Check List for the Layering Technique

D r. B u d M o p p e r C o n t i n u i n g E d u c a t i o n I n t e r a c t i v e S e m i n a r Dr. Bud Mopper Check List for the Layering Technique Always REMEMBER: 1) First use the Extra Coarse Sand Disc to simulate the etch step. 2) Apply the unfilled resin (blue bottle) and polymerize. 3) Apply clear liquid and polymerize. Once the Above is Complete, THEN: Apply Pink Opaque. Apply A1 Hybrid or Nano. Apply A1 Opaque (if needed). Place Tint on Cervical (Honey Yellow & Light Brown mixed together). Place Tint to simulate incisal translucency on incisal edge (use Gray Tint or Gray Tint mixed with a little Violet Tint). Apply A1 Microfill, inner sculpting anatomy into incisal third of tooth. Apply Flowable Incisal Light Microfill under filling the inner sculpted troughs. Apply Incisal Light Microfill over the incisal third of the tooth, blending it into the A1 Microfill, making sure there is no visible margin. Shape and Contour using course and medium FlexiDisks and ET burs. Use FlexiPoints or FlexiCups to add characterization to labial surface, and polish using Fine and SuperFine FlexiDisks. Polish to high luster with Enamelize and FlexiBuffs. Cosmedent, Inc. 401 N Michigan Avenue - Suite 2500 Chicago, IL 60611 (800) 621-6729 www.cosmedent.com 2008 Cosmedent, Inc. All Rights Reserved

D r. B u d M o p p e r C o n t i n u i n g E d u c a t i o n I n t e r a c t i v e S e m i n a r Dr. Bud Mopper Questions to Ask When Selecting a Composite Resin System 1. How does the material handle? 2. Does the finished material truly match its selected shade guide? 3. Does the system make color matching or color development easy? 4. Is the finished product color stable over time ( 15 to 20 years )? 5. How easy is it to polish, and will the composite hold the polish over time? 6. How strong is the restoration? 7. What are the translucency and opacity characteristics of the material? 8. When finished properly, are the composite and gingival tissues biocompatible? 9. What material has adequate strength for the purpose of use? 10. What material is more wear resistant? Why? Reprinted with Permission by Dr. K William Buddy Mopper, DDS, MS, from Dentristy Today, October 2008 Issue - Aesthetics Cosmedent, Inc. 401 N Michigan Avenue - Suite 2500 Chicago, IL 60611 (800) 621-6729 www.cosmedent.com 2008 Cosmedent, Inc. All Rights Reserved

INSIDE CONTINUING EDUCATION ESTHETICS RESTORATIVE IMPLANTS Contouring, Finishing, and Polishing Anterior Composites The key to beauty and biologic integrity of long-term restorations lies in the final steps of the procedure. By K. William Mopper, DDS, MS One of the most important steps in successfully creating bonded restorations is contouring, finishing, and polishing. Proper finishing and polishing greatly increase esthetic results, maximize patients oral health, 1 and increase the longevity of restorations. 2 Unfortunately, the proper sequence of polishing steps necessary to achieve optimum results is often overlooked. 3 The purpose of this article is to describe a technique that will help achieve maximum esthetics and biological success when contouring, finishing, and polishing anterior restorations (Table 1 and Table 2). Finishing and polishing anterior composite restorations is a sophisticated art form. However, proper technique is actually quite simple and extremely efficient once the practitioner understands the concept behind the finish and polishing process. 6,7 Step 1: Material Selection The ability to achieve a good finish and polish on anterior composites is determined by two very important factors access to the right materials and the artistic ability of the dentist. Having access to the right materials, however, K. WILLIAM MOPPER, DDS, MS Private Practice Glenview, Illinois Member and Fellow American Academy of Cosmetic Dentistry does not mean simply polishing discs and strips. The dentist must also realize that the type of composite(s) used will have a large impact on the restoration s longevity, durability, polishability, and wear-resistance. Achieving a good understanding of the materials available, and grasping their impact on overall results will maximize restorative success. Composites In terms of color stability and polishability, in the author s opinion microfill is the only composite material that really stands the test of time. A microfill must be used as the final layer in order to obtain the best polish, surface smoothness, and long-term wear resistance. Nanohybrids or nanofills can also be used to replace the enamel layer in composite restorations. These materials initially provide a relatively good surface smoothness and high shine. Over time, however, nanofill composites lose their luster and are less wear-resistant than microfill composites. 8 Microhybrids are the least polishable of the three main composite types. Used as an anterior enamel layer, microhybrids rapidly lose polish and are more susceptible to staining. To achieve a beautiful, long-lasting polish, a microfill composite must be used as the final layer. Finishers and Polishers Overview Where do polishers best fit into a practice s current procedures? One- or twostep polishers can certainly be used when polishing composite restorations quickly. But, if the goal is to achieve the best long-term polish, then it is more desirable to use a comprehensive polishing system. Different types of composites call for different polishing techniques, depending on the type of restoration and the dentist s ultimate goals. As a reference, diamond impregnated polishers should be used, followed by an aluminumoxide polishing paste when polishing nanofill and microhybrid composites. When polishing microfill composites, aluminum-oxide polishers should be used, followed by an aluminum-oxide polishing paste. 9 Polishing Materials Thorough and complete finishing and TABLE 1 polishing requires the use of a sequential series of finishing and polishing burs, discs, strips, and pastes. Following the proper sequence of materials ensures the long-term health and polishability of restorations. If a part of this process if skipped, the tooth will often be left rough and susceptible to plaque and staining. Either multi-fluted carbides or fine diamonds for gross contouring can be used to begin finishing the restoration. Discs Discs can be used for the contouring of all tooth surfaces as well as bulk reduction of excess material. Discs will help contour and finish curved surfaces such as labial proximal line angles, lingual marginal ridges, cervical areas, incisal edges, shaping and finishing of incisal corners, plus finishing and polishing of labial surfaces. They are also excellent for contouring and finishing of posterior marginal ridge areas, and for lingual and buccal surfaces. Why is Finishing and Polishing So Important? Proper finishing and polishing is important for several reasons, such as: 62 INSIDE DENTISTRY March 2011 www.dentalaegis.com/id

