Lauren Krzyzostaniak

	When it comes to dental restorations, both the patient and the dentist want the same thing: beautiful restorations that are as strong and esthetic as natural, healthy teeth. Both patient and doctor also prefer to have the procedure done efficiently and effectively; that is, no time is wasted waiting for a composite to set, and once the composite is in, it is both comfortable and durable. No patient wants to experience sensitivity, and neither dentist nor patient wants to spend what little time they have redoing a procedure that didn’t stick the first time.

Posterior restorations make up about 80 percent of what a general dentist does in the practice, but it’s unfortunately not something that gets a lot of attention. Because it’s the “bread and butter” of the practice, as David Rice, DDS says, it matters more than we think. Are you committing these composite faux pas in your practice?  

More from the author: 5 ways new bulk fills are providing better results

	1. Bulk filling with composites that weren’t designed for it

	“In some instances, I think that the idea of bulk cure materials out there has affected things somewhat,” says John Flucke, DDS. In recent years, more companies have brought bulk fill materials to the market. At the same time, many companies are introducing high-quality curing lights. The combination of advancements in these two arenas has led to a lot of misconception around what it takes to place a quality restoration, he says.

	“Doctors think that if they have a good curing light, they can bulk cure anything on the market, regardless of whether the material was designed for bulk cure,” Dr. Flucke says. “They’re confident that it will set with their light, but there are other things that go into a bulk cure that need to be taken into consideration.”

	One of those things is how much the composite shrinks and if there will be shrinkage stress. While it’s typically a minimal amount of shrinkage, it is a catalyst of a restoration’s failure, and some shrink more than others.

Related article: 10 common direct dentistry mistakes to avoid

	“The way you minimize the shrinkage stress is by placing the composite incrementally, in 2 to 3 millimeter bits,” he says. “You place it, condense it and cure it bit by bit. If a material has a high shrinkage factor, you can overcome it by putting smaller layers in there. If they shrink, they’re so small that it doesn’t make a big difference overall. But if you put them in as a whole, it pulls the tooth in as it shrinks.”

	As the material shrinks, the cuffs will bend and crack as it’s cured, leading to tooth fractures, long-term failure of the restoration and patient discomfort.

	“You can go with using an adequate composite, but you can’t try to make it do something that it wasn’t designed to do,” he says. “If you’re doing that, you’re going to get pain and problems, and you’re going to have to go back in.”

	3M Filtek One offers stress relief on bulk fill restorations up to 5 mm, which makes it an excellent option for about 80 percent of posterior restorations.

	“Our first obligation is to do no harm to our patients and to know what we’re using,” Dr. Rice says. He encourages dentists to do their own research when searching for the right materials and products for their practice and patients.

	The “bottom rung” of composites are those that are merely acceptable, Dr. Flucke says. On the other end of the spectrum are the exceptional composites, all known for exceeding expectations in specific areas, whether for bulk curing, esthetics or time savings, he says.

	“The first thing to do is do your research,” Dr. Rice says. “Trusting your rep is important, but trusting your rep over your own research is foolish.”

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	That means looking at clinical studies. “It’s not the most exciting thing to do,” he says. “It is, however, the right thing to do. You cannot go to a company’s website and expect to get the full story. Independent research is king.”

	For dentists who rely on word of mouth and referrals from their peers, he advises to speak to the specialists. “They traditionally do the homework, while many GPs tend to rely on referrals,” he says.

	Research might lead doctors to reading up on nanotechnology in composites (nanocomposites), which help to ensure a smooth surface after polishing and a more esthetic final result. According to a 2013 study in the European Journal of Dentistry titled “Nanotechnology and Dentistry,” nanocomposites are easier to shape, stronger and more resistant to abrasion.

	“The smaller the particles, the shiner and prettier the composite,” Dr. Flucke says. “Filtek Supreme has 50 percent of the U.S. composite market because it is so pretty and because of the way it handles. The thing about using nanoparticles is that the composite handles more like butter. It’s softer and easier to use. If you put large particles in the composite, it’s stiffer, making it harder to place in the tooth and manipulate. The tiny particles allow it to be much more workable. It’s esthetic. You can polish Filtek Supreme to shine incredibly well. It also has this consistency that allows you to place it exactly where you want it to go.” 

	“It used to be that particles were really big, so composites would look good on day one, but they would wear quickly and start to look bad and need to be replaced within a short duration,” Dr. Rice says. “Nanotechnology is about maximizing the performance of the material and how long it lasts from a wear standpoint as well as how it works with that tooth and how kind it is to the teeth around it.”

	3. Trusting that the latest always means the best

	It’s not just the composite choice costing you money and happiness -- it could also be your bonding system.

	Bonding systems are a critical component of the direct restoration, of course. Unfortunately, the way bonding systems are categorized is confusing for many dentists.

	“The other problem of referring to bonding systems by generation is the connotation that the higher up we go in generations, the better the bonding system would be,” 

, DMD, FAGD, and a member of the Spear Education team. “In the world of software, as you move up to higher versions, it becomes better and faster; however, bonding agent generations don’t work this way.”

