Simplifying Posterior Direct Composites: Workflow, Tips & Tricks

You're listening to The Dr. Phil Klein Dental Podcast Welcome to the show. I'm Dr. Phil Klein. New advancements in resin and photopolymerization technology allow us to simplify these procedures without compromising quality. Today we'll be discussing how to simplify your technique, understand the critical factors for successful posterior direct composites with the goal of making your process much more efficient. Our guest is Dr. Nada Albatish. She owns and operates a multidisciplinary practice, All Smiles Dental Center, just north of Toronto. She has co-authored a book and various journal articles and lectures nationally and internationally. Before we get started, I would like to mention that Dr. Albatish will be presenting a live webinar on VivaLearning.com titled Simplifying Posterior Direct Composites, Workflow, Tips, and Tricks. It is scheduled for Tuesday, October 4th at 7.30 Eastern Time, 4.30 on the West Coast. Simply visit VivaLearning.com to register. The webinar is free and you can earn live interactive CE credit. Dr. Albatish, it's a pleasure to have you on Dental Talk. Phil, thank you so much. It's a pleasure to be here. Yeah, and a good topic to discuss this morning because dentists... do posterior direct composites probably every day if they have a busy practice so it's something that's very relevant and we want to get the latest and the greatest from you as far as your recommendations as far as technique protocol and so forth so to begin let me ask you this what do you look for in a posterior composite because there's so many products out there and let's just assume you're starting your practice or you want to switch to a new composite what are you actually looking for in a posterior composite today One of the most important things that we don't think about until later, until we've done our composites and we've brought our patients back for their recall visits, is what the composites look like on x-rays. And it's one of the most important things because... they are not radiopaque enough, we're not able to tell if we really have well-stealed margins. We're not able to tell if what we're looking at is recurrent decay. So one of the most important things that I look for is high radiopacity. The second thing that I look for is low shrinkage stress. And we all learned in dental school about polymerization shrinkage and the C factor. And what that's about is the more walls you have, the more shrinkage you can potentially get as the composite pulls away from the walls. So with today's science and today's materials, there are materials out there that have really low shrinkage stress, and that allows us to be more efficient in our dentistry. And we'll talk more about that later on. Another thing that I look for is high mechanical strength. I have used composites in the past where I put the composite in. It's beautiful, right? We get nice aesthetics, even if we're in the posterior. I ask the patient to bite down. And the first thing that happens when the patient bites, when I'm trying to mark the occlusion, is that the composite fractures. That has actually happened in my chair. But I've seen this happen in the past with materials that are marketed to be extremely high aesthetic. But mechanical strength wasn't quite there. So that's something that's really important that I look for that typically comes with high filler content. I want good working time with my composite. I don't want it to set while I'm trying to place it and adapt it and use it. And I really want to think about the efficiency of the material that I'm using. So materials that have higher shrinkage stress, perhaps lower strength, actually need more increments. There are still many materials on the market that require use of increments, which are excellent. But there are also materials today that we can use that we can actually bulk fill because the shrinkage stress is much, much lower. So we can place larger increments. And what that creates for us is efficiency. And that's probably one of the biggest challenges that we'll talk about today. So looking for something that looks good, works well, not only functionally in the patient's mouth. while replacing the restoration efficiently. And then in the future, what it looks like on those radiographs is what I consider to be probably some of the most important things I look for in my posterior composites. So you've gone through several different iterations of posterior composites over the years in your practice. So tell us about that journey in the world of posterior composites. How has your experience influenced you in your evolution regarding which products work best for your patients? I love that question because it's always important to kind of look back on where we started and where we've gotten to. And 15 years ago, I graduated from dental school and I think we started learning composites in second year dental school. So, you know, it's probably been a good 18 years I've been handling composites. Initially in my journey, we were only placing. that required incrementation. And the real challenge and the reason why we were doing that at that time is, as I mentioned earlier, because of polymerization shrinkage. And the bigger an increment you would place, the more shrinkage that you would get, large composite increments, and you got that shrinkage, what you would see is marginal leakage, marginal staining, recurrent decay, postoperative sensitivity. So there