INSIDE ESTHETICS Four-Disc Grit Sequence: Aluminum-Oxide Discs The author is an advocate of the fourgrit disc sequence, which is designed to gradually reduce the amount of roughness caused by initial abrasion until a smooth glossy tooth surface is achieved. To provide maximum control for the operator, composite finishing should be done under low-speed/high-torque (speed from 0 rpm to 30,000 rpms). Coarse The coarse grit is the stiffest of all the discs. This grit is used in conjunction with multi-fluted finishing burs for gross contouring and shaping. When used with pressure, the coarse disc makes it easy to blend the composite into the tooth surface, eliminating the white line and raised margins. Medium The medium grit should be used to continue smoothing the restoration surface. Medium grits remove any remaining imperfections and marks. Fine This part of the grit sequence is where polish really starts to shine through. The fine grit helps remove the smallest imperfections while adding a nice luster to the restoration. Superfine The superfine grit further refines the surface smoothness attainable to create a highly polished restoration. Diamond Strips Diamond strips help start the interproximal finishing process while maintaining the integrity of the interproximal contact. A larger-grit (45-µm strip) should be used for interproximal stripping of natural teeth or for gross removal of material, and smaller grits (15 µm and 30 µm) should be used to start interproximal polishing. Aluminum Oxide Strips should be used to contour and polish interproximal areas. Use of a high-quality strip will remove tenacious stains and create a high polish at the interproximal without damaging the soft tissue. It is important that the strip is thin and will stay intact as it is drawn through the interproximal contact areas. Oxide Cups and Points Aluminum-oxide cups should be used to polish gingival margins, achieve labial characterization and anatomy, and effectively reach areas such as the gingival third and the gingival margins of anterior teeth. Aluminum-oxide points should be used to create labial grooves in veneers, to finish and polish occlusal surfaces of posterior teeth, and on lingual surfaces of anterior teeth. An aluminum-oxide polishing paste should be used as the last step in the finishing and polishing process. Polishing paste with felt discs and points can be FIG. 1 FIG. 2 FIG. 3 FIG. 4 FIG. 5 FIG. 6 FIG. 7 FIG. 8 FIG. 9 FIG. 10 FIG.11 FIG. 12 FIG. 13 FIG. 14 FIG.15 SCULPTING AND CONTOURING, REFINEMENT AND FINISHING (1.) Class III restoration preoperative view (note the long bevel). (2.) Lingual view of the preparation. (3.) Application of Renamel NANO Shade A1 (Cosmedent, www.cosmedent.com) using Cosmedent s 8A Composite Polishing Instrument. (4.) Lingual sculpting and shaping of Renamel NANO using Cosmedent s IPCT Composite Polishing Instrument. (5.) Addition of a small amount of Renamel NANO to blend onto the long bevel. This completed the block-out of shine-through and acted as an opaquer. (6.) Addition of the nano-hybrid composite is complete. Notice there is still enough room to apply Renamel Microfill (Cosmedent). (7. AND 8.) Sculpting and contouring of Renamel Microfill to proper shape and contour. (9.) A Brasseler ET-9 bur was used for for labial reduction. (10.) A Brasseler 0S-1 bur was used for lingual reduction. (11.) A Brasseler 8392-016 bur was used to refine the lingual and labial embrasure spaces. (12. THROUGH 15.) A disc system (FlexiDisc System by Cosmedent) from coarse to superfine was used to achieve a high polish and invisibly blend composite into the tooth structure. Note the high flex and resilience of the discs. 66 INSIDE DENTISTRY March 2011 www.dentalaegis.com/id

INSIDE ESTHETICS used to bring out the final beautiful polish of composites, metals, porcelain, or natural dentition after prophylaxis. Step 2: Conceptualization Before finishing and polishing, the dentist must conceptualize the desired end result. The dentist will not have to work as hard to obtain lifelike results if the restoration is pre-contoured to the correct shape and form before polishing. Many practitioners lose the shape of the restoration because of a lack of attention to the material application phase. Many dentists have a tendency to over-bulk the composite, and end up losing the intended shape. It is much easier to obtain the desired result if the composite is initially placed into the correct anatomical form and only slightly over-contour from the facial aspect. Step 3: Action A realistic tooth form should be developed before the pre-contouring phase begins. Now it is time to apply the correct technique during the final phases of the restoration. Handpiece Finishing and polishing should be achieved with a low-speed, high-torque handpiece, typically anywhere from 7,000 rpm to 30,000 rpm. A high-speed handpiece may be used to pre-contour, but using anything over 30,000 rpm during finishing and polishing is too high. Low-speed, high-torque is preferable, because it gives the operator complete control. The best finishing and polishing technique depends on the type of restoration the dentist is presented with. When polishing a Class IV restoration, for instance, the dentist should rely mainly on discs. However, cups and points will help develop more realistic characterization when polishing a veneer. A step-by-step guide to polishing on various restorations is outlined below. Class III, IV, and Diastema Closures Starting with a coarse disc or a carbidefinishing bur, the restoration can be completely contoured moving from restorative material to tooth surface, similar to burnishing metal. This can be done in a wet or dry field. The material YOUR PRODUCT RESOURCE www.dentalaegis.com/products Composite Finishing and Polishing should be extended well past the long bevel, and the dentist should not come back to the beveled margin. The final restoration should be feather-edged onto the tooth surface past the beveled margin. If done properly, any white line or raised margin will completely disappear. At this stage, the disc should be flexed for maximum finishing potential. FIG. 16 FIG. 17 FIG. 18 FIG. 19 FIG. 20 FIG.21 FIG. 22 FIG. 23 FIG. 24 FIG. 25 FIG. 26 FIG. 27 FIG. 28 FIG.29 FINAL POLISHING (16.) Gingival torquing opened the contact to start the interproximal finishing. (17. AND 18.) Use of both wide and narrow superfine diamond finishing strips (Cosmedent s FlexiDiamond Strips). Running these strips once or twice through the contact will smooth the contact area. (19.) This view shows that there is still more finishing and polishing to be done to further refine the embrasure space. (20.) Further refinement of the mesial labial line angle to further refine embrasure space and create symmetry of both centrals. Here, the use of the medium-grit (FlexiDisc) is preferred. (21.) Continuing the polishing with a fine disc. (22.) Polishing with a superfine disc. (23.) Polishing the lingual surface with diamond polishers (Cosmedent s nanohybrid composite polishers). (24.) Polishing the lingual surface with a superfine cup. (25.) Finishing and characterizing the labial surface with a superfine point. (26.) Application of an aluminum-oxide polishing paste (Enamelize, Cosmedent) with a felt buff (FlexiBuff, Cosmedent). (27.) Polishing the lingual surface with Enamelize and Felt FlexiPoint (Cosmedent). (28.) This is the incisal view of the finished restoration. Note the symmetry of the labial surfaces, the contour at the embrasures surfaces, the contact, and the beautiful blend of the polished material into the tooth surface. (29.) Labial view of the finished restoration. 68 INSIDE DENTISTRY March 2011 www.dentalaegis.com/id

