Continuing Education A Predictable Resin Composite Injection

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Continuing Education

A Predictable ResinComposite Injection

Technique, Part 1Authored by Douglas A. Terry, DDS, and John M. Powers, PhD

Upon successful completion of this CE activity 1 CE credit hour will be awarded

Volume 33 No. 4 Page 96

ABOUT THE AUTHORSDr. Terry is a graduate of University ofTexas (UT) Health School of Dentistry. Hepresently holds positions as an adjunctprofessor in the department of restorativesciences at the University of Alabama atBirmingham, assistant professor in the

department of general practice and dental public health at UTHealth School of Dentistry at Houston, and professor emeritusin the department of conservative dentistry and endodontics atthe VS Dental College and Hospital, Rajiv Gandhi University ofHealth Sciences in Bangalore, India. He is an accreditedmember of the American Academy of Cosmetic Dentistry, anactive member of the European Academy of Esthetic Dentistry,and an honorary member of the Indian Academy ofRestorative Dentistry. He has served as a past researchassociate for REALITY Re search Lab and a clinical associatefor REALITY Publishing. Dr. Terry has received a number ofprofessional awards as well as Fellowships in the Americanand International Colleges of Dentists, the InternationalAcademy of Dental Facial Aesthetics and is a past member ofthe AGD. He is a member and the US vice president ofInternational Oral Design. Dr. Terry is also an editorial memberof numerous peer-reviewed scientific journals and haspublished more than 230 articles on various topics in aestheticand restorative dentistry. He has authored textbooks innumerous languages including Natural Aesthetics WithComposite Resin (Montage Media, 2004), Aesthetic andRestorative Dentistry: Material Selection and Technique(Everest Publishing Media, 2009), Esthetic and RestorativeDentistry: Material Selection and Technique, Second Edition(Quintessence Publishing, 2013), What’s in YourMouth?/What’s in Your Child’s Mouth? (QuintessencePublishing, 2013), Smile! Your Guide to Esthetic DentalTreatment (Quintessence Publishing, 2014), and What’s inYour Mouth? Your Guide to a Lifelong Smile (Quintessence

Publishing, 2014). He has lectured internationally on varioussubjects in restorative and aesthetic dentistry and is a dentalmaterials clinical research consultant for industrymanufacturers. Dr. Terry is the founder and CEO of designTechnique International and the Institute of Esthetic andRestorative Dentistry. He maintains a private practice inHouston, Tex. He can be reached at (281) 481-3483 or via e-mail at [email protected].

Disclosure: Dr. Terryi reports no disclosures.

Dr. Powers graduated from theUniversity of Michigan with a BS inchemistry in 1967 and a PhD in dentalmaterials and mechanical engineering in1972. He received an honorary PhD fromthe Nippon Dental University in 2011. Dr.

Powers is the senior editor of THE DENTAL ADVISOR andclinical professor of oral biomaterials, department ofrestorative dentistry and prosthodontics, at the Uni versity ofTexas School of Dentistry at Houston. Dr. Powers hasauthored more than 1,000 scientific articles, abstracts,books, and chapters. He is coauthor of the textbook DentalMaterials—Properties and Manipu lation, and is co-editor ofCraig’s Restorative Dental Materials and Esthetic ColorTraining in Dentistry. He serves on the editorial boards ofmany dental journals and has given numerous scientificand professional presentations in the United States,Mexico, South America, Europe, and Asia. He received theE. B. Clark Award from the Society for Color and Ap -pearance in Dentistry in 2012. He received the 2013International Association for Dental ResearchDistinguished Scientist Wilmer Souder Award. He can bereached via e-mail at [email protected].

Disclosure: Dr. Powers is senior vice president of DentalConsultants, Inc (publisher of THE DENTAL ADVISOR)and is senior editor of THE DENTAL ADVISOR.

INTRODUCTIONThe injectable resin com posite technique is a unique and novelindirect/direct process of predictably translating a diagnosticwax-up into composite restorations. There are a myriad of


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A Predictable Resin CompositeInjection Technique, Part 1Effective Date: 4/1/2014 Expiration Date: 4/1/2017

applications for this technique using a highly filled flowable resincomposite. The clinical applications in clude emergency re pair offractured teeth and restorations, fabricating provisionalrestorations,1 transitional composite restorations (Class III, IV,veneers) and pediatric composite crowns, resurfacing occlusalwear on posterior composite restorations, establishing incisaledge length prior to aesthetic crown lengthening, anddeveloping composite prototypes for copy milling. In addition,this technique can be used to establish the vertical dimension ofocclusion and for altering occlusal schemes (anterior guidanceand posterior disclusion) prior to final restorations. Furthermore,this noninvasive technique is an integral tool for enhancingcommunication between the patient and restorative team duringtreatment planning.