	Whether you prefer to use self-etch, selective-etch, or total-etch is up to you and what works best with your technique.

More from the author: What digital dentistry means for implants

	“There are different ways to place composites through different generations of bonding,” Dr. Flucke says. “I use a fifth-generation technique. It gives you some incredibly high bond strengths, but it is technique sensitive. You’ve got to do it right. If you don’t, you might get some post-op sensitivity.”

	While fifth-generation bonding was the norm for dentists at one point, many are now favoring seventh- and eighth-generation bonding to speed up the procedure and eliminate sensitivity.

	“The idea is that it decreases the steps and offers friendlier chemistry, so it doesn’t cause sensitivity,” he says. “The trade-off is that they don’t bond as well. In the bond strength test of how well the composite sticks to the tooth, the fifth-generation gets much better results. I’d much rather do a fifth-generation technique right than do a self-etch technique right because if they’re both done well, the fifth-generation is going to last longer and be better for the patient.”

	“I think what’s important is to understand that you have options,” Dr. Rice says. “Everyone is going to have their favorite bonding technique, so it’s valuable to know that they can successfully use the technique that they prefer.”

	Scotchbond™ Universal Adhesive is a combined total-etch, self-etch and selective-etch adhesive that is said to offer virtually no post-op sensitivity.

	Dentists should cut cost on time, not materials, Dr. Rice says. You can do that by finding a material that allows you to do your best work in the most efficient way.

	“When people start looking at efficiency in a practice, it’s not about trying to save money on a product,” he says. “Invest your money in a product that you can place more efficiently and effectively so that you can save your money on time.”

	For an anterior restoration, the priority is esthetics. Dr. Rice prefers to layer a traditional composite because it looks nice and it’s durable. However, posterior restorations are more efficiently placed in bulk.

	“Instead of me needing to apply five or six layers of composite if I’m placing it the way I’m supposed to, I can now do it in one or two layers,” he says. “That does a few things for me. It makes me efficient because the time it takes me to place two layers is far less than the time it takes me to do six layers. The second piece is that every time you add a layer to a layer, there is an opportunity for those layers to not be fully integrated with each other. If you looked under a microscope, they’re not one big piece. You can tell that there are seams or micro-gaps between layers. That is cause for a restoration to fail prematurely. The fewer layers I have to place, the more predictable I am, and the less risk I have for any of those things to happen. I’m faster, I’m better, and depending on whose bulk fill composite you use, it can look really pretty in addition to those two functional benefits.” 

	5. Seeing too many redos in the practice

	Dentists can also save time by investing in long-lasting materials that allow them to perform at their highest standard.

	“For composites, it doesn’t matter what you’ve placed first. If you’ve done a reasonable job, it’s going to look great for the first year,” Dr. Rice says. “However, if you compromise on the quality of the product or your technique is compromised, within five years your restoration is going to break down.”

	Patients face a lot of obstacles in getting to the dentist, the most common of which include taking time off work and paying for the cost of the visit.

	“Patients don’t want to take time off work and do all of the things they have to do to get back into the dental office,” Dr. Flucke says.

Trending research: Can dentists use squid ink to check for gum disease? 

	“You really have one shot at having a tremendous reputation in your community and it doesn’t take a lot to tank that reputation,” Dr. Rice says. “Imagine that you decide to spend $30 on something instead of spending $50, and you’re going to save costs and cut your time on technique. Suddenly, you have a couple hundred patients who got a poor result and aren’t happy. Statistically, they each go tell 11 people, so that could expand to over 1,000 people in a very short period of time because you didn’t make the best choice.

	“If you have to redo something, you’ve now immediately lost money by treating that patient. For me, that’s my pain today. My pain big picture is the cost to my reputation. Communities are small, even in a larger city, and if people start talking about bad experiences, suddenly I’m no longer the go-to dentist in town and I’m in trouble.”

	“We’re programmed morally and ethically as dentists to do our absolute best every time we sit down,” Dr. Flucke says. “Sometimes, despite our best efforts and using the best materials, things don’t go right.”

	Choosing the composite material, bonding system and technique that work for you is the first step to getting your fill of bread and butter in your practice. Direct restorations may not be the coolest part of dentistry, but it’s certainly one of the most important for your practice and your patients.

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Are you committing these composite faux pas in your practice? 


5 Ways Your Composite Choice May Be Costing You Money – and Making Your Patients Unhappy

	We all know that the next big thing in digital dentistry is 3D printing, but the holdup is in materials. Until companies come out with 3D printing materials for long-term wear in the mouth, the industry will continue to wait.

In the meantime, dentists can take additional steps to make sure they’re getting the most use out of the digital tools in their arsenal. Here are five hidden uses of digital technology.

Read more: The future of digital dentistry

	We often classify digital treatment planning as taking, mocking up and sending photos to the lab, since there is a lot of information that dentists can transfer to the technician with photographs or radiographs. But the other part of digital treatment planning is in the implant realm, Dr. Flucke says.

