No More Dentist Stress With Class 2 Restorations

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. When it comes to Class II restorations, we all, at one time or another, face the bad and the ugly, like inadequate contacts, open proximal boxes, sensitivity, and insufficient anatomy, to name a few. Today, we'll be discussing how to avoid these pitfalls with new techniques and materials, giving clinicians confidence for better and longer-lasting Class II restorations. Our guest is Dr. Susan McMahon, who runs one of the largest cosmetic dental practices in Western Pennsylvania. An author and lecturer, Dr. McMahon has devoted her professional career to the pursuit of advanced technologies in cosmetic and minimally invasive dentistry. She has been voted by her peers as a top Pittsburgh dentist every year for over 20 years. That is an amazing track record. Dr. McMahon, it's a pleasure to have you on Dental Talk. It's great to be here, Phil. Thanks for having me. Yeah, so we were just talking offline briefly about the Pittsburgh Steelers, and I know you're out of Pittsburgh, and unfortunately they didn't do as well as we had hoped, especially since it's the quarterback's last game, but never a losing season, which is pretty good. Pretty impressive, and Pittsburgh loves their Steelers and so many other. towns do too so it was hard to see them lose but um everyone's always really proud of them and happy to see ben roethlisberger you know enjoy the next part of his life yeah exactly yeah that was a really nice game before that where they honored him i watched it through the end and they had a cameraman walking around the field with him and the fans were just so incredibly respectful to to ben to show him how much they loved him at that last game all right well getting into dentistry which this is a podcast on dentistry not sports Yeah. Although sometimes I wouldn't mind if it was on sports. I think I'll do better with dentistry than sports. So I'm glad we're transitioning. Yeah. There we go. Okay. So as I mentioned in my introduction, there's some issues with class twos that we don't really like to face. So what are the most common problems that clinicians see when doing class two restorations? And how does that affect the lifespan of a class two? Like what's the typical lifespan and what are these problems doing to reducing that? Yeah, so I think many of us, many clinicians face challenges with class 2 restorations. I know I certainly have in the past, and sometimes when I see radiographs on patients that have been mined for a long time and I see class 2s that I put in 10 or 15 years ago, I kind of cringe sometimes, right? So, you know, the biggest problem with class 2 restorations by far is recurrent. class 2 composite restorations is by far recurrent carries at the base of the box. But, you know, many of us also struggle with attaining adequate contacts and approximately. Sometimes it's a struggle with anatomy and or finish and polish. But all of those things, you know, cumulatively affect the life of these class two restorations, which also happened to be one of the most frequent restorations we do as dentists. So this is something we're doing all the time and we're seeing. more failures than would like. The average lifespan, I think, is something like 5.7 years now, which is not something that many of us would consider a big success to have a restoration only last five years. With the new matrix systems they have out there and the materials that we have, and we have flowables that are designed to get better adaptation at the lower part of the box. Why are we still seeing these problems occur over and over again? Is it the practitioner that's not as diligent during these procedures? And I don't want to blame it on the dentist. Or is it just par for the course? This is what we should expect when working in such a difficult area. Yeah, good question. I think it's a number of factors. And, you know, when I'm out in the country kind of lecturing about this, people tell me all sorts of different things. that even though we have matrix systems, that you can get better adaptation at the base of the boxes with like a wedge sectional matrix, right, as opposed to the Toffelmeyers that many of us started our careers on. We're getting better adaptation at the bottom of the box, but it's still a tricky area, right? There's still sometimes hemorrhage down there. Oftentimes, if you're taking out an old amalgam, you're subgingival or almost at the alveolar crest sometimes. So there's that. I think that flowables and, you know, lots of people are putting flowables down at the base of the box. They're using resin-modified glass ionomers and kind of a sandwich technique. We have the bioactives that are, you know, we're all talking about these days too. And all of those things are an attempt to get a better seal at the base of the box. But I think a lot of us still struggle with isolation. So you think inadequate isolation could be one of the main causes of? failures that we're talking about, either saliva contamination or blood contamination, et cetera? Well, I think that that could be part of it. Not good adhesion with our adhesive systems or like you said, contamination. But I think we also have problems with adaptation with our materials. After we get the adhesive layer down there, I think sometimes we're getting pullback on our flowables or when we're packing in traditional composite, I think we're getting voids down there. But, you know, we're certainly seeing it on a routine basis. You probably see a similar thing. Take a set of bite wings on a new patient, and if they've got a lot of composite restorations in the posterior that are interproximal, that it's not unusual to find several that have recurrent decay down in the box. Now, when we used amalgam back in the day, you know, I'm bringing up the word amalgam, and it's probably like, what is he talking about? Did we do better with amalgam as far as? class two restorations lasting longer? Because I mean, I have, I know you've heard this many times, but I had class two restorations from when I was 12 years old that are still in my mouth functioning quite well. That would be almost unconscionable as a composite restorative. Right, right. You just, right. You just would not see that. Well, so I think a Malcolm had certain properties that made it better seals down at the bottom of the