Episode #346: Posterior Composites, with Dr. Lee Ann Brady

Today, Dr. Lee Ann Brady from The Pankey Institute shares some of her favorite and must-try techniques for posterior composites. From her favored isolation systems to the many uses for plumber’s tape, she has a variety of advice to improve your dentistry today! To hear this expert’s tips, tricks, and techniques for creating the best, aesthetic composites, listen to Episode 346 of The Best Practices Show!

Main Takeaways:

• Patients find Isolite to be a comfortable form of isolation.
• ReLeaf isolation works best on patients with strong gag reflexes.
• Rubber dams might make a comeback peri-Covid for aerosol prevention.
• Ivoclar’s OptraDam is the kinder, gentler version of a rubber dam.
• Retraction pastes are probably the best hemostatic agents in all of dentistry.
• Pre-wedge every time for a successful matrix.
• Teflon tape has multiple uses in dentistry.
• Prep scrub every tooth you prep to prevent sensitivity and reduce bond degradation.
• Be cautious about mixing and matching universal adhesives.
• Composite warmers will transform your life.
• To prevent cross-contamination between patients, don't reuse composites in the warmer.

Quotes:

• “One of the biggest challenges we have when we do adhesive dentistry of any kind, direct or indirect, is managing contaminants, isolation — so, water, saliva, red blood cells, all of the contaminants that are automatically in the oral environment, and then some of the ones that we introduce through our handpiece. And they're actually not our friend when it comes to optimum adhesives, and we want to try to manage that.” (03:56—04:21)
• “I love working with an Isolite. Most of my patients find it really comfortable once you get it in and get it in position. And they prefer it over having to hope they're staying open wide enough for you or worrying about their tongue. It actually really does do a great job at managing isolation from a standpoint of moisture in the oral environment, managing aerosols.” (04:52—05:16)
• “I can't use [Isolite] on everybody. And so, the other device that you see listed on the picture is called ReLeaf, and it comes from a company named Kulzer. They're the people who make Ivory Rubber Dam materials. And I use ReLeaf for a couple of different scenarios. One is, somebody posted in the chat, ‘What about patients with a really strong gag reflex?’ This will work much better because you're not putting any pressure or contacting the tongue. And it also works really well for patients at high functional risk.” (05:45—06:19)
• “If you get the ReLeaf, get one for your hygiene department as well, because it’s probably the best thing that we can think about from a standpoint of using an ultrasonic.” (08:03—08:18)
• “Rubber dams are one of these things that most of us were super glad that we were able to leave behind when we left dental school. And then, there are other people who say, ‘I do all my dentistry under a rubber dam. I do think that thinking about going back to rubber dam isolation may be on people’s radar screen after we get back in our offices, simply because of the fact that it does isolate us from the patient’s oral environment, and it does prevent aerosols.” (09:03—09:32)
• “[The Ivoclar OptraDam is] actually what I call the kinder, gentler version of a rubber dam. Why is it the kinder, gentler version? Well, a couple of reasons. Number one, everything all comes together so you don't need to know where the frame is and sterilize it and find the dam material. It also isn't a flat piece of rubber dam, so it literally is the shape of the back of the mouth. And because it’s not under tension, you don't need a rubber dam clamp. And if you don't use a clamp, you don't need palatal anesthesia on the maxillary, and you don't need long buccal anesthesia on the mandibular. It’s already got the little holes punched in it, so you literally just punch the holes with your rubber dam punch.” (09:46—10:27)
• “There's a really great video on YouTube of how to put an OptraDam in. It’s not intuitive. But if you watch the video, in five minutes, you'll know how to put it in. It’s a quick, simple, easy way to do a rubber dam. It might be something people want to explore as they move forward. I will tell you, the only caveat is they don't make a latex-free version. So, if you're allergic to latex, or you have someone in your office who’s latex-allergic, or the patient, you can't use an OptraDam. They do make traditional rubber dam material in a latex-free version.” (10:28—11:04)