was a lot of challenges, right, that we used to deal with. If we weren't really careful and incrementing smaller was the way to go. If you got really fast at drilling, which I did earlier in my career. Right. And it was it's a fun challenge to time myself. Right. You almost compete with yourself. Then the rate limiting step actually became the placement of your direct restorative materials. So over time, we started to see more and more manufacturers coming out with different. technologies to try to make this process more efficient. We went from layering and incrementing traditional to what I'm using in my practice today, which I use the Tetric bulk fill posterior composite. That's a material that's actually made by Ivoclar. And, you know, I've tested many, many, many composites over the years and it is. by far my favorite because the part where I have to start putting the filling in is no longer the part that my assistant and I dread because it's going to take so long depending on how big the filling is. You know what? Even the patients notice, right? So the patients have noticed, it's been years now that I've been using it, but patients will notice like that we're in and out pretty quick. And so my assistant notices that when we're doing this dentistry, she's not. sort of yawning when I'm trying to get through the part where we're putting the filling in the tooth. Overall in the clinic, and I think perhaps this is one of the most important things, overall in the clinic, I think if you actually look at the spread of procedures that we do in the office, hygiene is really, really up there for a number of procedures we do a year, and then posterior composites. So it really makes a difference when you can make one of your most common procedures become one of your most efficient. And so the shift that we've made has been from the traditional composites to the Tetric bulk fill composite that I use only for posterior teeth. And that's basically made it so that I can place almost any size restoration that's four to eight millimeters deep. Four millimeters deep really only requires one increment of placement. And what I'm seeing as a result of that is Even though I'm doing things more efficiently, I'm happier. My hygienists are happier. Everybody's happier because everything's more efficient. What I'm also seeing, though. is less post-operative sensitivity, excellent margins on restorations, because the restorations are really radio-opaque, so I can really decipher the difference between the restoration margin and the tooth margin when the patient comes back in the future. Basically, patients saying nothing afterwards, which is really what you want. You've kind of tackled it. problem of the inefficiency of filling the material into the cavity prep. So what are the remaining biggest challenges that you face when doing your bread and butter restorative dentistry in your posterior restorations? There's a couple of things actually, but I want to touch on one more thing related to the efficiency, which is when your hygiene team needs an exam, right? Because when we first etch the tooth and our hygiene team needs an exam, They poke their head in the door and now you're in the situation where you're trying to maintain moisture control. And if the restoration is the rate limiting step, it's the longest part of your procedure, then your hygienists are having to wait longer than they really need to. And it's reducing the entire efficiency of your clinic and your other providers, not just. the time you're taking to work on the patient that you're working on. Some other challenges, though, besides that, that we see with composites is especially when bulk fills first came out, the creation of voids in the material. And if you do get voids or air bubbles in the material, then you can get patients with biting pain and postoperative sensitivity. Another challenge that you could experience is materials have different handling properties. So some materials are stiffer to handle and when you get into the bulk fill materials and you want strength a lot of these materials have to have high filler content so we really need to think about how we're going to get these materials into all the nooks and crannies that they need to go into. We never thought about this a lot but I thought about it later when things became much more efficient with a more efficient curing system, not just placement of composites. But one of the things is how long it takes to cure your materials. So when we were doing 40 second cures at each two millimeter increment, curing, it's all 40 seconds, it's only 40 seconds, but all that time actually adds up. And with the current material that I'm using, I'm using the three-second power cure system. So it's a really effective curing light, and it's a system. It works with the composite. So the composite has a material in it that is able to allow it to cure in that three-second period. And because of that, every layer we place is a three-second cure, which saves us 30 seconds. 