box. It was certainly more forgiving technique wise. because I placed amalgam when I first graduated too, so I'm no stranger to amalgam. In fact, when I first graduated, I went into an amalgam practice, and I would probably put 20 amalgams in a day. It was like a race to the end of the schedule with amalgam for me. But, you know, packing amalgam down into the box, condensing it down into the box definitely had very good adaptation down there, and you could condense against the band and get a nice tight contact. Amalgam inherently is bacterial static. So, you know, there's a component to amalgam that actually helps deter caries decay and bacteria from congregating around the margin. So, you know, it had some advantages. Of course, the disadvantage was that if you had any size decent, any decent sized filling there, as the margin started to corrode a little bit or break down, then you'd get maybe micro movement inside that amalgam and you'd see cusp fractures then. you know, kind of start that restorative downward spiral where you had a big amalgam and then you had an endo and then you had a PFM. And now we're putting implants in those teeth. So are we going to get to the level of reliability and lifespan that we did on amalgams with our composite restoratives? And to get there, what are some of the techniques that you recommend we use to overcome these issues we talked about? Yeah, I'm really hopeful. And I see a lot of changes and developments in our... and our techniques that allow these composite restorations to be placed better, to have less recurrent decay, and to function better. I think we're absolutely going to get there. I think that it's important that each of these restorations is given like the appropriate amount of time. You need a little bit more time in most cases to do a composite restoration than you do need to do an amalgam restoration. And a lot of us are inundated in our practices. And sometimes I think that's part of our issue too, is that we don't have enough, you know, clinical time set aside to do that. And I'm only talking about a few extra minutes per restoration. I'm not talking about, you know, an hour or anything like that. When you prep the tooth, number 30, DO, scheduling for a fully completed composite restorative. What is that chair side time? For me, I do a lot of quadrant dentistry. So I might do three restorations in a quadrant and I'll schedule 50 minutes for that. 50 minutes for a quadrant. For say three restorations in a quadrant. Yeah. And that's plenty of time to do everything. Yes, I think so. So what's the most important technique that you could emphasize to our audience regarding class two restorations? Yeah, I think there's a few things that everybody should consider doing. And one of them is a really good sexual matrix system. like Garrison, I love. One that has pre-contoured bands and rings that hold the bands proximally, buckle and lingually on both teeth. Because you can really get good isolation like that. The second thing is adequate wedging. There's a lot of Toffelmeyer bands out there on the market these days, the old traditional ones. There's the new ones that are disposable, and I don't really like any of them for these interproximal lesions. I think a good sectional matrix band is really important. And I also like selective etching. So I definitely want the enamel to be etched everywhere, but I like to use the self-etching on the dentin because I think you're getting better bonds on that. Either you're using a universal adhesive system where you can selectively etch, rinse it off, and then take your universal adhesive and scrub it all the way into the dentin and into the enamel, air off, and then cure, or a two-parter. There's still some two-parter systems out there where you're using a self-etch after, and then your adhesive system. tight isolation, thorough selective etching, and scrubbing it into the bottom of the Denton box. And finally, I think it's important that we use something at the base of the box. It's going to adapt really well. So there's resin-modified glass ionomers that I think work well down there. There's some other flowables. I like a couple of the bioactives. And I really like this new product that we're going to talk about a little bit, the ThermoVisco product from VOCO, which has the properties of being both... a flowable and a packable all in one ampoule. So it's kind of a time saver. It also gives you the benefits of both of those products in one single ampoule, which is kind of nice. Yeah, so that material from VOCO is warmed first in a specific warming device that comes with the system. If you could tell us about how that all works clinically. Yeah, it's a kind of a new category of material that's called thermoviscous. which means the viscosity of it is changing according to how you warm it. So there's two warmers. There's a warmer, an ampule warmer, or there's a gun warmer where you load, a delivery warmer, where you load the ampule, the carpule right up into the gun and warm it right in your hand in the gun. And that's actually the one I prefer. I like to have it right there in my hand to do it. So you prep, you clean it, you isolate with your band, you do your adhesive system, and then you load your ampule up. the delivery system you press a button on the back it takes about maybe like 20 seconds for it to heat up to temperature and then it actually works just like a flowable so you can take that down into the base of your box and flow it down into the base of the box and really watch it adapt to all of the line angles and to the floor of your box and after a few seconds or so After it's out of the ampoule, it starts to warm up a little bit, come back up to temperature, and then you can condense it. So then you can take a condenser and scrub it in there and kind of scrub it against the wall of your... matrix band so you get a really nice tight contact and it stays sculptable for a long time so it's as opposed to you know warming traditional composites which i also like and you know there's some benefits to warming composite for sure it improves the handling and you know there's some evidence that says that it may may increase the depth of cure a little bit and also decrease the polymerization shrinkage. So there's some things for heating composite that works not just with this one, but other heated composites. But this, you know, kind of