Slinging Plastic: What I've Learned in My 20 Years Placing Direct Composite

You're listening to the Phil Klein Dental Podcast Thanks for joining us. I'm Dr. Phil Klein. Today, we'll be discussing things to look for in a composite system and how to utilize these materials as efficiently as possible. Our guest is Dr. Anthony Mennito, a private practice dentist, as well as an adjunct faculty member at the Medical University of South Carolina. He currently works in a cosmetic dental practice that utilizes an evidence-based approach with the goal of providing the most durable and aesthetic dentistry possible. Dr. Mennito has published a variety of research articles on the topics of dental materials. Before we get started, I would like to mention that Dr. Mennito’s webinar titled Everyday Composites Made Extraordinary is now available as an on-demand webinar on VivaLearning.com. Simply type in the search field Minito, M-E-N-N-I-T-O, and you'll see it. It's an excellent webinar for the entire dental team. Dr. Mennito, it's a pleasure to have you on the show. Thanks for having me. I appreciate the opportunity. So to begin this episode, Dr. Mennito, let's address the question that many dentists have when they first start practicing or they've transitioned to a different office. In either case, they have the opportunity to select the direct restorative material that they'll be using day in and day out. And there's so many products out there. Can you give us some insight into how one would even begin to select the right composite for their practice? That's a great question. We all have things that we look for in a material, right? For instance, maybe it's the way that it handles, right? Some people like creamy. composite some like something that's a little bit stiffer for me I want something that I can use in the anterior and the posterior so I don't necessarily want to have a bunch of product in my office that I may or may not use before it expires I want one system that I can use for every basically every indication so I can simplify things for for my team in my office as far as ordering and keeping stock but also that are going to give me a great result when i have to work both in the anterior and the posterior and that can be sort of difficult to find because there's a lot of niche materials out there things that are used maybe specifically more geared towards aesthetic composites you know class fours veneers things like that And then some things that are geared more towards posterior composites. So to find that one sort of a material that fits all those indications is I think what I would look for personally in a material if I were just selecting one. So the material that you're currently using, and we'll talk about that in a few minutes, how did you come across that material and what made you start using it on a regular basis as your go-to material? You know, we get samples all the time in our office. We have people who come around and it's great, right? We get to try a lot of things without the risk of buying a lot of products. So I had a sample of Tetric Prime that my Ivoclar rep brought to me. And what I asked specifically for was a denton-shaped composite because that's something that I utilize a lot in my practice. I think there's a lot of benefit to having a material that's a little more opacious. to be able to utilize for a lot of different things. Maybe we'll talk about that a little bit later, but I wanted to try out that Denton Shade composite because I had currently been using, at the time, a product that had Denton Shades for each shade available. So we're talking about having to keep in stock about 30 different shades. of composites which in a busy private practice is incredibly difficult to keep track of all that material so I wanted something that was going to be a little bit more simplified as far as shade selection and a little bit more of that kind of chameleon effect right where I didn't have to exactly nail the shade each time I get a little bit of forgiveness in my shade selection and it still looks good on the tooth so really I was I was looking for something that had a dent in shade within that system but also had kind of good optical properties and would also simplify kind of the ordering. and stocking of those materials. So when we talk about utilization of a dentin shade in your kit, I assume that's used primarily for anterior teeth, or do you also use it in the posterior teeth with your bulk fill? I do use dentin shade composites in the posterior as well. I find that when I take out large amalgams, which I still do relatively frequently, there's a lot of staining in the teeth, and sometimes it can be helpful to have a more opaceous material that can kind of mask that. Also filling in things like endo accesses and implant accesses. I find that an opaceous material blends a little bit better to hide those seams. And also for class fives, you wouldn't think of, you know, doing like a non-carious cervical lesion on a maxillary premolar. If I want to really nail that shade, I find that the Denton shade that I currently use, the Tetric Prime, does that really, really well. if I can have the right shade. So, you know, it's not just in the anterior. I certainly utilize it in the anterior for times when I'm, you know, covering a discolored tooth or fixing a class four fracture, things like that. But you have to just kind of think outside the box a little bit sometimes and where you can utilize a more opaceous material. So talk about the bulk fill system that you use and what you're doing currently on those large restorations posteriorly where aesthetics is not a major concern. And you want to create a really beautiful restoration, but you want to do it quickly. You're in the back of the mouth. Access is difficult. And you want the most efficient chair side experience that you can get with you and your staff. Absolutely. I mean, I think we all have had experiences where isolation is difficult in the posterior and we need to get a restoration in as quickly as possible, right? I love the bulk fills for those types of situations. And the system I currently use is Ivoclar's Power Flow and Power Fill system. And I have the blue phase light that goes along with that system that allows me to cure it each increment in three seconds. And I was honestly a little skeptical about that system when it came out because I have an academic background. I taught it at the Medical University of South Carolina for 12 years. And so we're kind of... We're kind of taught to, you know, what does the research