	“When you take a CBCT scan and bring it up on the screen, the ability that you have now to be able to place an implant virtually and basically create your guided surgery pieces without ever really touching the patient is pretty amazing,” he says. “The software will show you a rendering of exactly what that implant would look like, and it looks just like the implant that the manufacturer sends. You can drag the implant around on the screen and get it superimposed inside the 3D volume. You can even tip it in all three planes - X, Y and Z - and when you’re done, you can look at it in 3D and rotate the patient’s head in all directions and say, ‘That’s exactly where I want that implant to end up.’”

Trending article: 4 things you didn't know you can do with a digital scanner

	That’s opposed to drilling and orienting the axes by hand, as it is done in the traditional analog method.

	“Now you can do this all virtually,” Dr. Flucke says. “The lab will take your case, which you have treatment planned and designed, and will create a depth-limiting surgical guide to send back to you. It snaps into the patient’s mouth and stays fixed so that you can’t vary the drill bit at all. It has to go exactly where you treatment planned it, even to the point of depth.”

	In the digital workflow, the procedure is no longer dependent on the dentist’s skill and attention. Instead, the skill is computerized.

	“With digital treatment planning of implants, making the hole is almost the least stressful part of the procedure because you’ve treatment planned everything else in the software,” he says. “Suddenly, the doctoring is in the treatment planning, not so much in the treatment itself because it’s really hard to make a mistake. That is a big deal because more and more people are getting implants and this rules out opportunities for error.”

	2. Draw to increase patient understanding

	While taking pictures allows for dentists to co-diagnose with their patients, there are quite a few other uses of digital photography in the practice as well.

	“You can take standard 2D X-rays and photographs and mock those up digitally and evaluate things digitally with those in ways that give you a lot more information than I think people are really using now,” Dr. Flucke says.

	More and more dentists take the standard six views with a digital camera on every new patient, but they don’t always think about what they can do with those views once they have them. Dr. Flucke has a few uses.  

More from the author: The state of intraoral scanning

	“We had a patient in recently who had lost teeth 30 and 31,” Dr. Flucke says. “Tooth number 2 had started to super-erupt because of the loss of those opposing molars. The patient was concerned, so I put their bitewing up on the screen and drew a black line through the tooth that showed where the tooth should have been.”

	To make things equal, Dr. Flucke would have to shorten the biting surface by 6 or 7 mm- not a simple procedure.

	“We’d have to do a root canal before we could address what to do with the missing teeth underneath,” he says. “At that point, it may not be worth it. We might be better off extracting the tooth that’s growing out of the gum and restoring everything with something manmade.

	“When you’ve got a tooth growing out of the gum and your dentist starts talking about thousands of dollars worth of treatment just to make it normal again, a lot of people don’t comprehend it so well. But the visual aspect of drawing one single line across that bitewing so that they understand where the plane of occlusion is makes a huge difference in patient understanding.”

	Dr. Flucke performs a lot of cosmetic procedures in his practice and has found incorporating digital photography in atypical ways helps him be a better dentist.

	“Let’s say someone comes in and I’m going to do some cosmetic contouring with the laser,” Dr. Flucke says. “In that situation, I’ll take some high-resolution digital photographs of the patient’s retracted smile and put them on the screen in the operatory.”

	At that point, the images are no longer for the patient’s benefit and understanding. Instead, they’ll serve as a reference of where he started and where he hopes to finish the procedure.

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	“If I’m working and removing tissue, I’m looking at the picture to see what I had before I started and where I’m going,” he says. “Sometimes before the case, I’ll sit down and use some photo editing tool to literally draw where I want my finish line to be. It’s just like taking a marker to a normal photograph. I draw how I want the curvature to be. That gives me an idea of where I’m going and what I’m doing. It gives me a road map.”

	As he says, it’s easier to plan for the finish than to “wing it.”

	“If you just sit down and remove tissue with a laser and scalpel, you could find yourself thinking, ‘Wait, I don’t know if I should have taken that much tissue away,’” he says. “I’ve found it’s much easier to use tools to plan ahead of time.”

	Here’s a common case: A patient comes in with some fairly significant cosmetic problems. The dentist completes a cosmetic treatment plan, bonds the porcelain restorations and completely changes their smile. But the patient requests a few tweaks.

	“They look like they’re ready to star in a movie,” Dr. Flucke says. “You’re happy with it, your assistant is happy with it, and then you hand the patient a mirror and say, ‘Take a look at that,’ and the patient looks at it and goes, ‘Well, if you could just round this one a little bit here and this one over here looks like it’s sticking out a little bit, so I think we need to drill on that one and move it.’ You almost want to put your head in your hands and think, ‘What have I done?’”

	The problem, Dr. Flucke says, is that people forget what they looked like. The solution is to remind them.

	To do so, Dr. Flucke places the pre-op photographs on a monitor, which hangs over the patient’s head during the procedure.