INSIDE ESTHETICS The different grit sizes medium, fine, and superfine should be continued through in succession. An enamel-like luster rapidly appears. The interproximal process should be started with diamond strips to maintain the integrity of the contact. One or two times through the interproximal should be sufficient, followed with the fine-superfine aluminum oxide strip on dry surface until no resistance is felt, and a smooth surface is apparent. For the final polish, an aluminum oxide polishing paste with felt discs and points should be used. This is the step that really brings out the amazing final polish. Class V On occlusal or incisal margins, 5/8 or 1/2 coarse disc should be used past the long bevel. Discs are always preferred on exposed margins. To start finishing from restoration to tooth surface, a coarse disc is used, followed by medium and then fine; finishing with the superfine disc to achieve maximum polish. The 3/8 disc should be used at the gingival margin. Although this is a small diameter, the 3/8 disc can be flexed to gain access to hardto-reach areas. The gingival half of the restoration can be polished nicely using flexible cups, but rubber must be kept off the occlusal and incisal margins. If Class V restoration invades the proximal surfaces, the diamond strips and aluminum oxide strips should be used in the narrow width for polishing these surfaces. An aluminum-oxide polishing paste with felt discs and points is recommended for the final polish. Full Resin-Bonded Veneer The coarse disc or contouring bur is used to start contouring and finishing. The coarse and medium discs can be used to complete the contouring of the veneer. It is desirable to maintain the character and anatomy placed in the facial surface. This cannot be done with discs, but cups and points are very useful for this purpose. To characterize, the cup is placed flat on the tooth surface, flexed slightly, and run with pressure up INSIDE DENTISTRY SWEEPSTAKES Enter to win an Odyssey Navigator Diode Laser! It s simple just use one of the three options below and follow the instructions to enter. The contest runs for the next 2 issues and there are 4 unique entry boxes in each issue. With 9 unique ways to enter in each issue, look for all the boxes and enter often to win. One winner will be selected by random drawing and featured in the June issue. Good luck! BAR CODE: *You can download a bar code reader from itunes or BlackBerry. URL: WEB ENTRY: * Contest is open only to dentists practicing in North America. and down the tooth surface. Blunting off sharp edges on a green stone prior to characterizing prevents scarring and over-characterization. After a grooved surface has been developed, augmenting with rubber points highlights the grooves. Polishing the surface is completed with fine and then superfine polishing discs. To polish the interproximal surfaces, diamond and aluminum-oxide strips are used as previously described. For the final polish, an aluminum-oxide polishing paste with felt discs and points is used. Maintenance of Composite Restorations Excessive staining is removed in the usual fashion. A small amount of aluminum-oxide polishing paste is then applied to each surface and polish. To remove interproximal staining, each interproximal should be packed with polishing paste, and a wide, fine/superfine polishing strip is used to polish the surface. Conclusion The proper contouring, finishing, and polishing of anterior restorations is a key component to the long-term success of bonded restorations. This article outlines the importance of three different phases in the finishing and polishing process. First, the appropriate restorative materials, from composites to polishers, must be carefully selected to help get the job done right. Then, the dentist must conceptualize the desired end result, and set up the restoration accordingly. And, finally, the proper finishing and polishing technique must be executed in order to achieve maximum restorative success. For a clinical example of the technique described, the author provides a complete case pictured in Figure 1 through Figure 29. Disclosure The author is part owner of Cosmedent. References 1. Jefferies SR. Abrasive finishing and polishing in restorative dentistry: a state-of-the-art review. Dent Clin North Am. 2007;51(2):379-397. 2. Turkun LS, Turkun M. The effect of one-step polishing system on the surface roughness of three esthetic resin composite materials. Oper Dent. 2004;29(2):203-211. 3. Mopper KW. How do composite resins stand the test of time? Dent Today. 2004;23(5):74-79. TABLE 2 Quick Tips 10 4. Ikeda M, Martin K, Nikaido T, Foxton RM, et al. Effect of surface characteristics on adherence of S. mutans biofilms to indirect resin composites. Dent Mater J. 2007;26(6):915-923. 5. Kantorski KZ, Scotti R, Valandro LF, et al. Adherence of Streptococcus mutans to uncoated and saliva-coated glass-ceramics and composites. Gen Dent. 2008:56(7)740-747. 6. Mopper KW. Let s talk composites! Dent Today. 2008;27(10):120-122. 7. Craig RG, Ward ML (eds). Restorative Dental Materials. Mosby, St. Louis, 1997,p263. 8. Barucci-Pfister N, Gohring TN. Subjective and objective perceptions of specular gloss and surface roughness of esthetic resin composites before and after artificial aging. Am J Dent. 2009;22(2):102-110. 9. Takanashi E, Kishikawa R, Ikeda M, et al. Influence of abrasive particle size on surface properties of flowable composites. Dent Mater J. 2008:27(6):780-786. 10. Cenci MS, Venturini D, Pereira-Cenci T, et al. The effect of polishing techniques and time on the surface characteristics and sealing ability of resin composite restorations after oneyear storage. Oper Dent. 2008;33(2):169-176. 70 INSIDE DENTISTRY March 2011 www.dentalaegis.com/id

50 45 40 60 55 5 35 30 25 5 20 10 15 30 25 10 20 15 uick Tips Pink Opaque for Stained Dentition K. William Mopper, DDS, MS Co-Founder and Chairman Cosmedent, Inc. Chicago, Illinois Director Center for Esthetic Excellence Chicago, Illinois Private Practice 2601 Compass Road, Glenview, IL 60026 Phone: 847.729.6080 Fax: 847.441.6082 moppers@ais.net Darkly stained teeth have always been difficult to treat cosmetically. Tetracycline-stained dentition and the single, nonvital tooth are among the most difficult teeth to treat esthetically with minimally invasive procedures such as composite resin veneers or porcelain laminates. Over the years, ceramic technicians have used pink to warm up cold, unesthetic grayish discoloration. 1,2 Cosmedent,Inc.,hasdevelopeda new pink opaque that treats the darkly stained dentition reliably and with natural results. Using pink opaque before applying the composite restorative material neutralizes gray tetracycline stains and results in a warmer, more natural color. Using other opaques, such as white, A1, or A2, and then overlaying with the composite will usually result in a decrease in value. Even when the color is correct, the result will still have a gray cast. Figure 1 Prepared tooth showing dark band of color. Figure 2 Application of pink opaque with No. 1 Cosmedent brush. Figure 3 Blending opaque to the tooth structure. Figure 4 Opaque after polymerization. Figure 5 Light application of more opaque to block and blend the dark areas that remained after polymerization. Figure 6 Continued application and blending. 40 CONTEMPORARY ESTHETICS AND RESTORATIVEPRACTICE

Quick Tips continued Figur e 7 A pplication of pink opaque completed on the upper left central incisor. A ll undesirable color has been neutralized without overopaquing. Figur e 8 The four completed incisor veneers immediately postoperatively. tooth, or teeth with metal posts and cores. Pink opaque is also effective in repairing the dark gingival discoloration often seen with porcelain and metal restorations. I R E NA M E L A MUST FOR R EFERENCES 1. 2. Nixon RL: Masking severely tetracycline-stained teeth with porcelain veneers. Pract Periodontics Aesthet Dent 2(1):14-18, 1990. Nixon RL: Masking severely tetracyline-stained teeth with ceramic laminate veneers. Pract Periodontics Aesthet Dent 8(3):227-235, 1996. Pi n k O PA Q U E EVERY RESTORATIVE DENTIST N OW YOU CAN NEUTRALIZE DARKLY STAINED TEETH AND CREATE A BRIGHT, LIFELIKE RESULT WITH COMPOSITE RESIN OR PORCELAIN. N EW PINK OPAQUE TREATS THE DARKLY STAINED DENTITION RELIABLY AND WITH NATURAL RESULTS. P R E PA R E D T E E T H T ECHNIQUE When using pink opaque as part of the Renamel Restorative System (Cosmedent, Inc.), follow these steps: 1. Prepare, etch, wash, and apply the bonding adhesive. 2. Apply a thin layer of Creative Color (Cosmedent, Inc.) clear liquid resin to the entire veneer surface, gently air-thin, and polymerize. The creation of a smooth surface makes it easier to apply the opaque. 3. Apply pink opaque in a thin layer and polymerize. 4. If dark areas shine through, gently add opaque to these areas to block it out. Apply just enough to do the job, and avoid overopaquing. 5. Apply a thin layer of Renamel hybrid. The color should be preselected to match the existing teeth or the new shade of the teeth. 6. After the hybrid is placed and polymerized, slight opaquing may be required. Use the color of opaque that corresponds to the hybrid chosen. 7. Overlay with Renamel body U SE and incisal microfill. 8. Finish and polish. PINK OPAQUE TO NEUTRALIZE ULTRA DARK STAINS ASSOCIATED WITH DEFECTS SUCH AS TETRACYCLINE STAINS, THE UNSIGHTLY NON - VITAL TOOTH AND THE GREYNESS OF METAL SHINE - THROUGH. sing pink opaque before applying the composite restorative material neutralizes gray tetracycline stains and results in a warmer, more natural color. U T HESE ARE AMONG THE MOST DIFFICULT PROBLEMS TO TREAT ESTHETICALLY A P P L I C AT I O N O F P I N K O PA Q U E WITH MINIMALLY INVASIVE PROCEDURES. T HIS AMAZING NEW OPAQUE WILL BLOCK OUT: DARKLY STAINED DENTITION GREYNESS OF METAL SHINE - THROUGH UNSIGHTLY DEVITALIZED TEETH DARK GINGIVAL DISCOLORATION ENDO AND IMPLANT ACCESS HOLES F I N I S H E D R E S T O R AT I O N C ASE A PPLICATION The case shown in Figures 1 through 8 graphically illustrates the application of pink opaque before composite application. The neutralization of the dark stripes can be easily observed. BEFORE Solves the Problem o f D a r k l y S t a i n e d Te e t h O THER A PPLICATIONS The same procedure can be used for preopaquing after preparation and before placing porcelain veneers on tetracyclinestained teeth, a gray nonvital DIRECT 1.800.621.6729 www.cosmedent.com to order call or visit AFTER CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE 41