say about this? And sometimes products are all marketing and, you know, you're going to not necessarily have the best outcome for your patients. But the research on that, it's actually been really positive. This three second curing time that the system enables has been shown to work up to four millimeters, especially for the flowable. I think the flowables. are more easily cured than the packable materials. So that's a big part of what I utilize in my practice. And I will even use the flowable really in almost every indication when I'm wanting to put a little bit of a base or a liner because of how effectively and efficiently those materials polymerize. Because let's face it, polymerization... is a key part of everything that we do in dentistry when it comes to placing direct composites. And I think that's overlooked a lot. So if I can have a material that is going to polymerize more efficiently, it's going to give me peace of mind that through each step of that process, that material is going to be fully polymerized. So I love the power fill system, but it's really the power flow as the piece of that that I really rely on for almost every indication in the posterior. Walk us through real quickly, how do you use the power flow and follow up with the power fill with getting the efficiency out of that light, which obviously that light will work with any composite, but the only way you get the three-second cure is obviously with the initiators that are proprietary to the IvoClor system. And that's a great point. The three-second curing time is only with this composite and this light, not to be used with other brands. In a class one or a class two, my first layer after my bonding agent is always a flowable. In class twos, I like to utilize that to seal off any small gaps I might have between my matrix band and my tooth. In class ones, I like to just basically add a layer that will cover my denton floor, and I try to fill that up to the DEJ, as close to the DEJ as I can get with that first increment. And whether or not I use the three-second cure just depends on kind of what's going on. There are times when I have perfect isolation and I don't necessarily need to speed through a process that I will, once again, for my own peace of mind, maybe cure in a regular time setting just because I'm old school. I may look young, but I've been doing this for 20 years, and I've certainly had my share of failures over the years. And so I want to make sure that everything that I do is being done to the highest level. So I will always use that power flow as a base layer. And then it's important to note that that material, as a bulk fill flowable, is not to be placed with any occlusal contacts at all. So it needs to be capped by a stronger material. It could be a bulk fill condensable material, or it could be a hybrid material. But one way or another, you need another layer of a hybrid type composite over the top of that to finish that restoration. So I generally do two increments of composite for most of my posteriors, and I've had good success with that. So I wanted to ask you this question about warming composites. Some dentists are warming their composites prior to placing it into the preparation, and that makes it more flowable, eliminates the need to actually use a flowable material. What are your thoughts on that? I have. I've used that a little bit. Not extensively, but I used to teach this at a dental school. So I always try to do a deep dive into the literature to figure out what the research says on any given. technique because we get a lot of new techniques that kind of come and this one does have a lot of merit from a from a standpoint of one adaptability of the composite obviously the more flow it has to it the more likely it is to adapt well to the to the floor of our restoration the other thing is is how well it's polymerized and and you have this thing called degree of conversion which is basically a measure of how much polymerization that any material undergoes And with warmed composites, there is a higher degree of conversion, a higher degree of polymerization, which is a good thing as far as our posterior composites especially go. There is a lot of benefit seemingly to that technique. It's not one that I use every day because it takes a lot of planning. You have to have the foresight to know exactly what shade you're going to use. And within a busy practice, sometimes we don't exactly have that as part of our day-to-day armamentarium. So I will pull it out from time to time, but it does seem like there's a lot of benefit to that technique. Are there things that you've learned over the years that have helped you place composites? You can call them tricks of the trade that have really allowed you through your teaching. Because I know when you teach, you learn things as well. I used to teach the undergraduates at Penn. I used to teach endo when I was in my grad program there. And I learned a lot about endo by teaching the dental students about endo. It was crazy that this would happen. But there are always cases and questions they would ask and say, you know, that's really interesting. So through your experience, what can you tell us, our audience, about making sure that we have durability mixed with aesthetics? And the key, of course, is long-lasting restorations. You want those patients to leave your office and not come back in six months or a year saying that something chipped off or they're unhappy with the way that restoration is performing. What can you share with us on that? The first thing that I always hearken to is isolation. There's few things more important in what we do than isolation. And I say that, but to be honest, every step is equally important, right? So it's this complex series of steps and you can't really get any of them wrong if you want to get the best durability and longevity for that restoration. My first thing that I tell young dentists is learn your materials and learn and understand the process. Understand exactly what is happening in each step and the ways that that can potentially go wrong so you can make sure that you get it right. And isolation is a big one because, once again, in busy practices, I am a fan of rubber dam. Say I place it a majority of the time when my patients will tolerate it. That is, I had one the other day who absolutely would not, and that happens from time to time. But if you can get good isolation, it really allows you to take a deep breath and focus on applying your materials in a way that I think ensures success. If you're concerned