	“When we tip them back to put the beautiful porcelain on, we don’t say anything, we just leave it up,” he says. “Then they take the mirror and look at their finished smile compared to what they looked like before. I can’t remember the last time one of those patients said, ‘Well if you could just change this thing.’ They say, ‘Oh my gosh, this is wonderful.’”

	During the process, people sometimes forget where they started, but when they get a reminder, they’re a lot happier with the final product.

	“The other thing is just combining some of these tools and using them in the proper way,” Dr. Flucke says. “There is a device called the Soprocare, which triples as a periodontal camera, an intraoral camera and a caries detection camera. So with one device, you can show people pictures like you normally would, but you can also push a button that changes the lighting system on it so that in one mode of color, it makes gingival inflammation, plaque and tartar show up much brighter on the screen than normal so that people can see where they have periodontal problems or where they’re not brushing or flossing properly. Then of course, with the caries detection piece, the tooth shows up red on the screen where there’s decay.”

Related article: How to maximize patient happiness with custom treatment options

	Dr. Flucke’s hygiene team uses the Soprocare regularly. “We do digital caries detection scans on everybody that comes in because it only takes a couple of minutes,” he says. “Doing that on everybody provides a great, impartial second opinion. You’re not just telling people there’s a cavity that they can’t see. Instead, when the patient asks to see it, you show them on the screen where the red is on their tooth. People expect us to do that now, and if we don’t, they ask about it by saying,‘Why aren’t you using the camera that shows me where the cavities are or where the gum problems are?’ Once again that helps you treatment plan, do better for the patient and helps the patient understand what you can do to do better for them, all in one fell swoop.”

	So, what can dentists be doing with the very basic digital technologies that they have to get the most out of them? “Quite honestly, use them,” Dr. Flucke says. “We’re creatures of habit. We get used to doing things a certain way and it’s really hard for us to incorporate a nice intraoral camera. It takes 20 seconds, tops. But for some reason, if you haven’t stopped for 20 seconds to take that picture, it is so easy to jump right past that step. And yet, to be able to communicate, treatment plan, and figure things out and document your cases in the long run, it is really helpful to do that. When I’m doing things in the operatory, the intraoral camera is my friend. I take pictures before I start, while I’m working and when I’m done. It’s not difficult or time- consuming, but you do have to remember to use the tools.”

Dentists need to make sure they’re getting the most use out of the digital tools in their arsenal. 


5 surprising ways digital tools can boost your abilities

	In the past, concerns with bulk fills were common: Would shrinkage be a result of curing the entire restoration all at once? Can the curing light reach the depth of the box form? Can the composite successfully adapt to the cavity if most of the restoration is being placed at once?

	These concerns were valid, especially since the majority of posterior restorations would need to fill up to 7 millimeters and early bulk fills could only be cured up to 3 or 4 millimeters. Plus, many dentists were using weak or dirty lights, preventing them from getting the most out of their cure time. With curing lights that didn’t cure at perpendicular angles or fast curing lights that didn’t cure as well in the three to five seconds advertised as slow curing lights did, there were a few obstacles to getting a lasting, esthetic restoration from a bulk fill composite.

Related reading: 10 common direct dentistry mistakes to avoid

	Fortunately, times have changed. Faster bulk fills no longer equal less esthetic results. Many leading bulk fills on the market offer fast, esthetic results that dentists can be confident in. Here are five ways new bulk fills are providing better results.

	“The traditional composite cure depth is 2 millimeters,” says David R. Rice, DDS and founder of IgniteDDS. “Today's top bulk fills easily cure to 4 millimeters as long as one owns the appropriate curing light.”
	This is an important factor to consider in depth of cure. No matter how good the composite is that you’re using or how well you’ve stuck to the script on applying and curing the material, if your curing light is ineffective, the whole restoration will be in shambles. “Tip design on one’s curing light dramatically affects the depth of cure,” Dr. Rice says.

	Dr. Rice advises working with a curing light that has a tip diameter of 10 millimeters and making sure it is clear of any debris, which can compromise its efficacy. Debride the tip with a scalpel and polish it to make sure the light is concentrated on the area you’re working on.

	“With bulk fill, you need to have a good, strong light,” says John Flucke, DDS. “You have to have a powerful light of at least 1,000 milliwatts per square centimeter, in my opinion. You’ve got to have a bright light to get those photons down into the composite, so you can get that photo-initiator to cure the composite.”
	“Make sure you are using a cure light that is up to date and effective for the materials you are using,” says Leah Capozzi, DDS. “The number one cause for failure with composites is inadequate cure, so don't skimp on your curing times.”

	The good news is that most high-quality lights on the market are in that range or higher. “Unfortunately, a lot of people have the idea that if they shine a blue light on the tooth, everything will be fine,” Dr. Flucke says. “The reality is that it requires a certain wavelength of blue light at a certain intensity. If you don’t have a good light, it doesn’t matter what kind of photo-initiating tricks a company’s using.”