www.dentistry.co.uk Clinical Correct use of composite resins K. William Mopper, DDS, DDS, MS, MS, explains his protocols for choosing anterior and posterior composite resin materials in aesthetic restorative dentistry Figure 1: Maxillary anterior composite restorations at 22.5 years postoperatively. Only minimal chipping and slight recession can be seen. Note the highly polished surface of the microfill composite resin material (Renamel Microfill, Cosmedent) Figure 2: Microfills are exceptionally color stable and wear resistant. Note the excellent color match of the restoration to the shade tab (VITA Classical, Vident) after 22.5 years William K. William Buddy Buddy Mopper, DDS, DDS, MS, MS, is isin in private practice in Winnetka, Illinois, where he has been involved with creating dental aesthetics for 42 years. He is an internationally renowned lecturer in aesthetic dentistry with an emphasis on composite bonding using direct application techniques. He co-authored, A Complete Guide to Dental co-authored, Bonding, which A Complete was the Guide first to definitive Dental Bonding, book for which the dental was profession the first describing definitive book bonding for techniques. the dental profession He is a member describing of bonding the Academy techniques. of Esthetic He Dentistry, a member andof a the fellow Academy of the of American Esthetic Dentistry, Academy and of a founder Cosmeticand Dentistry, fellow of diplomat the American of the Academy Americanof Board Cosmetic of Pediatric Dentistry, Dentistry, diplomat of andthe a fellow American of the Board American of Pediatric College Dentistry, of Dentists. and a He fellow taught of the direct American resin bonding College at many of Dentists. major Universities He taught including direct resin the bonding University at many of Minnesota, major Universities State University including the of University Iowa, the of Minnesota, University of State Nebraska, University Louisiana of Iowa, State the University, the of Nebraska, University Louisiana of Illinois and State the University, the ofuniversity Kentucky. He of Illinois is the and recipient the University from the American of Kentucky. Academy He is the of Cosmetic recipient Dentistry from the American of awardacademy for Lifelong of Cosmetic Commitment Dentistry to Providing of an Excellence award for Lifelong in Continuing Commitment Educationto inproviding CosmeticExcellence Dentistry in and Continuing an award Education for Outstanding Cosmetic Contribution Dentistry to Cosmetic and an Dentistry. award for He Outstanding received the New Contribution York University to Cosmetic College of Dentistry. Irwin He received Smigel Prize the New in York Aesthetic University Dentistry, College and of Dentistry the Lifetime Irwin Smigel Achievement Prize Award in Aesthetic from GenR8TNext Dentistry, and seminars. the Lifetime He is Achievement director of education Award for from thegenr8tnext Center for Esthetic seminars. Excellence He is director (Chicago) of and education is co-founder for the and Center chairman for Esthetic of Cosmedent, Excellence Inc., (Chicago) where heand is responsible is co-founder for and itschairman educational of Cosmedent, programs Inc., and where producthe development. Buddy is responsible for Mopper its educational will be speaking programs at and the product World Aesthetic development. Congress Buddy onmopper Friday 12 will be Saturday speaking 13at June the World 2009 inaesthetic London. Congress For further on information Friday 12 and Saturday to book 13 your June 2009 places, in please London. callfor Independent further information Seminars onand 0800 to book 371652 your or places, visit www.independentseminars.com/wac. please call Independent Seminars on 0800 371652 or visit www.independentseminars.com/wac. Figures 3a and 3b: A shallow labial prep is placed ranging from 0.8 mm at the incisal to 0.4 mm at the gingival. The gingival margin is placed 0.3 mm below the free margin for aesthetics. The application of Complete (Cosmedent) bonding adhesive after a total-etch technique was performed Today, in an attempt to replicate lifelike tooth structure aesthetically, there are a multitude of anterior and posterior composite resin materials from which to choose. As a result, dentists face a dilemma in deciding what product to use, and when. This article will explain the protocol that I follow and will also help readers identify and utilise the ideal product for a specific use that they may have in mind. In my experience, there is no other dental material as versatile and useful as this category of restorative products. There are many advantages to understanding and using direct composite resins regularly in your practice (Table 1). When one truly understands how to properly use these materials, long-lasting, truly aesthetic results are easily achievable. Composite resin can help you produce invisible aesthetic restorations of all types. I know this from my personal, long-time clinical experiences with this class of dental materials and their associated techniques. I have been using light-activated direct composite resin restoratively for more than 35 years, and for the past 20 years my practice has been limited to producing Figures 4a and 4b: Lingual surface of tooth six is reduced about 0.5 mm across the entire incisal third, allowing a complete labial-lingual wrap of incisal edge, creating better fracture resistance/retention form. The first application of Renamel NANO A2 is placed lingually to establish canine rise. (Note this material s no-slump, no-stick properties allow easy sculpting/shaping of the incisal tip) Table 1:Advantages of of direct composite restorations Aesthetics: When When done done properly, properly, one one of the of the most most aesthetic aesthetic restorations attainable Timesaving: Placed Placed in one in one practice practice visit visit Control: Aesthetic Aesthetic and and functional functional results results are are in in your your hands hands Minimally invasive: invasive: The most Theconservative most conservative restorative restorative material material choice available, choice available, helping to helping ensure to long-term ensure long-term health of health the tooth of the tooth Biologically compatible: Extremely compatible with the gingival Biologically compatible: Extremely compatible with the tissue, when properly placed and polished gingival tissue, when properly placed and polished Wear: Will not wear the opposing dentition Wear: Will not wear the opposing dentition Handling Handling properties: properties: Easy to Easy handle, to handle, manipulate, manipulate, and control and control Creative: Maximum creativity according to choice, technical and Creative: artistic abilities Maximum creativity according to choice, technical and Reparability: artistic abilities Easy to repair and can also be used for all-ceramic Reparability: and PFM repairs Easy to repair and can also be used for allceramic Long-lasting/high and PFMstrength: repairs Modern chemistry (research on Long-lasting/high particle size and filler content) strength: has increased Modern chemistry the strength and (research longevity of oncomposite particle size restorations. and filler content) has increased the strength and longevity of composite restorations. Article reprinted by permission of Dentistry Today, c2008 Dentistry Today