• “If you're not using a rubber dam or a well-inverted rubber dam and you're trying to control saliva and/or sulcular fluid or hemorrhage, a couple of things to think about. And my favorite is to use retraction paste. So, I actually don't think retraction paste is the best way to retract and actually get tissue retraction for an impression. But retraction pastes are probably the best hemostatic agents in all of dentistry. And so, unlike the liquid hemostatic agents, they don't turn the tissue brown, and they don't stain the tooth. They don't interfere with any of our other materials. They're really great at hemostasis — better than the liquids like cranberry Styptin, Traxodent, or any of those.” (11:07—11:51)
• “We all learned [pre-wedging] in dental school, and probably stopped. But when I was reading the research, here’s what caught my attention. It actually takes a wedge somewhere, on average, between three to five minutes to push the teeth, compress the periodontal ligaments, and create a big enough space between the two teeth to overcome the actual thickness of a matrix band . . . This is about 10 years ago in my clinical practice. And I will tell you, from that day to this day, I pre-wedge every tooth that I do an interproximal restoration on.” (15:52—16:51)
• “[Pre-wedging] is one of my favorite tips and tricks. It also does two other things. Now, I know for a fact that not a single one of the approximately 1,700 dentists who are listening to this right now have ever actually nicked an adjacent tooth. But for all those dentists not listening who maybe have had that happen, [laughs] if the teeth are actually physically not touching, it makes nicking an adjacent tooth a little bit less likely to happen.” (17:09—17:40)
• “Here’s the other thing I learned about myself. I know for a fact, from pre-wedging, that I prepped the papilla every single time I prepped a Class II. And I know that because now, I prep the wedge every single time I prep a Class II. So, one of the great things about pre-wedging is you have a whole lot less hemorrhage and bleeding and problems when you go to fill because the wedge is protecting the tissue. Now, you are going to have to put two wedges out on every tray table, because you're going to need to take the one that you cut during preparation and throw it away and put a brand-new one in when you go to fill the tooth.” (17:41—18:17)
• “What's the right size wedge to use? Well, the correct size wedge is exactly like you see in the picture. It’s equidistant, buccal, and lingual. So, you should have the same amount of wedge out both sides of the tooth. If there's more of the wedge on the side you inserted from, the wedge is too big. You can't get it all the way through the contact. If you've got more of the wedge on the opposing side from where you inserted, it’s too small. And where should you insert the wedge from? You should actually always insert the wedge from the side with the larger gingival embrasure, not the side that's most convenient.” (18:47—19:21)
• “As a caveat, when you first start to pre-wedge, after you're done with the prep and you take the wedge out to put the sectional band in, you may see a little bleeding because you've compressed the papilla. But it’s not cut. And as soon as you put the new wedge back in, it'll go away. You won't even need to use retraction paste. So, for me, pre-wedging is something that's an old-timey technique that is absolutely one of the easiest ways to predictably have nice, tight contacts every time you do a Class II and minimize the challenges with isolation.” (19:40—20:15)
• “There's no perfect matrix system because there are 50 booths in every exhibit floor from dentists who have invented matrix systems. We keep inventing them because we don't have the perfect one.” (21:53—22:04)
• “When we think about a matrix system, each piece has a job. The purpose of the band is to recreate the shape of the tooth you've prepped away. The purpose of the wedge is to seal the band against the gingival floor of a Class II box and to separate the teeth and overcome the thickness of the matrix band. And the purpose of a ring in a ring system is to seal the band against the buccal and the lingual wall of the tooth preparation so you don't get flash. So, every piece of the system has a purpose.” (22:05—22:38)
• “Sectional matrix systems work really, really well as long as the buccal and the lingual walls of your box don't go past the line angle. As soon as you prep past the line angle when you put the ring on, it pushes the band into the box, and you get a contact. But then, you get what looks like ribbon candy to the buccal and the lingual. The whole purpose of a sectional band was designed with composites. We didn't care about it with amalgam because all you'd have to do to trim the buccal and lingual was put an amalgam carver in that buccal space or lingual space, drag it up, easy-peasy, super simple to get that trim. But with composite, you have to do it with a handpiece. But if the prep is past the line angles, it’s not hard to get a handpiece there. So, I don't worry so much about the buccal and lingual.” (22:38—23:27)