new thermoviscous product is just the right flowable consistency and then just the right packable consistency. So you don't use a flowable with this material? No, it's one in the same. It's one product that does both things. Okay, so that seems to be a chair time saver, I would think. For sure it is. When you mentioned it warms up in your hand, which is nice to have in the gun, which I guess is nice for Pittsburgh in the winter days. Your hand's getting nice and warm while you're working. So once you put it into the tooth, you said you wait for it to warm up. Did you mean cool down? I guess I did mean cool down. Yes. I just wanted to clarify that because you said warm up, like almost like it gets warmer once you insert into the tube. Okay. You're absolutely right. I did mean cool down. So it flows in, you flow it in, let it adapt. And then as it cools down a little bit, it's then completely packable and stays packable and carvable for pretty much as long as you need it to be packable and carvable. What I do understand about this product, the material itself was designed to be warmed versus other materials that. Some dentists are warming, but they weren't really designed to be warmed. And there's a difference. That's exactly right. This material is designed to be warmed and used, you know, used out of this gun. It's designed to be placed in as a flowable and then pack it and carve it as it cools down just slightly to temperature. And this is a Voco product. What's the name of the composite itself? The product's name is Viscolar. And it comes in regular depth cure and it also comes in a bulk fill in maybe like four different shades of each. Okay. What's the difference between the bulk fill and the depth cure? So the bulk fill, I think you can cure four to six millimeters according to the DFU. And, you know, the traditional Viscolar, you would cure it in two to three millimeter increments. Okay. Just like regular composite. Yeah. I see. Okay, great. Do you feel that this is a material that has really attacked those challenges that we talked about earlier, which is inadequate contacts, open proximal boxes, even sensitivity with your patients? It's an exciting material that it will do so many of those things. I think I'm getting really nice adaptation down in the bottom of the box, and I'm seeing that in radiographs. And there's never a worry about open contacts because you can really push it and sculpt it into the band. So yeah, I think it's doing both of those things. And I personally like how I can sculpt the anatomy into it because I just like to do that a little bit. I like my composites too. I always take a little extra time to do that. And the finish and polish on it is really beautiful. And it has a nice chameleon effect into the enamel. So as far as an aesthetic product too, I really like it. That's kind of the basis of my practice is quite a lot of bit of aesthetics. So I've been using it on some class five restorations as well and have even tried it on a couple of like anterior class threes and class fours and gotten nice results. It looks like the research and development done on the VOCO side, and they have a huge group of PhDs and laboratory research centers in Germany that developed these products they obviously were working to solve the issues that we talked about which is the uh those inadequate contacts and you're getting the best of both worlds apparently i was never a restorative dentist i'm a retired endodontist but i did see so many open contacts when i would be looking at x-rays prior to doing a root canal on a patient that was referred to me most of the time on these molars you can see the decay coming in in approximately because the patient probably did not floss too much and a combination of uh the box breaking down which is where all the food is being trapped it doesn't take too long to get to the pulp so uh in these cases this material sounds like it really if you're going to use composite which most people are using now we're certainly not using amalgam it sounds like this is a very strong option for dentists to look at. No, I completely agree with you. I'm excited about this product. And I always have a lot of confidence in VOCO just because of what you said, because their research and development is so thorough and so filled with expertise. Yeah. What I like about the company is also they listen to the clinicians. They send out the material before it's commercially developed for everybody else. And I don't know whether you're one of the evaluators for VOCO, but they listen to the feedback from the dentists. and the key opinion leaders. And then they delay the release of these materials for months, if not years, to get it exactly where they want it. And by doing so, they're giving up some of the revenue that they could have gotten by selling it earlier. So, which I think is very, very good behavior for a company, a very good culture for a company to do. I've always had a great amount of respect for Voco for that reason. Do you have any webinars scheduled with Viva Learning coming up? I do have one coming up. It's February 9th on Viva. Yeah, if you want to sign up for that, just go to vivalearning.com. You can type in Susan's last name, McMahon, M-C-M-A-H-O-N, and then her webinar will show up. You can just click reserve seat. i'll be doing some of these restorations with this material so you could kind of see how that works and you know watch it flow and then watch it sculpt and talking a little bit more about class two like reducing class two stress and i'm talking about the dentist stress not the polymerization stress so much you know sometimes where it's very stressful you see them on your on your schedule and you think, well, I'd rather do a crown prep than do two class twos. And there's, you know, some technique that can make that easier for all of us. Yeah, it's funny you say that because, you know, as I said, I went into endo, so I didn't do any general dentistry as a career. But in dental school, I ended up going to grad endo at Penn. I would prefer doing a molar root canal than doing an MOD on some of these patients. So nothing's changed. It's the same thing. That was a long time ago. All right. Well, listen again, great insight. Thank you so much, Dr. McMahon, and we look forward to your webinar coming up on Viva Learning. Thank you. Thanks so much, Phil. Nice talking with you. Good night.