Alan Mead, DDS
Translucent bluish-gray halos. Hyperchromatic splotches. Opaque body shades showing through carefully sculpted translucency. What can be done with composite by the masters never ceases to amaze me. I’ve been in the presence of greatness before. I’ve taken courses in layering from amazing clinicians. I’ve witnessed what can be done with composite resin by some of the best, and I’m grateful for their abilities and their teaching.
But that’s not what this article is about.
Not every clinician has the talent to do what the masters do. In fact, most of us don’t. Furthermore, not every anterior composite that you do needs three layers, opaquers, and tints. Most of the dentists who do anterior composites day in and day out have limits on what they can do for their patients. The limits may be monetary, as in “I’m working on a fee schedule that doesn’t really allow for an AACD-style layered restoration.” We’re often limited by time as well. A “regular” dentist working a “regular” schedule cannot spend the time necessary to create the kind of restorations that the masters are showing on Facebook on a regular basis. And that’s OK. Sometimes it’s OK to just do a “regular” filling.
But I would propose that there are ways to make anterior direct restorations predictable, profitable, and—frankly—fun. I find these kinds of anterior restorations to be a respite from the daily grind. Often, you can make a big difference in a patient’s smile in a short amount of time—even when you aren’t promising a full-mouth smile makeover. With that, here are my seven tips to make anterior composites more predictable, profitable, and fun.
Tip 1: Bond to clean teeth
One of the least talked-about steps in placing anterior restorations (or any restorations, for that matter) is biofilm. The same bacteria that cause tooth decay and periodontal disease also secrete super sticky media onto the teeth that give them a place to live. I want my beautiful new front tooth filling to last a long time. I don’t want it to leak, and I don’t want the margins to stain. For that reason, I don’t want to try to bond to this bacterial scuzzy stuff. So, I need to clean the surface of the tooth.
The only real way to do this is to mechanically remove the biofilm. If you’ve ever used a plaque-disclosing liquid on a tooth, even after you think you’ve cleaned it with pumice, you’ll soon realize that pumice in a prophy cup doesn’t get the job done. Your very best bet is to use some kind of powdered medium. I like to use aluminum trihydroxide powder in an air polisher handpiece that delivers the medium with water.
Why aluminum trihydroxide? First, it effectively removes biofilm, but it’s not hard enough to actually prep the tooth. Secondly, it’s an actual food additive and is technically edible. Not that I want my patients swallowing this stuff, but it’s not going to hurt them if they do.
I use a plaque-disclosing solution on the teeth and “blast” the biofilm until the disclosing solution is gone. It doesn’t take a long time, and it’s incredibly satisfying. It’s a wicked mess, though. Make sure your patient has eye protection at the very least if not some kind of drape.
I know what you’re thinking. You’re thinking: “This step isn’t necessary. I know it’s not necessary, because I’ve been working for years without it and everything is fine.” It’s OK. I was once like you. I promise that once you start removing biofilm in this way, you’ll see a difference. Working on clean teeth is where it’s at. Adhesive dentistry works better on clean, dry teeth. And speaking of dry teeth . . .
Tip 2: Use proper isolation for the situation
You’re thinking to yourself, “Oh no. Is this where he gives us the rubber dam lecture?” Well, kind of. It’s much easier to get isolation in the anterior than further back. Probably the biggest challenge is to keep the patient’s lips off of your clean, dry tooth surface. A rubber (or nonlatex, as the case may be) dam is excellent for this. But I would argue that one of the many excellent cheek retractors on the market—such as the OptraGate (Ivoclar Vivadent) or the ComfortView Lip and Cheek Retractor (Premier Dental Products)—can often do the trick. The main thing is that you don’t slack on your isolation simply because it’s easier to do so in the front of the mouth.
If you choose a rubber dam, be sure you place it in such a way that you’ve got room to work. My happy place is working on anterior teeth with a dam placed second premolar to second premolar on the upper. I floss the dam from midline back and then place a premolar retainer on each second bicuspid. It retracts lips and cheeks like a dream and gives me plenty of room to work. (Pro tip: Place your dam like this before disclosing the biofilm and blasting. It keeps the water/powder off the patient’s face much better and cleanup is way easier.)
Tip 3: Ludicrous bevel
I want you to picture your clean, beautifully isolated tooth in your mind. Next, take that tooth and create your preparation. Be sure to put a nice, long bevel on it. Angle that bevel nice and wide. Can you picture it? OK. Now, make the bevel even longer!
The importance of a huge bevel from the edge of the cavosurface onto nice clean enamel cannot be underestimated. Whenever possible, I create a bevel width at least two times longer than the actual width of my preparation. I’m not suggesting a heavy bevel. And definitely not into dentin.
So, why am I so obsessed with the bevel? It’s because this is the key to getting your composite to blend into the tooth structure. What I’ve found is that when I’m blending over a wide area, the shade of my composite becomes less important. A wide bevel makes it so that my shade selection doesn’t have to be perfect. This blending happens by allowing more and more of the natural tooth shade to show through a thinner and thinner layer of composite as we approach the edge of your preparation.