Clinical www.dentistry.co.uk aesthetic changes using only composite resin. Although my practice is all encompassing, with my partners doing indirect restorations of all kinds, I have limited my practice to direct placement restorative techniques. Procedures that I use direct composite resins for include: Class I restorations Class II restorations Class III restorations Class IV restorations Class V restorations Tooth shaping Tooth alignment Diastema closure Repair of intraoral defects Veneering for colour change Veneering mutilated dentitions Tooth lengthening Incisal edge reinforcement Composite and porcelain repairs. Composition of composite resins What categories of composite resin materials are available to us for use in our clinical armamentarium? Let s examine them by discussing their properties and seeing where they fit into our clinical techniques. Microfills Microfills are important if you want to create truly aesthetic, life-like restorations. This class of composite resins offers the highest level of aesthetics because they most closely simulate the actual enamel surface of a tooth. Since microfills have the smallest average particle size (0.04 microns) of direct composite resins, they polish to a higher lustre than any other material on the market. They also hold their polish over time and exhibit better wear characteristics than other types of composite resins. Microfills are also more stain and plaque resistant, making them more biologically compatible with the gingival tissue. In addition, they have the highest refractive and reflective index of any composite resin category, producing the most realistic translucency. However, microfills are less filled than other composite resins. As a result, they will not exhibit the same strength-properties as microhybrid or nanofill composites. Because of this, I use a layering technique placing an enamel layer of microfill composite resin (Renamel Microfill, Cosmedent) over a stronger, dentine layer composite. For the dentine layer(s) I use either a microhybrid or nanofill composite (Renamel Microhybrid or Renamel NANO, Cosmedent). Restorations built in this way exhibit optimal aesthetics and wear resistance due to their outer microfill enamel layer. Microhybrids Microhybrids are able to most closely simulate the dentine of natural tooth structure. Because of their higher strength and greater opacity, microhybrids are perfect for supporting the microfill enamel layer. Microhybrids have a larger particle size than the nanofill and the microfill composites, resulting in higher-strength properties. Since microhybrids are the most opaque of the three composite types, they are also great for masking out unwanted colour and achieving extreme colour changes. Microhybrids are also less polishable, more difficult to marginate, and will wear faster than microfill resins. As microhybrids most closely simulate the dentine of tooth structure, they will not obtain the same aesthetic results for an enamel layer as a microfill resin. In my practice, I use microhybrids as the substructure under microfills in areas that require high strength. Nanofills The incorporation of nanofill technology into composite resins is an important advancement in the field of aesthetic dentistry. Nanofill composites combine conventional-filler technology with nano particles to achieve both strength and aesthetics in one material. Currently, there are two distinct types of nanofill composites in the marketplace: completely nanofilled resins and nano-hybrids (i.e. Renamel NANO, Cosmedent). Completely nanofilled resins contain nanometer-sized particles throughout the resin matrix. Nano-hybrids, on the other hand, consist of larger particles surrounded by nanometer-sized particles. Although these nanofill materials vary in composition, the goal is the same, creating a universal dental composite. As previously mentioned, nano-hybrids nanohybrids contain nanometer particles combined with more conventional Figures 5a and 5b: After polymerisation of the incisal tip, Renamel NANO (Cosmedent) was used on the mesial proximal to add to the width of the cuspid to match the other side of the mouth. Note the space between cuspid and laterals is not fully closed because it would have delivered a disharmony in size. Proper morphology of each tooth is completed making finishing and polishing much easier Figures 7a and 7b: Use of titanium-coated instruments ensures easy placement of nanofills without sticking. Similar to buttering bread, the composite is spread and thinned simultaneously. A G3 instrument (Cosmedent) allows for easy placement on facial surfaces. An IPC Carver (Cosmedent) cleaves excess material interproximally and at gingival margins. Morphology and contours are achieved, but the material has not yet been polymerised Figures 9a and 9b: Incisal material in place and polymerised (note the translucency difference between the incisal edge and the body material). When gingival margins are involved, apply a small amount of Renamel Microhybrid (A2) (Cosmedent) material and sculpt with the IPC instrument to completely seal gingival and proximal margins filler technology. These large particles provide similar strength properties to hybrid materials while exhibiting higher polishability, as seen with the microfill resins. Unlike microhybrids, nanofill composites have a lifelike opacious translucency that is very natural in appearance. It is important to note that these materials will not hold their polish as long as microfill resins and, as a result, may be more susceptible to plaque and staining over time. However, when compared with conventional microhybrids, nanofill composite resins will maintain better surface smoothness and are thus great for the single-product user. Where should you use nanofill composites? Although you can really use nanofill materials to create cosmetic dental restorations of all kinds, I have identified a few key areas where nanofill composites fit into my dental practice. They are as follows: Posterior restorations Veneering lower anteriors Building up incisal edges Figures 6a and 6b: Addition of facial NANO A2 and the use gloved finger (no powder and clean and dry) to manipulate material into place. Apply light pressure with a tapping motion to allow for rapid and easy placement and precontouring Figures 8a and 8b: After polymerisation of facial surface, Renamel NANO (Cosmedent) Medium Incisal shade is placed with a Multipurpose instrument (Cosmedent) into the incisal areas to enhance the overall lifelike appearance of the finished veneer (Note colour and translucency of this material). The G3 instrument is used along with finger pressure to aggressively compress incisal material into the pre-formed incisal grooves Figures 10a and 10b: The G3 is used to smooth/sculpt subgingivally to completely seal margin. Material application and morphology is complete (note how much attention is given to properly sculpted tooth form). Then the material is light-cured for 60 seconds The classic class IV restoration When restoring or increasing cuspid rise. They can also be used when the dentist wants to use only one material, instead of layering a microfill over a microhybrid; as a support material for Class IV restorations; any tooth lengthening; adding cusps to worn molars or bicuspids; and for veneering mandibular anterior teeth (when strength is a concern); and posterior restorations. Opaquers and tints Opaquers and tints are key ingredients to creating beautiful invisible restorations. During the restoration procedure, opaquers allow you to block-out unwanted colour while tints help you bring the desired colour back into the tooth. The use of both is where your creativity as a dentist can really shine! However, opaquers and tints should always be used sparingly. Also, be careful when choosing them as some manufacturers make these materials too opaque. Let s examine the difference