Developing transitional resin composite restorations usingthe injectable technique is an excellent method to increase thepatient’s understanding of the planned clinical procedure andanticipated final result.2 Transitional composite prototypesallow the patient and restorative team to establish parametersfor occlusal function,3 tooth position and alignment,4

restoration shape and physiologic contour,5 restorativematerial color and texture, lip profile, phonetics, incisal edgeposition, and gingival orientation. This process also eliminatesconfusion and misunderstanding between the patient and therestorative team during the treatment planning stage.2 This in -jectable technique can also be used in the development andmanagement of soft-tissue profiles and in the design of thedefinitive restoration.6-9 The clinician and technician can use

this reversible and preparation-less technique as a guide fordeveloping a preapproved functional and aesthetic finalrestoration. This process aids the clinician and technicianduring the design and fabrication of the definitive restoration byproviding a visualization for the patient and the restorativeteam as well as the ability to communicate extensive detailsconcerning the treatment plan and the fabrication of finalrestorations.10 In some cases, these transitional restorationscan be worn for months or even years by patients during long-term interdisciplinary rehabilitation.1

This technique can be performed intraorally withoutanesthesia. A clear vinyl polysiloxane (VPS) impressionmaterial is used to replicate the diagnostic wax-up. Theclear matrix can be placed intraorally over the unpreparedteeth and used as a transfer vehicle for the flowablecomposite resin to be injected and cured. After adjustmentand polishing procedures are completed, the transitionalcomposite restorations can be further modified to satisfythe functional and aesthetic needs of the pa tient. Thisprocedure can reduce the potential for patientdissatisfaction and litigation since the process is reversible,can be performed without preparation, and allows thepatient to accept the visual and functional result before thedefinitive restorations are fabricated. In addition, this simpleprocedure helps to regulate the dimensions of thepreparation design, ensures uniform spatial parameters forthe restorative material, and increases the potential for amore conservative preparation design.1


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A Predictable Resin Composite Injection Technique, Part 1

Before Image. Preoperative facial view of the maxillary anteriorsegment. A 63-year-old patient presented with incisal wear andfracture on the maxillary anterior teeth. Patient requested aconservative aesthetic enhancement without orthodontic treatment.

After Image. The composite transitional restorations establishthe optimal aesthetic parameters for a natural smile.

This article presents a case report in volving the use ofthe injectable resin composite technique to developtransitional res in composite restorations.

CASE REPORTA 63-year-old male patient presented with concernsregarding incisal wear and fracture of his maxillary anteriorteeth (Before Image). Clinical evaluation revealed multiplediastemas and cervical corrosion on the central incisorsfrom lemon sucking (Fig ures 1a to 1c). Additional occlusalfindings indicated insufficient canine guidance andposterior disocclusion.

Clinical ProtocolAfter occlusal evaluation, a new occlusal scheme wasdeveloped with a diagnostic wax-up (Figure 2a). A clear VPSimpression (EXAClear [GC America]) of the diagnostic wax-upwas taken using a nonperforated plastic tray (RSVP Tray[Cosmedent]) (Figure 2b).

Each tooth was pumiced and cleaned with 2%

chlorhexidine (Con sepsis [Ultra dent Products]). Also, prior tothe restorative procedure, a hybrid resin composite wasplaced in the clear matrix and positioned on the maxillaryright central and light cured. This technique allowed thespatial dimension of a large diastema to be controlled duringthe composite injection procedure (Figure 3). Each toothwas then separated by applying Teflon tape (Du Pont), or asmall amount of glycerin, to the adjacent teeth (Figure 4a).This proximal adaptation technique allowed for optimalintegration of flowable resin composite in the interproximalregion while preventing adhesion of the material to adjacenttooth surfaces.11-13 De pending upon the duration oftreatment, the method for bonding requires either selectivespot-etching or complete etching of the tooth surfaces to berestored.1,2 A 37.5% phosphoric acid semi-gel (Gel Etchant[Kerr]) was applied to the enamel surface for 30 seconds(Figure 4b), rinsed for 5 seconds, and then gently air dried.A single-component adhesive was applied with anapplicator to the enamel surface (Figure 4c), allowed todwell for 10 seconds, air dried for 5 seconds (Figure 4d),