	With the right curing light, depth of cure on some bulk fill composites can reach up to 4 or 5 millimeters - without sacrificing esthetics. For deeper preps, rely on layering.

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	“Bulk fill composites cure in 4-millimeter increments,” Dr. Capozzi says. “Make a system for yourself that takes this into account. Use layers to keep your increments within 4 millimeters - don't just fill your prep up with one layer if it's more than 4 millimeters deep.”

	Less layering means a lower risk of moisture contamination as well. “Placing with less increments results in less time placing and curing,” Dr. Capozzi says. “This decreases the risk of moisture contamination and allows that patient to spend less time open.”

	While dentists used to worry about shrinkage with a bulk fill composite, new developments prevent the issue from occurring.

	“Decreased polymerization shrinkage is also a bonus and contributes to our ability to place in over 4 millimeter increments,” Dr. Rice says. “That translates to less post-op sensitivity when all bonding procedures are equal.”  
	“One of the ways they do this is by making the materials so highly filled that they can’t shrink much,” Dr. Flucke says. “The composite is composed of a resin, which is the plastic part of it, and filler particles. The more filler particles you put into it, the less it will shrink. As the plastic tries to shrink, the filler particles touch together.”

More from the author: The future of dental practices

	Some leading composites are using methacrylate monomers to lower polymerization stress. Addition fragmentation monomer (AFM) and aromatic urethane dimethacrylate (AUDMA) work together to provide stress relief without compromising wear resistance. AUDMA is a large monomer that limits the number of shrinkage zones, reducing the amount of shrinkage that occurs during polymerization. Use of these two monomers together allows a one-step placement up to 5 millimeters.

	“A good analogy would be to take a handful of gravel and squeeze it in your hand,” Dr. Flucke says. “Let’s say that air is the composite resin and the gravel is the filler particles. You can only squeeze your hands together before those rocks won’t go any further together. If you can highly fill a composite, which is what a lot of these companies are doing, then you overcome the shrinkage factor because the filler particles don’t shrink.”

	Self-adaptation and less shrinkage leads to stronger, healthier restorations.

	“I place bulk flow into the box of my Class II preps,” Dr. Capozzi says. “Due to the self-adaptation and self-leveling properties, I feel confident with the marginal adaptation of the material. Pair this with the low polymerization shrinkage and the result is a well-adapted, solid restoration with less post-op sensitivity.”

	“In the past, because you couldn’t get the light to go through more than 2 or 3 millimeters of composite at a time, companies would recommend layering the composite to cure it bit by bit,” Dr. Flucke says. “With all of those pieces being squished together and set, squished together and set, you have the potential for those pieces to not become one solid block of composite. If you don’t have to do that with bulk fill, that means you have to put fewer layers in so you have fewer chances for micro-gaps.”

	The point of bulk fill is to simplify posterior restorations by allowing the clinician to apply the material in one step, saving time in the process. As a consequence, there is no need for an additional capping layer, which means less chance for micro-gaps.

	“Even the best technique in condensing composite in layers cannot eliminate every micro-gap,” Dr. Capozzi says.
	“Decreased layering equals decreased potential for micro-gaps between layers and a more sound restoration through and through,” Dr. Rice says.

Read more: Why better adhesion means happier patients

	Bulk fill materials offer true efficiency and quality in restorations. They are viscous and flowable without needing a flowable tip. With tip designs that provide easier access to deep cavities, there is no need for dispensing devices, additional layers or multiple steps, and dentists can be confident in bulk fill’s wear resistance and stress relief.

	Another benefit of leading brands’ bulk fills are the esthetics. Before, clinicians had to choose between speed and esthetics. Now, bulk fills offer both.

	“This requires a paired flowable composite that has the ability to opacify to mirror dentin. With it, bulk fills (despite their decreased shade variance) will be invisible,” Dr. Rice says.

	Some leading brands use smart contrast ratio management to increase material opacity without reducing the depth of cure, leading to more esthetic restorations without sacrificing quality or time. By using a more translucent material, light can reach to the bottom of the restoration easier. Some materials become opaque as they cure, offering a more esthetic restoration while still allowing for the most effective curing possible.

Related article: 7 things you may not know about universal adhesives

	Certain materials such as nanofillers also ensure wear resistance and polish retention.

	“I’m excited about long-term results,” Dr. Flucke says. “I have some friends at the Arthur A. Dugoni School of Dentistry in San Francisco who did a study in which students did two restorations on each patient: one with a normal, incremental fill composite and another with a bulk fill, then compared them over time. Every time a patient came in for a cleaning, they would contrast and compare the old way with the new way. This is probably three years in, and they don’t notice any difference between the two materials. I’m excited about it.”

	5. Increased efficiency and effectiveness

	Clinicians have been choosing bulk fill restoratives for their strengths in adaptation and handling and their simple process. Now, bulk fills offer those benefits, plus superior esthetics, quicker bonding time and long-lasting quality.

	“Add all that together and we deliver efficiency and effectiveness,” Dr. Rice says. “With today's busy pace, patients win as much as the practice when we minimize their chair time.”