Clinical www.dentistry.co.uk between these two materials. Opaquers: The main advantage of opaquers is that they produce opacity and block light transmission. Use them anywhere you would like to produce opacity in your final restoration. Since opaquers increase the value of a restoration, they are great for masking out metals and dark stains. Tints: Tints are used to help increase the hue and chroma of your restoration. Since tints transmit light, they are great for adding translucency back into your restoration. Unlike opaquers, tints decrease value. I use them to help develop a realistic-looking enamel surface from within. Figure 11: Final right cuspid composite resin veneer (tooth 6) after finishing and polishing. (Figures 13-15 demonstrate finishing and polishing steps on tooth 11) System advantages To excel in direct composite resin techniques, you should find a system that gives reliable and long-lasting results then stick with it! Ask yourself the following question: How many composite materials have I shelved because some guru says another product is better only to be disappointed once you have used it? When you are looking for a system, you should consider certain criteria (Table 2). Application technique First, one should understand that no material in itself will deliver the ideal restoration. This is because material selection is only one part of direct resin bonding. Second, one must consider the dentist s technical ability. Proper technique involves many components including the following: proper preparation technique for each procedure; method of material placement this involves complete understanding of tooth morphology and sculpting techniques necessary to achieve it; knowledge of layering and how to use various materials in combination to enhance the overall physical, aesthetic, and biologic results of each procedure (i.e. when to use microhybrid, nanofill, microfill, tints, and opaquers); and using the proper finishing and polishing techniques to achieve the most lustrous, plaque resistant, stain resistant and wear resistant finished result. One must understand when and how to use finishing burs, discs, rubber impregnated points, and polishing paste to obtain the desired result. (Note: knowledge and technical abilities in Figures 13a and 13b: Use of discs to contour the labial surfaces and to properly contour line angles and to develop embrasure surfaces. Note retraction with an 8A instrument to protect gingival tissue and an 8392-016 diamond (Brasseler, USA) while trimming and defining the gingival tissue Figure 12: Upper left cuspid (tooth 11). Composite application complete and polymerised prior to finish (note the two most important views when finishing and polishing are from the incisal and profile. Incisal view: Sets up incisal gingival contours, mesial distal contours and labial lingual relationships. It also helps to visualise embrasure space development. Profile view: Helps to silhouette one tooth against another to establish the alignment and emergence profile) Figures 14a and 14b: Further define tooth and pre-polish with a fluted ET6 bur (Brasseler USA). A diamond-impregnated point (Diamond Polisher Medium, Cosmedent) is used to form/polish mesial and distal grooves and further develop central lobe on cuspid Table 2: Key questions when selecting a composite resin system 1. How does the material handle? 2. Does the finished material truly match its selected shade guide? 3. Does the system make colour matching or colour development easy? 4. Is the finished product colour stable over time? (15 to 20 years?) 5. How easy is it to polish, and will the composite hold the polish over time? 6. How strong is the restoration? 7. What are the translucency and opacity characteristics of the material? 8. When finished properly, are the composite and the gingival tissues biocompatible? 9. What material has adequate strength for the purpose of use? 10. What material is more wear resistant? Why? all the above-mentioned areas can be greatly enhanced by an excellent hands-on workshop experience. I would recommend that you consider this if you have not already done so.) Case report: direct composite resin technique Many years ago, I placed direct composite resin veneers on my son s maxillary anterior teeth (6 to 11) to close spaces using only a microfill (Renamel Microfill, Cosmedent). Over considerable time, Robert had some chipping due to aggressive eating habits. These defects were easily repaired. Photos, taken at 22.5 years postoperatively, show minimal chipping of the composite material and excellent color stability of the material (Figure 1). As mentioned previously, microfills hold their polish long-term better than any other type of composite resin material, especially when the right dentifrice and toothbrush are used (Figure 2). I made the decision to redo Robert s case in autumn Figure 15: Fine and superfine disks (FlexiDiscs, Cosmedent) are used to achieve a high lustre while maintaining facial anatomy. This is followed with a buffing procedure (FlexiBuff and Enamelize polishing paste, Cosmedent) to achieve exceptionally smooth surface and immediate high polish. A Felt FlexiPoint (Cosmedent) and Enamelize polishing paste are used to enhance the mesial and distal grooves Figure 16: Note the excellent colour match of the completed veneer to an A2 shade tab (Vita Classical, Vident) 2007. The treatment goals were to achieve great aesthetics while establishing proper disclusion by improving his canine rise. Therefore, the new aesthetic restorations were done by utilising both nanofill and microfill composites. Let me take you through the reasoning involved in the proper material-selection thought process. I could have done the entire case using a nanofill and achieved excellent results, but I wanted the best of both worlds, both strength and aesthetics. I wanted a microfill surface because of its long-term polishability and optimal, life-like aesthetics. I used a nanofill to complete the functional portion involving the right and left cuspids. This would give me the strength required on a support tooth, along with great aesthetics and an excellent colour match to the laterals and centrals (the technique is shown in detail in Figures 3-16). Now, many would ask, why not Figure 17: Completed case: tooth numbers 6 and 11 were done with Renamel NANO A2 Body and Medium Incisal. Tooth numbers 7 and 8 were done with Renamel NANO and overlaid with Renamel Microfill A2 Body and Medium Incisal. Tooth 9 was not veneered, but the mesial and distal diastema closures were done using only Renamel Microfill Figure 18: Completed case at three-week post-op (note the accurate color match) porcelain veneers? And, I would ask, why porcelain veneers? What did we achieve with my son after 23 years? We achieved long-lasting results with minimal preparation. We observed only minimal (nonpathologic) recession due to material biocompatibility (and good oral hygiene habits); total colour stability with excellent aesthetics; complete and intimate bond of the composite-to-tooth surface (no cementation); and easy-to-repair restorations (Figures 17 and 18). Oh, and by the way Robert still eats ribs!

GIVE BACK A SMILE My Turn to Give Back A Great Smile is an Eye Opener Buddy Mopper, DDS, MS, FAACD Introduction Over the years I have seen what great work the AACD s Charitable Foundation has done for survivors of domestic violence. Their Give Back a Smile (GBAS) program encourages AACD members nationwide to volunteer their time and give back a smile to survivors of domestic violence with missing or damaged teeth. The impact a smile can have on a person s appearance, confidence, and happiness is profound. Working with this patient reinforced how important a smile is to a person s overall appearance and well-being. Patient History and Findings Diane presented in early 2010 with a missing maxillary right central incisor, fractured left central incisor, fractured right lateral incisor, and a semi-closed eyelid where her eye had been replaced (Figs 1-3). Diane was violently attacked by her ex-boyfriend in 2000. The blows to her face were so vicious she lost her upper right central, fractured her right lateral and left central incisor, and suffered such severe damage to her eye it had to be removed. After meeting Diane and hearing her story of domestic abuse, I was anxious to start treatment as soon as possible. The impact a smile can have on a person s appearance, confidence, and happiness is profound. Treatment Planning When Diane came to my office she was a very sad woman, and understandably so. At the time of the consult I was able to show her, through the use of a direct composite mock-up (Renamel Nano, Cosmedent; Chicago, IL), what she would look like when she was finished. By the end of the mock-up she was so happy with her new smile she started to cry. 22 Spring 2011 Volume 27 Number 1

The treatment plan was as follows: 1. Repair both fractured incisors. 2. Add enough material to both incisors to allow for proper contouring, spacing, and complete symmetry of both central incisors. 3. Construct a resin retained bridge. a. Trough lingual surfaces of left central incisor and right lateral incisor to allow for the placement of dental fiber reinforcement (Ribbond; Seattle, WA) internally, which would help support the construction of the missing right central incisor. b. Cover exposed Ribbond and properly contour the lingual surfaces of both incisors with the use of nano-fill composite. c. Create a freehand matched right central incisor with proper bonding techniques. In my opinion, this type of bridge is conservative and more predictable for longevity for the following reasons: Lower modulus of elasticity, which allows for the flex of natural dentition and therefore actually becomes less likely to break. When fabricating a restoration of this type, you will not see wear on the lower incisors. I have found composite resin to give a more predictable esthetic outcome than does porcelain. If the bridge should fracture at the connector site or any other place, it is far easier to repair. In my experience, this type of bridge has direct apposition of the composite to the tooth structure, therefore delamination is almost impossible. Figure 1: Pre-treatment, full-face image of patient. Notice semi-closed right eye. Treatment Both incisal edges were freshened with the use of a coarse FlexiDisc (Cosmedent). A long bevel was placed on the labial of the central and lateral and the lingual surface of each tooth was reduced fivetenths of a millimeter following the end of the long bevel. A chamfer was placed in the same vicinity on the lingual corresponding to the end of the long bevel on the labial. After etching (always etch beyond the long bevel), Cosmedent Complete bonding agent was placed and light-cured. To build up incisal edges and to give strength and opacity, Renamel Nano composite was sculpted to the leading edge of each long bevel and blended just slightly to the middle third of the bevel, which left room for the Renamel Microfill. Nano was also blended onto the lingual surface and sculpted to the lingual chamfered margin, creating a smooth intact lingual surface. Microfill was used for the final layer on the labial surface. It was sculpted past the long bevel and blended into the tooth surface and polymerized. The restorations were contoured, finished, and polished using the ET bur system (Brasseler USA; Savannah, GA) followed by FlexiDiscs, FlexiCups, FlexiPoints, FlexiStrips, Enamelize polishing paste, and felt FlexiBuffs (Cosmedent). This technique was completed prior to the Ribbond placement. 1-3 Immediately following treatment, I informed the patient that the restoration might be slightly too light in the gingival third. At her next appointment, that assumption was confirmed (Fig 4). At the next appointment, I reduced the microfill layer slightly all the way to the middle third of the tooth. Figure 2: Pre-treatment, natural smile view showing damage from abuse. Figure 3: Pre-treatment, retracted view. Journal of Cosmetic Dentistry 23

