The Injection Resin Technique










QDT 2020 245
The Injection Resin Technique: A Novel Concept for Developing Esthetic Restorations
CASE 1
Developing the Functional Composite Prototype (Figs 6 to 12)
Fig 6 Preoperative facial view of the maxillary anterior segment
of a patient who presented with incisal wear and fracture of the
maxillary anterior teeth.
Fig 7 Development of a diagnostic wax-up that establishes
new parameters (ie, esthetic, functional) for the final restora-
tions.
Fig 8 Clear PVS matrix (Memosil 2, Kulzer) was fabricated to
replicate the diagnostic wax-up.
Fig 9 Flowable composite resin material (Filtek Supreme Ultra,
3M ESPE) was injected through a portal in the matrix, allowing
the material to completely cover the conditioned unprepared
enamel surface.
9
6
7 8

TERRY ET AL
QDT 2020246
10a 10b 10c
11 12
Figs 10a to 10c Functional resin composite prototype was completed and inspected in centric relation and protrusive and lateral
excursions.
Fig 11 Functional resin composite prototype established the optimal esthetic parameters for a natural smile.
Fig 12 Facial view at 6-year follow-up.
CASE 2
Orthodontic Space Management (Figs 13 to 18)
Figs 13a and 13b Preoperative facial views prior to interdisciplinary orthodontic treatment of 11-year-old patient, who presented
with a tooth size discrepancy on the maxillary anterior segment and caries on the proximal surfaces of the maxillary lateral incisors.
During orthodontic and restorative evaluation, the patient and parent were explained the significance of achieving specific space
requirements so the orthodontist could position the teeth in the most optimal restorative position that will require a minimal prepara-
tion design. It is important that the appropriate and anticipated result be decided prior to the placement of the orthodontic appliances.
13a 13b

QDT 2020 247
The Injection Resin Technique: A Novel Concept for Developing Esthetic Restorations
Figs 17a and 17b Completed resin composite restorations
with optimal anatomical form for the 11-year-old patient. The
composite injection technique allowed the establishment of
harmonious proportions of the transitional restorations and the
surrounding biologic framework. Use of the technique for tooth
size discrepancies in the preorthodontic treatment-planning
stages simplifies the understanding and management of this
restorative dilemma for the patient and the interdisciplinary
team.
Fig 18 Seven-year follow-up of composite transitional
restorations after orthodontic treatment. Note the minimal wear.
Fig 14 After review with the patient, parent, and orthodontist, a
diagnostic wax-up was designed to modify the size and shape of the
maxillary lateral incisors. This wax-up allowed the restorative team to
evaluate form and function.
Fig 15 A clear PVS matrix was fabricated to replicate the diagnostic
wax-up. A small opening was made above each tooth that was to be
restored using a needle-shaped finishing bur (ET Series bur, Brasseler
USA).
Fig 16 After the adhesive protocol was completed, the clear silicone
matrix was placed over the arch and shade A1 flowable resin composite
(G-aenial Universal Flo, GC America) was injected through a small
opening above each tooth. The resin composite was cured through
the clear resin matrix on the incisal, facial,
and lingual aspects for 40 seconds.
14
15
16
18
17a 17b

You're Reading a Preview

Become a DentistryKey membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Was this article helpful?