	“As a dentist, we often think the fast way is somehow compromising care, but when following the right protocols, new bulk fill materials really do allow us to do dentistry faster and more easily while still providing an incredible result,” says Amisha Singh, DDS.

	“Bonding is not rocket science,” Dr. Flucke says. “It’s just making sure that the chemistry was there.”
	Newer restoratives from top companies offer quality adaptation similar to flowable bulk fill materials, but at a faster pace. They even handle well and are easy to sculpt. Patients enjoy a shorter chair time, but they also appreciate that quality wasn’t sacrificed for time. New bulk fill materials offer superior wear resistance and polish retention, so your patients’ restorations will last longer and stay looking great.

The newest leading bulk fills are simple, esthetic and long-lasting, but they still require the clinician’s focus. 


5 ways new bulk fills are providing better results

 universal composite can be used for all restorative purposes, resulting in long-lasting biomimetic restorations. Available in 20 different shades in an easy-to-handle formula, Mosaic is impressing both dentists and patients.

	We spoke with Dr. Jaimeé Morgan, a cosmetic dentist in Midvale, Utah, about her thoughts on Mosaic and why she chooses to use it in her practice.

	When choosing a composite, I start with the basics, specifically the physical properties such as strength, shrinkage, flexural properties and wear resistance. Then, I look at optical properties because, let’s face it, if a composite resin system doesn’t have similar optical properties as the natural tooth, they’re not going to match. Then, I evaluate handling properties because a composite may have the best attributes on the market, but if the handling properties are not good for me, it will be a struggle to place the composite.

Related reading: 5 ways composite advances can change your workflow

	Mosaic universal composite is a nanohybrid with a firm consistency and high polishability. It has enhanced physical properties, which means that not only is it a beautiful composite with optical properties that mimic natural tooth structure, it is also wear resistant and has high compressive and flexural strengths, while maintaining low stress and strain levels in the tooth.

	The introduction of Mosaic was intriguing because 

already has a successful composite system that I had used for many years. Needless to say, I was skeptical until I ran it through the rigors. It is a stiffer composite and very easy to sculpt, whether I am placing an anterior restoration or a posterior restoration. I found that the exquisite polish that is easily obtained with this composite is remarkable.

	It comes in 4.0g syringes, which were designed to decrease the potential of cross contamination, and 0.2g unit dose compules.

	It has six enamel shades that mimic natural enamel translucency and a versatile Enamel Trans shade when you need even more translucency. It also includes Opaque White, which can be used for stain block out, crown build ups and for those patients who have whitened their teeth beyond “glow in the dark.” The 13 dentin shades in the system are fluorescent like natural dentin and have optical properties similar to natural dentin (including two bleached shades, B0.5 and A0.5, which I find extremely useful).

	Whether you use one shade or multiple shades, this is an easy system to use and allows the clinician to implement multiple shades if he or she desires, but it is not a requirement to get enhanced esthetics. Also, this system can be used for anterior or posterior restorations.

	How does it handle and how does it compare to other composites you have used?

	It is a firm composite that is ideal for freehanding restorations or using a veneer template such as Uveneer (Ultradent Products). The firmness makes it easy to shape and to clean excess away from the restoration or the template. It also does not lose it’s shape prior to curing.

	What would you say to dentists who may be considering Mosaic?

	For those using a veneer template system (e.g. Uveneer), Mosaic is an ideal composite because of its viscosity. When using Uveneer, I found softer, less viscous materials made cleaning up around the template labor intensive, while Mosaic’s stiffer consistency made peeling the excess composite away from the template easy, making the process much faster and simpler.

A cosmetic dentist explains why she switched to using Ultradent’s Mosaic.

Double Take: 'Mosaic is an ideal composite because of its viscosity'

	Early intraoral scanners had some major challenges. They didn’t replace the traditional workflow right away, they came with an intimidating learning curve and they often required the use of multiple other supplies to get a useable scan. It was almost as if the digital dentist and laboratory had one foot in the future and one in the past; one hand operating in the modern workflow and one stuck in tradition. 

	“Even back in the early days of intraoral scanning, a lot of times the labs would create their restorations using traditional methods,” says Jim Graham, global research and development director at 3M Oral Care. He says that labs would use digital files and 3D print models, but often relied on analog techniques to create final restorations. 

	Early adopters are always willing to put up with the murk of nascent technology, but to most, it just wasn’t more attractive than performing the skill they’d learned and honed long before. 

	“Within the clinical setting, you had this traditional impressioning capability that everybody had been taught from day one of dental or hygiene school,” Graham says. “Everybody knew how to use it, so it was simple, quick and effective. Suddenly, you’re asking your clinicians, assistants and hygienists to adopt this new technology that was completely different than anything they had been taught in the past.” 

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	Now, the capabilities of intraoral scanners and the software available outweighs any learning curve. And with the potential of what digital impressions could be in the future, the time to adopt is now. They’ve come a long way in the last few years

	“My history of chairside oral scanning started back in 2006,” says Payam Ataii, DMD. “Since then, the quality has improved tenfold, if not more. Scanned images appear instantly with crisp definition.” 