GIVE BACK A SMILE Technique Steps 1 2 After the mock-up. Ribbond cemented in place with Insure resin cement (Cosmedent) and overlaid with Renamel Nano (Cosmedent). 3 4 5 Teflon tape was placed over the gingival tissue to aid in the creation of a smooth gingival surface for the pontic. Application of nano-fill composite over the Ribbond to form the dentin layer of the tooth surface. Application and sculpting of lingual surface with nano-fill. 6 7 8 Addition of small amount of flowable Renamel Microfill. Smoothing flowable Renamel Microfill with Cosmedent #3 brush. Polymerized flowable creating the artist s canvas. 9 Creation of cervical chroma. 10 Gray tint applied to enhance incisal translucency. 11 Gray tint was added to the incisal third. 24 Spring 2011 Volume 27 Number 1

12 13 14 To create the enamel surface, Renamel Microfill was placed and sculpted to the exact proximal contour while at the same time slightly over-contouring from the facial. Great attention was given to the proper formation of line angles and embrasures. This technique of sculpting greatly simplifies the final technique of contouring, finishing, and polishing. 15 Prior to finishing, measurements were taken from the mesial of the lateral incisor to lateral incisor with a digital boley gauge and then divided by two, to determine the total width of space needed for both central incisors. 16 Symmetry is accomplished in the eyes of the dentist. Angulation and inclination have to be done by eye-balling it. 17 Completed restoration prior to polishing. 18 Polishing completed; notice lack of gingival chroma. 19 Notice moist cotton pellet on adjacent central to prevent dessication to achieve perfect color match. 20 More gingival tint was added to the cervical third prior to final microfill; notice the increased chroma. 21 What a difference a new smile can make! 22 Finished case, immediately postoperative. Journal of Cosmetic Dentistry 25

GIVE BACK A SMILE I placed a thin moist cotton pellet on the adjacent tooth to keep it from desiccating, a great trick to help determine correct tooth color. Because the cotton pellet keeps the tooth moist it is easier to see the perfect color throughout the procedure. I added a little more tint to the gingival surface of the pontic in an attempt to create a perfect match. Finishing was completed with the Brasseler ET contouring system and polishing was completed with Flex-discs, Flexi-points, Flexi-cups, Flexi-strips, Enamelize polishing paste and Felt Flexi-buffs. Rewards Figure 4: Postoperative evaluation confirmed that the gingival chroma needed to be enhanced. Figure 5: One year after treatment. Immediately after treatment Diane said, I now have a beautiful smile it has lifted my self-esteem. One year later, Diane s self-esteem is at its highest. She says, It feels good when you can smile and know that the world is smiling with you (Fig 5). I smile all the time now, but for 10 years I couldn t. Whenever I looked in the mirror I saw a monster; today, I see a beautiful woman. The GBAS program and Dr. Mopper gave me my life back! Diane also recounts the difference having her smile back has made in her life. She now can go out in the world with her head held high, and she can look people in the eye without being embarrassed. Her new smile has had such an impact on her that she now wants to be a spokesperson against domestic violence. Diane s newfound confidence and zest for life reaffirmed for me how much patients really do appreciate our work; a smile truly is contagious. What a difference a smile can make. Now Diane smiles not just with her lips and teeth, she smiles with her whole face (Fig 6)! Volunteering for the Give Back a Smile program was incredibly rewarding for my staff and me. Restoring Diane s smile reminded us of the significance of a smile in a person s life. If you are not currently volunteering with GBAS, I strongly encourage you to do so. Acknowledgment The author thanks his partner, Dr. Dennis Hartlieb, for his assistance with this case. References 1. Radz G. Beyond the Maryland bridge. J Cosmetic Dent. 1996;12(1):18-22. 2. Benjamin G, Kurtzman GM. An indirect matrix technique for fabrication of fiber-reinforced direct bonded anterior bridges. Compend Contin Educ Dent. 2010;31(1):60-4. Figure 6: One year after treatment a very happy patient! 3. Piovesan EM, Demarco FF, Piva E. Fiber-reinforced fixed partial dentures: a preliminary retrospective clinical study. J Appl Oral Sci. 2006;14(2):100-4. jcd Dr. Mopper is in private practice in Glenview, Illinois, and teaches CE in bonding at the University of Iowa and the University of Illinois. He is an Accredited Fellow member of the AACD and is the recipient of two awards from the AACD: Award of Excellence in Cosmetic Dental Education and Outstanding Contribution to the Art & Science of Cosmetic Dentistry. Disclosure: The author is co-owner of Cosmedent, Inc. 26 Spring 2011 Volume 27 Number 1

D r. B u d M o p p e r C o n t i n u i n g E d u c a t i o n I n t e r a c t i v e S e m i n a r Dr. Bud Mopper Materials List Cosmedent s Renamel Restorative System The Renamel Restorative System is the only fully integrated system of microfills, microhybrids, nanofills, flowable microhybrids, flowable microfills and opaquers, all color matched to each other and the VITA shade guide. Complementary tints are also available to greatly enhance your esthetic results. One shade restorations make the Renamel System predictable and reliable. All composites and opaquers are matched in color but have different opacities depending on the type of composite you use: Renamel Microhybrid The most opaque Renamel NANO Exhibits an opacious translucency Renamel Microfill Has an enamel like translucency (All three Renamel composites have built in fluorescence which mimic natural dentition) Where do I use the following materials in my office? Renamel Microhybrid I primarily use microhybrid to start veneering techniques when I require both strength and opacity. Great for blocking out undercolor because of its high opacity and color density Superior tensile strength makes this a great dentin replacement Has a flowable consistency that is easy to manipulate and place in thin layers Thicker oxygen inhibited layer makes it easy to layer composite if necessary Tremendous wetting properties resulting in the best adhesion to tooth surface and bonding adhesive. Renamel NANO This is Cosmedent s universal material. I use nanofill to repair incisal fractures by itself or with a microfill overlay, for posterior restorations of all types, and as a veneering substructure in anterior restorations. Great Working Properties Virtually no slump making incisal buildup and fracture repairs much easier. Esthetic Has an opacious translucent quality resulting in good esthetics when used alone or with the other composites. Easy to apply 1

D r. B u d M o p p e r C o n t i n u i n g E d u c a t i o n Materials List, continued Time Saving Because of Renamel NANO s no slump consistency, you can easily build-up the substructure of a tooth in one piece. Low shrinkage plus increased compressive strength makes it an excellent choice for posterior restorations. Renamel Microfill Microfill is the only composite material that truly mimics the enamel surface. Renamel Microfill has the translucency of natural enamel and can be used as your final layer in Class III, IV and V restorations, anterior veneers, diastema closures or really anywhere you want to replace missing enamel either anteriorly or posteriorly. Most Translucent Resembles natural enamel better than any other material Most Esthetic Easier to polish and retains polish long term better than any other composite type. Most wear resistant of all composites. Best refractive and reflective index of all composites. The best composite to place over tints. Its increased transparency allows the effects of incisal and gingival tints to shine through for increased translucency and gingival chroma. Built-in fluorescence mimics natural dentition Long lasting Long term clinical results show amazing durability and color stability over time. Renamel Incisal Shades Use incisal shades, dark, medium or light to mimic the intensity of translucency needed. Creative Color Opaques Creative Color Opaques help you block unwanted under-color from shining through to your final restoration. They are used to block out areas that are too translucent, mask unwanted under-color, and create effects such as white spots and hypoplasia. Use Creative Color Opaques in between your composite layers. They will also raise the value of your restorations and can be used to mask metal. Both color and value have been matched to Renamel composites so you can easily blend the corresponding opaquer into the restoration to achieve a more natural result. (Helps to prevent over opaquing.) 2