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Figures 1a to 1c. Clinical evaluation revealed multiple diastemas and cervical corrosion on the central incisors from lemon sucking.

a b c

Figures 2a and 2b. (a) Development of a diagnostic wax-up that establishes newparameters (ie, aesthetic, functional) for the final restorations, and (b) a clear vinylpolysiloxane matrix was fabricated to replicate the diagnostic wax-up.

a b

Figure 3. Before the restorative procedure,a hybrid resin composite was placed in theclear matrix and positioned on the maxillaryright central and light cured. This techniqueallows the spatial dimension of a largediastema to be controlled during the composite injection procedure.

and then light cured for 10 seconds using anLED curing light (Silverlight [GC America])(Figure 4e). The clear VPS matrix was placedover the arch and an opacious A-2 shadedflowable resin composite (G-ænial UniversalFlo [GC America]) was initially injected througha small opening above each tooth, followed bya translucent B-1 shaded flowable resincomposite (G-ænial Universal Flo) (Figure 5a).The resin composite was cured through theclear matrix for 40 seconds (Figure 5b). Theexcess polymerized resin composite was re moved with a scalpel (No. 12 BD Bard-Parker[BD Medical]) (Figure 6a). The incisalcomposite sprue was removed with a 30-flutedtapered finishing bur (Figure 6b). The gingivaltissue was retracted with a gingival protector,and the tooth-resin composite interface wasfinished using a tapered finishing diamond(Figure 6c). The initial hybrid composite mock-up on the maxillary right central was re moved with the No. 12scalpel blade (Figure 7). The proximal surfaces and contourswere smoothed with a tapered finishing diamond and finishingstrips (Figures 8a and 8b). This restorative procedure wascompleted for each tooth before restoration of the next tooth.

After isolation of the adjacent central with Teflon tape, theadhesive surface preparation (Figure 9a) was completed usingthe total-etch technique. The same shade combination offlowable composite material was injected through a smallopening in the matrix above the tooth (Figure 9b), allowing thematerial to completely coverthe conditioned enamelsurface. The resin compositewas then light cured throughthe clear matrix for 40 seconds.After the incisal compositesprue was removed, the ex -cess polymerized compositeresin was removed with the No.12 scalpel blade (Fig ure 10a).After each composite injection,the same re stora tive procedurewas completed for each toothin the anterior segment.


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c d e

Figures 4a to 4e. (a) Before the adhesive surface preparation, each tooth is separated byapplying Teflon tape (DuPont) on the adjacent teeth; (b) a 37.5% phosphoric acid semi-gel(Gel Etchant [Kerr]) was applied to the enamel surface for 30 seconds, rinsed for 5 seconds,and gently air dried; (c) a single component adhesive was applied with an applicator to theenamel surface, allowed to dwell for 10 seconds; (d) air dried for 5 seconds; and (e) lightcured for 10 seconds using a halogen LED curing light (Silverlight [GC America]).

a b

Figures 5a and 5b. (a) The clear siliconematrix was placed overthe arch and anopacious A-2 shadedflowable resin composite(G-ænial Universal Flo[GC America]) wasinitially injected througha small opening aboveeach tooth, followed bya B-1 shaded flowable

resin composite; and (b) the resin composite was cured through theclear resin matrix for 40 seconds.

a b

Figures 6a to 6c. (a) The excess polymerized compositeresin is removed with a scalpel blade (No. 12 BD Bard-Parker [BD Medical]); (b) the incisal composite sprue wasremoved with a 30-fluted tapered finishing bur; and (c) thegingival tissue was retracted with a gingival protector, andthe tooth-composite resin interface was finished using atapered finishing diamond.

a b c

Figure 7. The initial hybrid composite mock-up on the maxillary right central was removedwith a scalpel blade (No. 12 BD Bard-Parker).

An optimally finished transitional restoration should providea smooth surface that will prevent plaque accumulation14-17

and resist staining.14,18 The transitional composite restorationshould also possess proper marginal adaptation andintegrity14,19 with the ideal contours and emergence profile forimproved tissue compatibility.14 For this pa tient, the gingivaltissue was retracted with a gingival protector (8A TNPFIA6

[Hu-Friedy] and/or Zekrya Gingival Pro tector [DMG America])to prevent tissue laceration, and the tooth-resin composite in ter face was finished using a tapered finishing diamond(Figure 10b). The lingual tooth-resin composite interface wasfinished using a 30-fluted pyramidal shaped finishing bur(Neumeyer H274 [Brasseler USA]) (Figure 11). This bur has anideal shape that conforms to the appropriate curvature of the


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Figures 8a and 8b. The proximal surfaces and contours weresmoothed with a tapered finishing diamond and finishing strips. This restorative procedure was completed for each tooth prior to restoration of the next tooth.