37 seconds. Doesn't sound like much if you're placing one layer and then double that if you're doing two. And then if you take off your matrix band, if you're doing an M or a D or you're curing buccally and lingually, that time really adds up. That's per tooth, not just per patient. You know, so if you're doing a quadrant. You know, you're shaving a lot of time off and you're avoiding some of the errors. Like another challenge with longer curing times that we used to deal with is if your assistant didn't hold still in the right spot, curing needs to be done in just so, right? The surface of the curing light needs to be parallel to the surface of the restoration and within two millimeters. So when the assistant has to hold that in the right spot for a longer, significantly longer. period of time, then we would see drifting. And if the light would drift as the assistant's hand would drift because nobody wants to stare at a blue light and it's harder for them to see through the orange filters, then we can't guarantee that we actually got proper depth of cure and proper polymerization all the way through of our composites. So this system that you're talking about is a composite and it... paired with a specific light that works with the initiator for that composite so that you can reduce the polymerization time from 40 seconds to three seconds? Correct. Yeah, that's a huge savings. That's not a small amount of time. I was always under the impression that most of the polymerization was in the 20-second range, but you're saying that it's 40 seconds. Well, with the traditional composites, I mean, over the years and actually still what we do at the end of using a traditional composite, we do 20 second increments. Then at the end, we do a 40 second cure. 15 years ago, we were curing everything, not 20 seconds. It was 40 seconds, but this is part of the journey, right? It was 40 seconds for each increment. And then we shifted to 20 seconds for the inside the tooth increments. And then we just did a final. Do you use a flowable at all, a flowable material? with your posterior composites? You know, as part of this system, there is a tetric power fill and the tetric power flow. So the tetric power fill part of the material is the packable and the tetric power flow material is a flowable. So you can use a flowable underneath the packable. And I actually like to place a small layer. You can go up to four millimeters with each. one of those materials. If you had a restoration that, let's just say, was five millimeters deep, you could do a millimeter with your flowable and then four millimeters with your packable. I like to have a small millimeter with my flowable. And the really nice thing about the power flow that's also part of the system that is also able to be cured in three seconds is that it's self-leveling. So you put it in and you just don't touch it. And if you keep watching it, it will actually level. And the nice thing is that if you had any regulation, or any, you know, corners, sharp corners rather than rounded line angles or anything like that, when you were prepping, it will really smooth out the walls and the floor. And then you can place in your packable after that very easily. So you've talked a lot about bulk fill techniques. What are the risks of incorporating voids in the material? Voids can become an issue when you're using bulk fill materials. One of the ways to avoid voids in your composite is to keep the tip in the composite while you're dispensing. It's really the same as with traditional impression materials. If you pull the tip out, you can introduce air when you bring it back down. So that's one thing. The other thing that I really like to do in my practice is to warm the composite. i use a composite warmer what we do is we warm the composite and when we warm the composite it becomes more flowable and so with the packable materials that are stronger i like to have a more flowy feeling in the composite then i warm my composite in order to do that and what we need to know about warming composites the real question is are we harming the composite are we changing it um in one way or another when we warm the composite and there are studies that show improved qualities in the composite after warming. There's really two kinds of studies that we've seen. Some that show that the composite quality is actually better. It's stronger after you warm it and you cure it. And some that show that there's no change, right? Some say that you warm it and their evidence shows that once you cure it and they test the composites afterwards, it's the same whether you had warmed it or not. So when I look at studies, like I look at the spread. And I think, is this something that makes sense for me to do? Well, I'm not causing any harm and I'm possibly improving the clinical outcome because some studies are suggesting that there's higher strength in warm composite. And at the same time, I'm making the handling easier for myself. Then that's a go for me. Is there a special warming system for Tetric or is there a generic warming system that you just... Any composite warmer. Where would you find that? Is there a particular brand? that you buy that you could recommend you know what um actually no you can get any one from your dental supplier you can buy even on ebay or amazon like really it's not part of the system it's not even part of the manufacturer's instructions it's just something that I like to do. Yeah. That's been great information, Dr. Albatish. We really appreciate your insight. And it sounds like you've gone through quite an evolution in your journey using posterior composites. You do have a webinar coming up in October with Viva Learning called Simplifying Posterior Direct Composites. So we look forward to that on October 4th. That's at 7.30 Eastern time, 4.30 Pacific. So thank you very much and look forward to you doing more stuff with us in the future, Dr. Albatish. Thanks so much, my friend. Good seeing you Phil, take care.