	In fact, digital impressioning technology has evolved so much that it is “over-delivering” by consistently and quickly acquiring quality data to ensure predictable outcomes, says John Cox, vice president of Technology Sales at Henry Schein.

	That’s not to say that using an intraoral scanner is akin to waving a magic wand around the mouth (this mental image courtesy of Justin Chi, DDS, CDT, but more on that later)-but it has seen some major improvements. 

	“What I bought the first time was really a tooth-by-tooth system,” says David Rice, DDS. With improved accessibility, things have changed. “Now, I can do multiple teeth in a quadrant and work on bridges and dental implants. The range of procedures that we can now work with is almost limitless.” His range also includes working with orthodontics (both traditional appliances and clear aligners) and integrating with 3D cone beam CT scans for airway and sleep apnea cases. 

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	Cameras are getting much better, and many of them can capture images in color, allowing clinicians to see subtle nuances. 

	“What you see is a 3D image of the clinical situation now,” says John Flucke, DDS. “Nowadays, companies have all made it look like a clinical impression: even the coloring on the screen. It’s just like taking a model and holding it up in front of you with two hands.” 

	Digital impressions have a huge impact on patients who certainly notice the difference between an impression tray and a digital wand. 

	“I have an older system and my patients still think that I have some ridiculously high-tech thing,” says Leah Capozzi, DDS. “They can’t believe that they’re looking at their tooth on a screen.” 

	Digital impressions make it easier to educate patients. By using images that are of the patients’ own mouths, they can better understand the situation of their health and recommended treatment.

	“[Intraoral scanners are] just becoming more of a universal tool,” Dr. Rice says. “If we’re just trying to educate rather than create, we can use them now to take intraoral images.” 

	Dentists are also using digital impressions to create a more complete patient record. 

	“We use a scanner every day, on every patient because I can use the scan as a diagnostic image,” Dr. Ataii says. “When we had the older scanner, we only used it part-time. Time was a problem because it would take four or five minutes a scan. With the new Element, we can scan every patient in less than two minutes during routine visits.” 

	The visibility of the impression has improved as well, meaning dentists can tell if they have a good impression right away. “Clinicians can see their preparation on the screen, magnified greater than they’ve ever seen before,” says Dr. Chi, who worked as a certified dental technician before becoming a dentist and clinical research associate at Glidewell. 

	“One of the biggest complaints and issues in labs across the world is a lack of tooth preparation reduction,” Dr. Chi says. “If there’s a lack of reduction, then laboratories can’t really fabricate the ideal crown for function, fit and longevity because it compromises the thickness of that final restoration if the dentist didn’t reduce enough.” 

	Many new digital impressioning systems have provided a solution to that issue in the form of a prep-reduction verification. “They can instantly see how much space they have on the screen,” he says. “It’s great, because if there are any issues with the preparation as far as reduction or retraction - anything that wasn’t done as good as it could be - they can go ahead and make that modification to the tooth right then and there and rescan it.” 

	That makes a huge difference in time savings in the dental office because not only do digital impressions allow for fewer remakes, they also allow for fewer adjustments, which can shave 10 or 15 minutes off a restorative case. 

	“If the dentist is able to deliver the restoration soon after the preparation appointment, there’s also less of a risk of the teeth shifting around,” Dr. Chi says. “Though we all like to think we make great temporaries, when we’re moving quickly I don’t think any office is really creating provisionals at the same quality and fit and occlusion that a final restoration should have.” 

	If a temporary is out of occlusion, there is a risk of teeth shifting, which will require more adjustments when the crown comes in. 

	“I think digital offers that precision because they can set those values, and each time you get that consistent result,” he says. The bonus is that there is close to no margin for error because you can see everything right away.

Trending article: The top 5 reasons your lab loves intraoral scanners

	“Dentists can learn a lot from incorporating digital,” Dr. Chi says. “Pretty much every dentist that I’ve spoken to that has gotten into digital impression systems all say that it’s made them a better dentist because you can see the preparation in a way that you hadn’t been able to see before. As a dental technician also, I know what is required to create that ideal crown as far as the preparation reduction and the retraction. The digital scanner is a great teaching tool for dentists to be able to improve the work that they do.” 

	“When you’re doing an onlay or crown, you can take a quick scan in the beginning instead of taking pre-op impressions,” Dr. Capozzi says. “If you’re sending to the lab, you can do it electronically while you’re still in the room. You’re not filling out slips and packing boxes and waiting for the mail or for a pickup.” 

	It also helps that everyone can speak the same language now that the data is digital, says Dr. Gary Severance, chief marketing officer of E4D Technologies. 

	“By capturing that information and having specialists be able to look at it immediately if you need consults or being able to share the information with dental laboratories or specialists, you just get a bigger community of people talking the same language,” he says. “There is much more communication when you all speak the same digital language. You can do consults much quicker, you can send the information over, and dental professionals-technicians, specialists, clinicians, or even team members-are able to see things they were never able to see before without so much redundancy because they’re all looking at the same file.” 