D r. B u d M o p p e r C o n t i n u i n g E d u c a t i o n Materials List, continued Pink Opaque A unique opaquer designed to mask gray colors, non-precious metal, and very dark stains such as tetracycline stains. Pink Opaque neutralizes color without over increasing value so results are more natural. It is most often used prior to the placement of your composite layer. Creative Color Tints Tinting is an invaluable tool that will help you create lifelike effects. Tints should be placed within the surface not on the surface for the most natural shine-through. Use to: Impart incisal translucency and cervical chroma Mimic surface artifacts such as pit and fissure staining Recreate craze lines, check lines and maverick colors Decrease the value of your restoration Creative Color tints and opaques are microfill based,10% filled, and polishable. De-Mark This highly radiopaque flowable composite enables you to clearly differentiate your composite restoration from tooth structure on an x-ray. Because of its extreme opacity this is a great product for lining posterior preparations. Quick Tip: Most people under polymerize. As a rule of thumb, double the polymerization time recommended by the light manufacturer. Instruments Cosmedent Nonstick Composite Placement Instruments (titanium coated) 8A (Long and Short) Used for application and contouring of composite G3 Wider version of the 8A. Use this instrument to place and sculpt large amounts of material. IPC (Long, short and off angled) Extra thin and flexible instruments used to refine margins in interproximal areas, develop line angles, sculpt finite gingival margins, and refine incisal edges. Multi Use Used to mimic areas of incisal translucency and as a posterior placement instrument 3

D r. B u d M o p p e r C o n t i n u i n g E d u c a t i o n Materials List, continued Preparation, Contouring, Finishing and Polishing The Mopper System (by Brasseler) Anterior / Posterior preparation and finishing kit. Comes in 18 diamond and carbide high speed burs in varying shapes, both regular and micro burs. Brasseler ET System (Komet ET System) Carbide burs used to start the contouring and finishing process. Comes in 12, 16, and 30 fluted high speed burs. Cosmedent s Top Finisher System is a completely integrated, fully color-coded system for the contouring, finishing and polishing of nanofills, microfills, hybrids, porcelain, enamel, metal, gold and natural teeth. FlexiDisc System Helps you contour, finish and polish restorations of all types. FlexiDiscs are extra thin, flexible and resilient. Designed to give you more control and an unbeatable final polish. These discs are available in regular and mini centers and have a vivid color coding to help you quickly identify the correct grit. Where Should FlexiDiscs Be Used? Blending marginal areas into tooth surface to create invisible margins Contouring and finishing of curved surfaces such as labial proximal line angles Finishing and polishing of smooth (no anatomy) labial surfaces Contouring and finishing of incisal edges, and shaping and finishing of incisal corners Contouring and finishing of facial aspects of Class III restorations Contouring and finishing of cervically involved areas Contouring and finishing of marginal ridges and lingual and buccal surfaces of posterior restorations. FlexiCups and FlexiPoints Aluminum oxide rubber polishing instruments. Use to: 1. Enhance characterization and polish labial and buccal surfaces. 2. Polish gingival margins with ease and reliability. 3. Finish and polish lingual surfaces 4. Better polishing of occlusal surfaces. 4

D r. B u d M o p p e r C o n t i n u i n g E d u c a t i o n Materials List, continued FlexiDiamond Strips Used to start interproximal finishing. The wide strips are for proximal surfaces and the narrow are used at the gingival crest. FlexiStrips Aluminum oxide strips are used to complete polishing of interproximal surfaces of composite. Also available in both wide and narrow. Enamelize with Felt Points and FlexiBuffs Used for the final polish. Enamelize is an aluminum oxide polishing paste designed to greatly enhance the polish on all microfill, nanofill and hybrid composites as well as bring natural tooth structure and metals to a high luster. For the highest shine use Enamelize with Cosmedent s Felt Points or Felt FlexiBuffs. NANO / Microhybrid Diamond Polishers These diamond polishers are designed to quickly and easily create a beautiful contour and polish on nanofill and microhybrid composites. The use of high quality magnifying optics will greatly enhance the gingival biocompatibility and esthetic results of any restoration. Suggested optics: 1. SurgiTel 2. Designs for Vision 3. Zeiss My preferred bonding adhesive is Cosmedent Complete, a 5th generation bonding agent with added features. It has: 1. Dual-cured catalyst when added in correct proportions can make the light-cured dentin enamel bonding adhesive either dual-cured or self-cured. 2. It has an unfilled resin that makes durable composite repairs possible. 3. It is a multipurpose bonding agent that will bond to all surfaces enamel, dentin, composite, porcelain, metal, acrylic, and core-paste. 5 #1799c 11.19.01

It was a pleasure meeting with you and discussing your restorative and cosmetic dental needs. We look forward to working with you. The following are some suggestions for your upcoming visits that should help to make them more comfortable and enjoyable. *** Important Note *** Please make sure you have had your teeth thoroughly cleaned at least 10 days prior to your appointment. Wear comfortable clothes... You may want to bring a sweater as the treatment rooms are kept cool; please note, a blanket is available. Please do not wear any makeup. Feel free to bring an i-pod, MP-3 player or DVD. The first two hours are usually completed without a break. After the first two hours, small breaks may be taken. Bring a light, soft snack and drink such as Yogurt, Jell-O, pudding, cottagecheese, crackers, or a light sandwich. While we estimate the length of time required, please be advised that your appointment may run a little longer than expected. Please keep this in mind when planning the rest of your day. Should you have any questions, please do not hesitate to contact us. Drs. Mopper, Hartlieb & Associates

MAINTAINING YOUR NEW SMILE It was a pleasure working with you today and creating your new smile. We are confident that you will enjoy these restorations for many years to come. Brushing after every meal, or at least twice a day, and flossing at least once a day will help you maintain good oral hygiene. If you need instructions on how to properly brush and floss your teeth, please feel free to ask and we will demonstrate the proper technique. Regarding tooth brushing, we recommend using Supersmile or Crest plain toothpaste. The most common question we receive is Doctor, how strong is the material and how long will it last? We can only state that we have been doing bonding for over 30 years now and most of our original procedures are still intact. The materials are extremely strong and resistant to breakage. The following information will help you maintain the longevity of your bonding procedure: 1. Do not bite your fingernails (this may cause chipping); 2. Do not bite or chew on extremely hard objects (i.e. hard or frozen candies, ice, rib or chicken bones, hard crusts, shelled nuts, etc.); 3. If you clench or grind your teeth, a night guard is highly recommended to help prevent wear and tear of the natural chewing surfaces of your back teeth. The appliance will also help prevent chipping or fracturing of the edges of your front teeth; 4. If you play contact sports, use an athletic mouth guard (preferably one we ve made specifically for you at our office); 5. If you are not a regular patient of our practice, please tell your dentist about the procedure so he or she can exercise proper care during cleanings! Because of the bonding we perform, it is often difficult for even the most experienced hygienist to recognize that there is bonding material in your mouth, it is that natural looking; 6. We would like to see you six months after your bonding procedure for a bond polish to make certain the esthetic results have been maintained and that things are in good order. Thereafter, we will schedule an appointment with you annually for a bond polish; 7. You can eat normal foods in a normal manner. Flash your smile and enjoy. We had a great time working with you!

Dr. Bud Mopper Continuing Education Interactive Seminar Dr. Bud Mopper