Placing Strong Class V Restorations Without Esthetic Compromise

The filler component of composite resins plays a key role in their clinical performance. Macrofilled composites demonstrate high strength but do not polish well and have been associated with higher plaque retention. Alternatively, microfilled composites demonstrate excellent esthetics and polishability but suffer from a lack of strength and decreased resistance to wear. Hybrid fillers, nanofillers, and nanohybrid fillers are newer developments that aim to increase the advantages of composite resins while decreasing their drawbacks.^1-3

Class V lesions, due to their location and the forces applied to this area, present a more difficult restorative challenge than many might think. There are two common causes of Class V lesions. The first is smooth surface decay from plaque and bacteria in the oral cavity. The second cause is noncarious cervical lesions.⁴ Although there is no singular agreed-upon reason for their appearance, brushing habits, occlusal forces, and gingival phenotype are all thought to contribute.

Improving the survival of Class V restorations involves choosing materials that can minimize the influence of physical and chemical processes that ultimately lead to their failure. Selecting a composite that meets the physical demands of a Class V restoration is one part of the challenge. The material must have enough physical strength to resist wear and enough flexibility to resist dislodgement under normal occlusal load cycling, especially when restoring posterior noncarious cervical lesions. Esthetically, Class V restorations need to be excellent, which requires clinicians to choose materials and shades that can blend seamlessly with the rest of the tooth. These composite resins also need to be highly polishable to produce the same light-reflective values as normal tooth structure, which is incredibly important for lesions in the anterior region that are more visible.

Many composites do not have the ability to combat the number one reason for the failure of Class V restorations, which is recurrent decay and a breakdown of the composite-tooth interface. Over time, bond degradation and staining are almost guaranteed events in the oral cavity.^5,6 However, certain composite resins offer bioactive benefits that improve resistance to recurrent decay, leading to longer-lasting and more esthetically pleasing clinical results.

A 28-year-old female patient presented with a combination of noncarious cervical lesions and carious cervical lesions affecting several maxillary anterior teeth (teeth Nos. 5 through 12). The severity of these lesions ranged from mild to moderate (Figure 1 through Figure 3). After discussing possible treatment options, the patient declined treatment with ceramic veneers to address her diastemas and change the general morphology of her anterior dentition because she was happy with the overall appearance of her teeth. Therefore, a clinical decision was made to utilize composite resin as the restorative material.

The decay was removed in a two-step process using a round-ended chamfer diamond bur (Revelation^® Diamond, SS White Dental) followed by a round carbide bur (Carbide, SS White Dental). To complete the preparations, an infinity bevel was added using the round-ended chamfer diamond bur (Figure 4 through Figure 6). A viscous 38% phosphoric acid etchant (Etch-Rite^™, Pulpdent) was then applied to each tooth for 15 seconds and rinsed thoroughly for 5 seconds, working two teeth at a time to allow for optimal isolation. After the teeth were air-dried without desiccation, each tooth received a 20-second active application of a universal bonding agent (BeautiBond^® Xtreme, Shofu Inc.), which was cured for 5 seconds using an LED curing light (VALO^™ Grand, Ultradent Products Inc.).

Next, a flowable nanohybrid composite (Beautifil Flow Plus^® X [F00, Shade A1], Shofu Inc.) was carefully applied from the cervical aspect to the incisal aspect of each preparation, allowing it to slightly overfill the contours, and light cured for 20 seconds. This composite was selected for this case for several reasons. First, the material's physical properties impart restorations with high wear strength, high flexibility, and excellent polishability. Second, the shape of the material's nanohybrid filler particles enable it to produce a slight chameleon effect, which helps it blend with the natural tooth shade for a better color match and maximized esthetics when appropriately polished. Third, this composite includes Giomer Technology, which actively releases and recharges six beneficial ions, including fluoride, that continuously protect the tooth by neutralizing acid, imparting an antibacterial effect, and reducing tooth mineral solubility. This intrinsic bioactivity, which is important in fighting the degradation and failure of the bond layer, allows the composite to interact with the oral environment dynamically, restrengthening any areas weakened by bacterial acid erosion. And finally, this composite is 30% less expensive than other name brands.

Following placement of the composite, gross contouring was completed with a medium grit diamond needle (Revelation^® Diamond, SS White Dental), and then the fine contouring and polishing were completed with a series of polishing discs (Super-Snap^® polishing system, Shofu Inc.) and a diamond-impregnated polishing paste (DirectDia Paste, Shofu, Inc.). The patient was dismissed and returned in two weeks for a follow-up appointment, at which time she expressed her satisfaction with the highly esthetic outcome that was achieved (Figure 7 through Figure 9).

Neville Hatfield, DMD
Private Practice
Mahwah, New Jersey