Figures 9a and 9b. (a) After isolation of the adjacent central withTeflon tape, the adhesive surface preparation was completed usingtotal-etch technique; and (b) the same shade combination of flowable composite material was injected through a small opening in the matrix above the tooth, allowing the material to completelycover the conditioned enamel surface. The composite resin wascured through the clear matrix for 40 seconds.

Figures 10a and 10b. (a) After the incisal composite sprue was removed, the excesspolymerized composite resin was removed with a scalpel blade (No.12 BD Bard-Parker);and (b) the gingival tissue was retracted with a gingival protector, and the tooth-compositeresin interface was finished using a tapered finishing diamond.

Figure 12. Proximal surfaces and contourswere smoothed with finishing strips(KerrHawe).

Figure 13. The incisal and proximalcontouring and smoothing wereaccomplished with finishing and polishingdisks (OptiDisc [KerrHawe]).

Figure 14. The facial surfaces werepolished with silicone points (ET IllustraPolishing Points [Brasseler USA]).

Figure 11. Thelingual tooth-composite resininterface wasfinished using a 30-fluted pyramidal-shaped finishing bur(Neumeyer H274[Brasseler USA]).

aa bb

a b

tooth surface and restoration.The interproximal surfaces were smoothed with aluminum

oxide finishing strips (Finishing and Polishing Strips[KerrHawe]), which were used sequentially from fine to extra-fine (Figure 12). The incisal edges of the resin composite werecontoured with finishing and polishing disks (Opti Disc[KerrHawe]) (Figure 13). Pre-polish and high-shine siliconepoints (ET Illustra Polishing Points [Brasseler USA]) were usedto smooth and polish the resin composite surface (Fig ure 14).

The gingival region was smoothed and polished with pre-polish and high-shine silicone hollow cups (ET IllustraPolishing Cups [Brasseler USA]) (Figure 15). The cup

provides additional flexibility at the cervical curvature of thetooth. The facial surface was polished to a high luster withsynthetic diamond paste using a goat-hair wheel, and thefinal surface gloss was accomplished with a dry cotton buffusing an intermittent staccato motion applied atconventional speed (Figures 16 and 17).

The transitional resin composite restorations werecompleted and inspected in centric relation, protrusive, andlateral excursions (Figures 18a to 18c). The compositeprototype achieved using this noninvasive injectabletechnique established the optimal aesthetic parameters fora natural smile (Figures 19a to 19c and After Image).


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Figure 15. The gingival region was polishedwith silicone hollow cups (ET IllustraPolishing Cups [Brasseler USA]).

Figure 16. A goat-hair wheel and diamondpolishing paste were used to further refinethe surface luster of the composite resin.

Figure 17. High surface gloss wasaccomplished with a dry cotton buff appliedwith an intermittent staccato motion.

Figures 18a to 18c. The transitional resin composite restorations were inspected in centric relation, protrusive and lateral excursions. Noticethe improved posterior disclusion and anterior guidance.

a b c

Figures 19a to 19c. The completed transitional resin composite restorations with optimal anatomical form. The composite injection technique allowed the establishment of harmonious proportions of the transitional restorations and the surrounding biologic framework.

a b c

IN SUMMARYThe injectable resin composite technique is a valuablecommunication tool for increasing the patient’s understandingof the clinical procedure and anticipated final result. Thisprocess allows the functional and aesthetic concerns to beresolved by the entire restorative team before final restorativetreatment is initiated. The future clinical applications of thisnovel technique may provide clinicians and technicians withalternative ap proaches to various clinical situations whileallowing them to deliver im proved and predictable dentaltreatment to their patients. Although the long-term benefits ofthis novel in jectable composite technique re mains to bedetermined, the clinical results achieved in the past 7 years bythe author are extremely promising.

Part 2 of this discussion will illustrate another revolutionaryapplication of the injectable resin composite technique for usewith the primary dentition described as the Terry InjectablePrimary Composite Crown.