I need to give credit where credit is due here. David Clark, DDS, teaches a lot of these principles in Tacoma at his Bioclear Learning Center. One of my favorite David Clark sayings is, “Where is our margin? I don’t know, and I don’t care.”
Since we’re bonding to clean and etched enamel, we can actually bond composite past the margin of our preparation, and we don’t have to worry about it. This gives me confidence about my bond and about how well we can match a shade without spending a lot of time choosing multiple shades.
Tip 4: Use a single-body shade
This tip is bound to be controversial, but hear me out. Most of the time, if you’re bonding on clean enamel and you’ve placed a ludicrous bevel, you won’t need multiple shades to get a really nice shade match. Body-shade nanocomposites offer just the right amount of balance between translucency and opacity for this technique. The result is that when you use a body-shade nanocomposite with a gigantic bevel, you get a pleasant blending of shade without multiple shades.
It’s not foolproof by any means. But what I’m finding is that I don’t have as many failures of shade matching as I used to. Am I saying you can stock fewer shades of composite? Perhaps. This blending effect works well enough that you can be a little “wrong” on the shade and it still looks pretty terrific.
Tip 5: Heated composite overfilling the preparation
More controversy! I’ve been heating composite for a bunch of years now. Although there is ample evidence that heating composite can improve its physical properties and increase polymerization, I don’t do it for that reason. With a great curing light, most of these composites have excellent physical properties, and depth of cure is rarely an issue. I like to heat composite for its handling properties.
Heated paste composite (in a compule) flows much like unheated flowable composite. This allows you to handle composite in a completely different way. Instead of placing composite onto a tooth and patting it into place with some kind of applicator, you can take advantage of greater flow properties of paste composite and injection-mold it.
This injection molding changes the way that you use your matrix. Instead of simply keeping you from bonding the teeth together, the matrix becomes a form that you can inject against with pressure. When you light-cure this injection-molded composite against whatever mylar matrix suits your fancy, the result is a super-smooth contact interproximally.
The goal is to create a form to inject into much like a form that concrete is poured into. This allows you to reduce the amount of finishing and polishing you have to do in the places that are the most difficult to do it.
The trade-off is that you’ll end up overfilling the preparation. This overfilling drives our anal-retentive dental selves to distraction. But don’t despair! You’re overfilling into the buccal, lingual, and incisal—all areas that are very easy to access with a bur or a disk. Furthermore, you’re overfilling past your gigantic bevel onto clean enamel. What you end up with is a big, beautiful, overfilled tooth. Which is ready to be finished.
Tip 6: Finishing
Back when you used to place composite dead level with the tooth structure, you patted yourself on the back about how much time you’d save on finishing your composite. What you didn’t realize, though, is that placing composite in this way was much more time-consuming than injection molding. Once you realize that you spend most of your time creating a form to inject into, the actual placement of the composite is very quick.
You take your overfilled front tooth and start making it look a little closer to a tooth. Feel free to use a relatively coarse bur to start. The trick is to leave some excess. You don’t want to finish with a coarse diamond right to the level of the tooth. Leave a little bit so you can apply the real magic touch to the finishing process: disks.
There are a ton of disks on the market that do a great job. The most important thing you need to know is to choose one that allows you to pull. Either use a disk that has two sides or—even better—use one that can be flipped forward or backward. You’ll find that using a disk with some back action will cause your overfilled facial and lingual surfaces to disappear. I’m also fond of very fine diamond burs at this stage, although I highly recommend that you use them sparingly. Even very fine burs can gouge. Disks cannot.
At first, this kind of finishing will seem time-consuming. After a few tries, you’ll get the hang of it. You’ll find that you can follow the natural contours of the tooth. You’ll find yourself blending the composite into a shape that appears after just a little work. This is some touchy-feely stuff that I’m proposing, but trust me—it will become fast in your hands with just a little practice.
Tip 7: Polishing
Polishing these restorations is pretty quick. You’ve done the majority of the heavy lifting in the finishing stage. There are a bunch of great polishers on the market. I’ve become pretty fond of some of those that look like pinwheels, but I’m also pretty partial to cups. Especially rubber cups that have a bit of give under pressure. My main tip about polishing is to use an electric slow-speed handpiece—low RPMs (between 5,000 and 6,000) with heavy water. If you don’t have an electric, go as slow as you can in an air-driven handpiece, and make sure you’ve got water on it. These two things have made polishing a much quicker and more consistent process in my hands.
This recipe has made anterior composite restorations predictable, beautiful, and quick for me. More importantly, it’s helped put a smile on my face when I see them show up on my schedule! What used to be a frustrating roll of the dice has become a leisurely and enjoyable procedure that my patients are pretty excited about.
Alan Mead, DDS, a 1997 University of Minnesota School of Dentistry graduate, practices in Saginaw, Michigan, at Mead Family Dental. He is the cohost of The Dental Hacks podcast and writes for and edits their group blog at dentalhacks.com. He is also creator of The Alan Mead Experience, a more personal podcast about dentists and their stories. He lives on a horse farm with family, pets, and a miniature donkey named Floyd.