• “We actually get greater polymerization rates, greater depth of cure, in a Class II box when we’re using a shiny metal matrix band because you're actually able to refract the light off the internal of a shiny band and shorten the distance from the source to the material polymerizing. So, in my practice, I actually use the shiny metal sectional matrix bands when I'm doing the posterior composites.” (24:28—24:58)
• “I actually use Teflon tape for lots of things. Someone should write a book like, 1,000 Uses for Teflon Tape in Dentistry. But don't, because then you won't be able to buy it at Home Depot, and they’ll charge us a lot for it.” (26:25—26:36)
• “Here’s the other thing I use Teflon tape for. Once I put a matrix band in place, I've got the band, the wedge, and the ring in place. I stop and I look down in the prep. Any place that band is not intimately in contact with the prep, you're going to get extrusion of material. And I don't care how you fill, with what density of composite. You're going to get extrusion of material here. So, you could do a couple things. You could take the ring off and reverse the wedge. Maybe I put the wedge in from the wrong side. You could try a bigger wedge. But I'm going to tell you, in my world, this is the perfect place for Teflon tape. Because I don't know about anybody else, but I get cold chills thinking about trying to trim that little, tiny thin of composite. By the way, that's the distal lingual of a lower first molar. Fun place to get a Mosquito Diamond and a handpiece. So, we’re going to do that with Teflon tape.” (26:39—27:34)
• “One of the gifts of Teflon tape is it is condensable. It gets really, really firm and rigid. And you need it to be tight enough in that box that you can actually condense composite in the other tooth against it. Why use Teflon tape for this versus wax or silicone? Because the Teflon tape doesn't contaminate or dirty the adjacent prep at all. There's nothing to clean up when you're done. You literally just pull it out with the cotton plier, and you're ready to go.” (29:11—29:39)
• “Let's talk about prep scrub desensitizers. This is a pretty confusing area of materials because some manufacturers call these prep scrubs, some manufacturers call these desensitizers, some manufacturers call these rewetting agents. They're all the same group of materials. There are only three active ingredients in this group of materials: 2% chlorhexidine, 2% to 5% glutaraldehyde, and hema.” (30:25—30:52)
• “2% chlorhexidine and 2% to 5% glutaraldehyde are interchangeable. They both do the same three things. They're antimicrobial, so they kill off the bacteria in the dentinal tubules. That helps prevent sensitivity from a reversible pulpitis. It also reduces the instance of an irreversible pulpitis and need for endo. Both chlorhexidine and glutaraldehyde are rewetting agents, so if you were total-etching, it remoistens the dentin, opens the dentinal tubules, allows for your primer to chase down into the dentinal tubules for maximum hybrid zone. And both chlorhexidine and glutaraldehyde prevent the production of MMPs, matrix metalloproteinases, which are largely responsible for the bond degradation over time to dentin. What does that mean? It means it'll increase the longevity of your adhesively placed restorations.” (30:54—31:50)
• “Hema is the second ingredient that is only combined with glutaraldehyde. It’s the desensitizer. So, hema actually goes down into the dentinal tubules, causes a little coagulative collagen, prevents fluid movement called hydrostatic sensitivity, and prevents postop sensitivity. So, you're either going to use 2% chlorhexidine, so that's Consepsis from Ultradent. Here’s a note if you want to use chlorhexidine. Do not dilute mouthwash. You cannot dilute Peridex, PerioGard, Periostat. Anything sold as a chlorhexidine-based mouthwash also has glycerin, flavorings, other ingredients that could impede bonding. You need to buy a pure 2% chlorhexidine prep scrub. Or what I do is I buy a gallon jug of 2% chlorhexidine that's sold to irrigate endodontic preparations, pull it up in my own syringes, and use it that way.” (31:51—32:50)