ACKNOWLEDGEMENTThe authors would like to acknowledge the followingtechnicians for the laboratory design of the diagnostic wax-up: Bassam Haddad, CDT; Victor E. Castro, CDT; andMark L. Stankewitz, DDS, CDT.

REFERENCES1. Terry DA. Developing a functional composite resin

provisional. American Journal of Esthetic Dentistry.2012;2:56-66.

2. Terry DA, Leinfelder KF, Geller W. Provis ionalization.In: Aesthetic & Restorative Dentistry: MaterialSelection & Technique. Houston, TX: EverestPublishing Media; 2009.

3. Heymann HO. The artistry of conservative estheticdentistry. J Am Dent Assoc. 1987;115(specialissue):14E-23E.

4. Gürel G. The Science and Art of Porcelain LaminateVeneers. Hanover Park, IL: Quin tessence Publishing; 2003.

5. Baratieri LN, Berry TG. Esthetics: Direct AdhesiveRestoration on Fractured Anterior Teeth. São Paulo,Brazil: Quintessence Publishing; 1998.

6. Donovan TE, Cho GC. Diagnostic provisionalrestorations in restorative dentistry: the blueprint forsuccess. J Can Dent Assoc. 1999;65:272-275.

7. Preston JD. A systematic approach to the control ofesthetic form. J Prosthet Dent. 1976;35:393-402.

8. Yuodelis RA, Faucher R. Provisional restorations: anintegrated approach to periodontics and restorativedentistry. Dent Clin North Am. 1980;24:285-303.

9. Saba S. Anatomically correct soft tissue profiles usingfixed detachable provisional implant restorations. J Can Dent Assoc. 1997;63:767-770.

10. Terry DA, Geller W. Esthetic and Restorative Dentistry:Material Selection and Technique. 2nd ed. Chicago, IL:Quintessence Publishing; 2013.

11. Terry DA, Leinfelder KF. An integration of composite resinwith natural tooth structure: the Class IV restoration.Pract Proced Aesthet Dent. 2004;16:235-242.

12. Terry DA. Restoring the interproximal zone using theproximal adaptation technique—Part 1. CompendContin Educ Dent. 2004;25:965-973.

13. Terry DA. Restoring the interproximal zone using theproximal adaptation technique—Part 2. CompendContin Educ Dent. 2005;26:11-30.

14. Terry DA. Natural Aesthetics with Composite Resin.Mahwah, NJ: Mon tage Media Corporation; 2004.

15. Stewart GP, Bachman TA, Hatton JF. Temperature risedue to finishing of direct restorative materials. Am JDent. 1991;4:23-28.

16. Berastegui E, Canalda C, Brau E, et al. Surfaceroughness of finished composite resins. J ProsthetDent. 1992;68:742-749.

17. Yap AU, Sau CW, Lye KW. Effects offinishing/polishing time on surface characteristics oftooth-coloured restoratives. J Oral Rehabil.1998;25:456-461.

18. Goldstein RE. Finishing of composites and laminates.Dent Clin North Am. 1989;33:305-318, 210-219.

19. Yap AU, Ang HQ, Chong KC. Influence of finishingtime on marginal sealing ability of new generationcomposite bonding systems. J Oral Rehabil.1998;25:871-876.

SUGGESTED READINGTerry DA, Geller W. Esthetic and Restorative Dentistry:

Material Selec tion and Technique. 2nd ed. Chicago, IL:Quintessence Publish ing; 2013.

Terry DA. What’s In Your Mouth? Chicago, IL:Quintessence Publishing; 2013.

Terry DA. Smile! Your Guide to Esthetic Dental Treatment.Chicago, IL: Quintessence Publishing; 2014.


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POST EXAMINATION QUESTIONS

1. The injectable resin composite technique is anintegral tool for enhancing communication betweenthe patient and restorative team during treatmentplanning.

a. True b. False

2. This injectable technique cannot be used in thedevelopment and management of soft-tissue profilesand in the design of the definitive restoration.

a. True b. False

3. This injectable technique can be performedintraorally, without anesthesia.

a. True b. False

4. The long-term benefits of this novel injectablecomposite technique are proven and supported bywidespread reports in the literature.

a. True b. False

5. In addition, this simple procedure helps to regulatethe dimensions of the preparation design, ensuresuniform spatial parameters for the restorativematerial, and increases the potential for a moreconservative preparation design.

a. True b. False


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Continuing Education A Predictable Resin Composite Injection