offices is destroyed the moment they step on the rheostat.

The question must be asked whether handpieces have evolved beyond these issues.

The Borden highspeed air driven handpiece debuted in 1957 and this introduction revolutionized dentistry; however only incremental changes have occurred in the air handpiece arena since this time. Air-driven handpieces today are certainly lighter, smaller and somewhat quieter then they once were; however these advancements are still relatively minor. Practitioners continue to battle the fact that air-driven handpieces tend to loose their cutting efficiency with dense materials and patients continue to have anxiety based on the noise and vibration associated with these handpieces.