• “Alternatively, you're going to use a product that is glutaraldehyde and hema combined together. I personally use Gluma from Kulzer, but you can also use Telio CS from Ivoclar Vivadent, or MicroPrime G — make sure you're getting MicroPrime G from Danville. So, there are alternative products on the market for that.” (32:51—33:13)
• “I put a prep scrub on every tooth I prep, indirect, direct, and I actually am OCD enough that when I'm bonding an indirect restoration, like veneers, I clean the prep with Consepsis or chlorhexidine, and then I also apply Gluma as part of the adhesive process.” (33:57—34:13)
• “From a standpoint of sensitivity, remember, [prep scrubs] don't just prevent sensitivity. They rewet so that they increase your dentin adhesion; they're antimicrobial, so they prevent reversible and irreversible pulpitis or minimize it; but most importantly, why to add these to your posterior composites or your indirect restorations, reducing the production of MMPs, increasing the longevity of the restoration in the oral environment.” (34:17—34:49)
• “So where do you apply [prep scrubs]? Right before the dentin adhesive. I don't care which system you use, total-etch, hybrid-etch, self-etch. These go down right before the first step of your dentin adhesive. So, if you total-etch, etch, rinse, dry — apply these, then move to your adhesive. If you're self-etching, apply these, and then move to your adhesive.” (34:50—35:16)
• “Pretty much every company on the planet now has something they call a universal adhesive. First, you need to understand what the manufacturer of the adhesive you're using means by the word “universal.” They do not all have it mean interchangeably. What does this category mean you can do? First, it means you can use any etching technique and use the same adhesive. So, that's great for inventory control. You can self-etch, you can total-etch, you can hybrid-etch, you can selective-etch. Any of those four etching protocols use one adhesive. Some of these adhesives have something that's called a dual-cure activator, or a DCA. You can add a drop and you can turn these into dual-cure adhesives. Others do not. They’re purely light-cured.” (37:00—37:52)
• “What is the magic behind this category? It’s the fact that the monomer science in universals is a chemistry called MDP. And MDP, for a lot of years, was actually patented by Kuraray. And when their patent expired, it allowed the other manufacturers to put it into their dentin adhesives. MDP’s pH is perfect to allow you to total-etch and use it without over-etching, or it'll etch on its own and you can self-etch.” (37:53—38:25)
• “The other thing that's phenomenal about MDP is it is a universal primer. It primes dentin, enamel, metal, composite, glass, ceramics, and zirconia. In addition, MDP has much lower technique sensitivity because of its moisture tolerance. So, MDP is a more hydrophilic monomer, so it’s moisture-tolerant until it’s polymerized. And once you light-cure it, it becomes hydrophobic, so it tends to repel water. So, MDP, the chemistry of MDP, actually does really advance adhesive technology.” (38:25—39:06)
• “The only place that I will tell you to be cautious about mixing and matching between manufacturers [for universal adhesives] is when you're placing indirect restorations. We’re having a conversation about direct adhesives, direct bonding. Mix and match across manufacturers all you want, as long as everything is light-cured. And as soon as you get to placing veneers, bonding inlays or onlays, buy a kit, use a kit. Because none of the manufacturers test their materials with other people’s materials, and you don't want to risk incompatibilities as soon as you go to any of those systems.” (39:25—40:04)
• “When we think about [injectables], this is not a flowable. GC America brought G-ænial injectable to the market maybe Chicago, midwinter, last year. Maybe 2019. It’s not a flowable, which is why they named it injectable. In general terms, we can typically understand the filler content of a composite based on its viscosity. So, the thicker a composite, the higher its filler content. And the thinner or less viscous a composite, the lower its filler particles. Why do you care about that? Because the higher the filler percentage, the better the physical properties of a composite-based material. The challenge is that usual way we look at it has gotten more complicated lately. And so, we now have high filler percentage flowables, and those are very different than the old-school traditional flowables. And now, we have G-ænial injectable.” (41:05—42:10)