about the patient swallowing or closing or, you know, oh, is that saliva creeping into my prep? Now you're having to rush. Now you're having to think about other things other than the application of those materials and, you know, oh, how long have I scrubbed the bonding agent on and things like that. So I find that really good isolation allows you to really pay attention to the rest of the important details. In addition to the rubber dam, what else do you use for isolation for your restorative cases? So Isovac, I think, is a godsend as well for patients who, for whatever reason, won't allow us to place a rubber dam or if I just can't get the rubber dam on, you know, for whatever reason. So those two, I think, are my go-tos. And I would say 95 plus percent of the time, it's one or the other. There are some patients who just won't tolerate either. And then we've got to figure it out, right? Then I'm sweating bullets and I'm using my power fill system. And that is a big advantage. Is that speedy? cure because that's the worst thing you want to do is have contamination or a big swallow and a whole gulp of saliva going right over your preparation. There's nothing worse. And I'm not a restorative dentist. I was an endodontist for 15 years, but I did enough post and cores to know that. Yeah. Talk about any tips for aesthetics for anterior composites. That's really important. We know the patients want to be satisfied when they walk out the door. What can you tell us about some of the things you've learned as a teacher and practitioner on creating beautiful anterior composites? I talked a little bit about the dent and shape composite. And I think when you have a patient who comes in and they have a class four fracture or a chipped tooth and you're trying to mask. that fracture line i think that's where a lot of dentists kind of miss out initially is is one how do you how do you prep that tooth because you do have to create some beveling on that tooth to be able to hide that fracture line and then optically the composite that you're using how is that going to help also hide that fracture line. Because if you just use a regular composite, those tend to have enough translucency in them that you can see almost straight through them. And therefore, you can tell exactly where that tooth stops in that composite again. So that's one thing is incorporating those more opaceous composites in as a part of your class four restoration. The other thing are the instruments that you use. I mean, you can really help yourself out by using the correct set of instruments in the anterior because a lot of times, polish can mask. If something is going to mimic enamel, it has to be highly polished, right? Because that's the nature of enamels that has that luster. And so what I found is there's a little pad that Ivoclar makes called the Optroscope pad that is fantastic for... helping you to flatten and smooth a composite prior to polymerizing it, which I think sends you so much further along in the finishing and polishing process than you would be if you just use the plastic instrument. So that's interesting. That's used actually before you polymerize. What is that product called? It's called an OptraSculpt pad. It's a simple little handle that has a disposable foam pad. It's the simplest design you could imagine. And it works so well in the anteriors. Ever since I discovered that, it honestly helped kind of take my anterior composites to another level as far as the finishing and polishing. Because that's a huge part. If you have a really well -placed resin that is... you know, perfect shade match, but you can't get that same degree of luster as the enamel, it's going to stand out a little bit. It's going to look a little dull. So that would be the two things. Having the right kind of level of opaciousness in your composite to mask any fracture line and having the right instrument to help you get kind of a luster that mimics enamel. Right. So using that instrument, you actually were able to attain a seamless flow between the composite and the actual tooth structure. So there's no way, like you mentioned, it's very hard to detect where the tooth structure ends and the composite begins. Exactly that. And it helps to work out any air bubbles that you might have placed during the, or incorporated during the placement of that composite. So, you know, there's nothing. There's nothing worse than placing a composite and doing all your finishing and polishing and then having a void or two in that facial surface that's going to break up the light and collect stain maybe as that composite ages. Right. Now, we talked a lot about direct restorative, and we're going to wrap up this podcast because we're running out of time. But as far as indirect, do you scan? Do you use digital interaural scanners? in your practice or are you still taking impressions? No, it's funny that you asked me that because I'm kind of known more for being a digital dentist than I am for my direct composites. I've been doing CAD CAM, in-office CAD CAM for about 13 years now. You do the milling chair side? I do the milling. I love the staining and glazing, all that. It's right up my alley. Fantastic. Yeah, well, we got to do some more podcasts with you on that because that's... You know, intraoral scanners are now really, really picking up momentum. Absolutely. You know how it works. You get the first group of dentists that adopt these things very early, like you, and perfect them and then give feedback to the manufacturers and tell them what you don't like. And then they fix it and new things, new versions and generations come out. And you're definitely a valuable asset to these. companies that are making these new products. They need docs like you out there that are smart teachers, good clinicians, and good communicators to be able to keep the process going where we keep perfecting these products so that the companies are making things that you guys that are doing the work clinically could see the benefit from. Otherwise, it could be great, but if the dentists don't like it, what good is it? Dr. Mennito, thank you very much for your time. Appreciate it. I know how busy you are, and thanks so much for your insight. Appreciate you having me. If you've been enjoying our podcast, we'd love to hear your thoughts and feedback by leaving a review on your favorite podcast platform, whether it's Spotify, Apple, Google or any other platform you listen on. Leaving a review is a fantastic way to support us and help others discover our show. Thanks for listening. See you next time.