	He adds that by keeping the data in the cloud instead of in storage, clinicians can learn more about their patients and improve treatment overall. 

	The short-term goal of digital impressions is like that of other digital technologies: to increase efficiency and productivity. Companies will be working on little tweaks for their latest versions as they bide their time waiting for researchers and scientists to develop industry-changing technologies and materials that will redefine what is possible in the dental office. In the short-term future, we’re going to see those tweaks: higher resolution imaging, increased speed and accuracy, smaller wands, ease of use and more affordability. But those tweaks can only go so far. 

	“There is going to be a limit in how small they can get and how fast they can get,” Dr. Severance says. “There is a critical balance between the size of the capture and the speed. You can make it very small, but you can’t capture a large amount of data quickly. As electronics improve, we’ll probably be able to capture and transfer more data. One company has gone wireless. Other companies are focused on USB 3.0 and some of the other ports that now allow more power and more transfer of data quickly. They’ll continue to improve as the technology and electronics improve.” 

Trending article: 5 questions you need to ask before buying an intraoral scanner

	When it comes to resolution, Cox says there is a point where good enough is good enough. If the naked eye can’t see as well as the camera, where is the value? 

	“The technology has to accommodate the specific workflow of the dental practice,” he says. “If it gets too far advanced where it doesn’t provide a clinical benefit and challenges the hardware requirements of an office, then it’s exceeding the ROI. We have a lot of practices that have to upgrade some of the hardware because of the graphic requirements of digital impressions. A full-arch scan is a big file; you need computer processing power that will handle it.” 

	Companies will continue working on the resolution, not because of what is needed today, but what will be necessary tomorrow. 

	“You’re starting to see a couple platforms that are enabling time lapse or change comparison over time, so an improvement in resolution of the scans will help enable that type of technology to move forward,” Graham says. 

More on intraoral scanning: Streamlining the workflow with CAD/CAM dentistry

	As with resolution, scans are about as fast as they need to be. 

	“The staff can’t keep up and scan much faster than the scanners go today,” Cox says. 

	However, Dr. Flucke foresees a greater efficiency rather than increased speed. “I can envision the camera becoming much more miniaturized,” he says. “Maybe it has several camera heads in it so you can just drag it along the arch, taking pictures from all sides simultaneously.” 

	Current intraoral scanners are fast. They’re also accurate. But they aren’t always both at the same time-yet. 

	“I think you’re going to see faster scan times while maintaining accuracy,” Dr. Adam Hodges, DDS says. “In order to be an effective scanner, it has to get quality data in an effective amount of time.” 

	Ease of use is one tweak that will bring real value to the dentist. 

	“I think the biggest area of improvement in quality that we’re seeing is in the software that’s driving the scanners themselves,” Graham says. “We’re almost to the point where you can pick up a scanner and learn how to use it without requiring a trainer to come in and teach you.”

	He says scanners will get to the point of being able to detect what the dentist is doing and where they are in the mouth while acting as a guide through the process. That will give dentists the option to pass that task on to someone else in the office so that they can focus on procedures that only they can do. 

Technique: How to use an intraoral digital impression scanner for restorative dentistry

	Soon that automation will expand into treatment protocol. 

	“Everybody is working on some artificial intelligence that doesn’t require the user to make the decisions because the computer can learn from previous [cases],” Dr. Severance says. “For instance, the computer can diagnose caries and the software can automatically go to the next step and start preparing for that restoration.” 

	“Where we’re going with software is to eliminate steps: Tasks that are done routinely every day by a team member will become automated,” Cox says. “With an automated process, we can take the image and it automatically captures the information, attaches it to the patient file and submits it to the insurance.” 

	“As the software becomes more sophisticated, it’s going to enable the doctor to have a dialogue with the patient about their oral condition and be able to simulate what effect or change the doctor might be recommending,” Graham says. “Patients will be able to see what their teeth might look like after aligner therapy. You’re going to see more of these capabilities applied to restorative work and smile outcome simulators, even on the scanners themselves.” 

	“I think in the future it’s going to be like a virtual patient-prior to the dentist meeting the patient, they can gather all the information they need and have a much better idea of what process they’ll want to continue with the patient, without having met them,” Dr. Severance says. 

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	At the moment, many dentists fail to see value in investing in an intraoral scanner. Dr. Chi hopes that will change. 

	“I think that is a big barrier with digital scanners,” he says. “As business owners, dentists certainly need to make the best business decisions.” 

	“We’ll probably see more systems that allow us to take it from start to finish in the future, and hopefully pricing will shift to bring more dental practices to the table,” Dr. Rice says. 

	Dr. Hodges thinks a shift toward more affordable systems is likely, as materials and equipment improve, costs decrease and they experience a greater adoption by dentists. 

Exploring the exciting current reality of intraoral scanning, as well as what’s coming in the future. 