• “G-ænial injectable comes in a syringe. It feels like a flowable, but it has a high enough filler percentage that it can be used in place of any traditional composite that you normally get in a syringe or would put in a composite gun. So, you get the handling properties of a more flowable material with the physical properties of a high filler content material. They do make it in a regular two-millimeter depth-of-cure material, and then in a bulk-fill higher four to five-millimeter depth-of-cure. I will tell you that I've been using this material in my practice since it came on the market. Here’s where I love it. I love it for Class V. It’s such an easy, gorgeous material to use for a Class V.” (42:11—42:55)
• “The other place I use [injectables] is really small Class I restorations. It doesn't quite qualify for sealing. You've got to do a little prep, so you do need to fill it. This is a gorgeous material for that. And I will also tell you, I have started using it just recently as the labial enamel layer in some of my anterior composite restorations. It is really gorgeous and really easy to apply from handling properties.” (43:08—43:36)
• “[Bulk-fills] are not all created equal. Some have a four-millimeter depth-of-cure. Some go up to a six-millimeter depth-of-cure. Some require a cap layer so you can use them up to the top one to two millimeters on the occlusal. But then, you have to put a different composite that has a higher filler percentage, better physical properties, at the top one to two millimeters. Other bulk-fills can go right all the way up to the occlusal table and do not require a cap layer. Some bulk-fills come in a syringe like a flowable. Some bulk-fills come in a traditional syringe. Some require their own special handpiece. So, you've got lots of different ways to use them. (45:09—45:57)
• “My standard Class II protocol is, I use a bulk-fill composite from the floor of the box all the way up to that top two-millimeter layer. And then, I use a cap layer of material in my practice. That's my personal preference. And, by the way, I'm a big fan of composites that are radiopaque. We have a real issue in dentistry because of radiolucent materials for the last decade, and so I like more radiopaque composites versus more radiolucent. That's a personal preference. I want to be able to see them on an X-ray.” (47:35—48:11)
• “If you've not ever used a composite warmer, it will transform your life. It'll be the best couple hundred bucks you've ever spent. And that's about all they're worth, is a couple hundred bucks. I use a Calset composite warmer, and I buy it from a company called AdDent.” (48:20—48:36)
• “If you like the ability to inject a composite and have it flow really nicely, but you want to use a high filler percentage composite, composite warming is the way to do it. And I use one in my practice. It’s plugged in in every operatory, turned on in the morning when my assistants turn on the operatory, and it stays in there all day long. If you need to switch colors, they warm up pretty darn quickly. Just do your shade at the beginning so your assistant can load the right colors. And, by the way, studies have shown when you use warmed composite, you get better adhesive bonds, you get better marginal adaptation. It actually improves several pieces of a composite because it makes the technique easier.” (49:24—50:07)
• “I personally don't reuse [composites] between patients. So, if I only use part of a Cavifil, we throw it out. We only ever keep fresh ones in the composite warmer. If you reuse those, my guess is that you have a protocol for wiping them down with CaviCide or one-minute wipes, because you also have to put them back into a tray setup or a drawer or someplace. So, whatever you're doing to disinfect them before you put them back someplace else, would also keep you from contaminating your composite warmer.” (51:02—51:37)

Snippets:

• 0:00 Introduction.
• 2:59 Isolation techniques.
• 8:57 Rubber dams.
• 11:07 Retraction pastes.
• 12:56 Pre-wedging.
• 20:15 Q&A: What wedging system do you like?
• 21:45 Matrix systems.
• 23:55 Clear matrix systems versus metal.
• 25:04 Uses for Teflon tape in dentistry.
• 30:22 Prep scrub desensitizers.
• 33:14 Q&A: Does Gluma replace the need for a liner in a deep cavity?
• 34:49 Where to apply prep scrubs.
• 36:49 Q&A: Universal adhesives.
• 40:05 Q&A: Scotchbond and Gluma.
• 40:52 Two new composites on the market.
• 43:48 Bulk-fill composites.
• 48:13 Composite warmers.   
• 50:07 Q&A: Cross-contamination with composite warmers.
• 52:00 Q&A: Best bulk-fill and capping composites that have high radiopacity?
• 53:18 Q&A: Tips for minimizing the risk of having the dreaded white line?
• 55:36 How to get involved with The Pankey Institute.

Further Reading:

The Pankey Institute: https://www.pankey.org/

PankeyGram: https://pankeygram.org/

PankeyGram free webinars: https://pankeygram.org/webinars/