QDT 2020 245The Injection Resin Technique: A Novel Concept for Developing Esthetic RestorationsCASE 1Developing the Functional Composite Prototype (Figs 6 to 12)Fig 6 Preoperative facial view of the maxillary anterior segment of a patient who presented with incisal wear and fracture of the maxillary anterior teeth.Fig 7 Development of a diagnostic wax-up that establishes new parameters (ie, esthetic, functional) for the final restora-tions. Fig 8 Clear PVS matrix (Memosil 2, Kulzer) was fabricated to replicate the diagnostic wax-up.Fig 9 Flowable composite resin material (Filtek Supreme Ultra, 3M ESPE) was injected through a portal in the matrix, allowing the material to completely cover the conditioned unprepared enamel surface.967 8 TERRY ET ALQDT 202024610a 10b 10c11 12Figs 10a to 10c Functional resin composite prototype was completed and inspected in centric relation and protrusive and lateral excursions.Fig 11 Functional resin composite prototype established the optimal esthetic parameters for a natural smile. Fig 12 Facial view at 6-year follow-up. CASE 2Orthodontic Space Management (Figs 13 to 18)Figs 13a and 13b Preoperative facial views prior to interdisciplinary orthodontic treatment of 11-year-old patient, who presented with a tooth size discrepancy on the maxillary anterior segment and caries on the proximal surfaces of the maxillary lateral incisors. During orthodontic and restorative evaluation, the patient and parent were explained the significance of achieving specific space requirements so the orthodontist could position the teeth in the most optimal restorative position that will require a minimal prepara-tion design. It is important that the appropriate and anticipated result be decided prior to the placement of the orthodontic appliances. 13a 13b QDT 2020 247The Injection Resin Technique: A Novel Concept for Developing Esthetic RestorationsFigs 17a and 17b Completed resin composite restorations with optimal anatomical form for the 11-year-old patient. The composite injection technique allowed the establishment of harmonious proportions of the transitional restorations and the surrounding biologic framework. Use of the technique for tooth size discrepancies in the preorthodontic treatment-planning stages simplifies the understanding and management of this restorative dilemma for the patient and the interdisciplinary team.Fig 18 Seven-year follow-up of composite transitional restorations after orthodontic treatment. Note the minimal wear. Fig 14 After review with the patient, parent, and orthodontist, a diagnostic wax-up was designed to modify the size and shape of the maxillary lateral incisors. This wax-up allowed the restorative team to evaluate form and function.Fig 15 A clear PVS matrix was fabricated to replicate the diagnostic wax-up. A small opening was made above each tooth that was to be restored using a needle-shaped finishing bur (ET Series bur, Brasseler USA).Fig 16 After the adhesive protocol was completed, the clear silicone matrix was placed over the arch and shade A1 flowable resin composite (G-aenial Universal Flo, GC America) was injected through a small opening above each tooth. The resin composite was cured through the clear resin matrix on the incisal, facial, and lingual aspects for 40 seconds.1415161817a 17b TERRY ET ALQDT 2020248CASE 3Restoring Posterior Primary Tooth with an Injectable Composite Crown (Figs 19 to 24)19a 19b20Figs 19a and 19b Preoperative occlusal view and radiograph of the primary mandibular second molar of 78-year-old patient with an existing Class II compos-ite restoration and caries on the distoproximal surface of the tooth. Upon initial consultation with the periodontist, the recommended treatment included an implant and bone graft, and the patient needed to temporarily discontinue his warfarin regimen. After subsequent medical history and radiographic review and discussion with the patient and periodontist, it was decided that the injectable resin technique would be a viable alternative treatment for this clinical situation, and the patient agreed. Fig 20 A clear PVS (ExaClear, GC America) matrix was fabricated to replicate the preoperative diagnostic model, and an opening was made above the primary mandibular second molar with a tapered diamond bur (6847, Brasseler USA).21 22Fig 21 Adhesive preparation design included removal of preexisting defective composite restoration and carious dentin and enamel; occlusal reduction of 1.5 to 2 mm; a circumferential chamfer 0.3 mm in depth; vertical proximal, buccal, and lingual walls with slight convergence toward the occlusal; all internal and external line angles rounded and cavity walls smoothed; and unsupported enamel walls removed to improve the path of material flow. Fig 22 After the injection process was completed, the matrix was removed and the excess polymerized resin composite was scoured on the facial, lingual, and interproximal regions with a scalpel blade (#12 BD Bard-Parker, BD Medical) and removed with a scaler. The occlusal composite sprue was removed using an 8-fluted pyramidal-shaped finishing bur (H274, Brasseler USA). QDT 2020 249The Injection Resin Technique: A Novel Concept for Developing Esthetic Restorations23a 23bFigs 23a and 23b Completed primary composite crown. The radiograph reveals ideal proximal contours and contacts with an optimal marginal integrity at the restorative interface. Fig 24 Clinical follow-up at 18 months. The patient was pleased with the results achieved using this minimally invasive injection technique. 24CASE 4Single Anterior Implant Immediate Placement Technique (Figs 25 to 30)25 26Fig 25 Facial view of the maxillary anterior segment and surrounding tissue of a 28-year-old patient. Fig 26 Diagnostic wax-up was used for presurgical planning of the interrelationship between the definitive restoration and the oral structures and to fabricate the provisional restoration. TERRY ET ALQDT 202025027 2829 30Fig 27 Prefabricated zirconia abutment was placed and secured in position, and the access opening was sealed. Sterilized Teflon tape was applied on the adjacent teeth to separate the abutment, and glycerin was applied to the entire surface of the abutment. Fig 28 A clear silicone matrix was placed over the anterior segment of the maxillary arch, and an opacious shade A3 flowable resin composite (G-aenial Universal Flo, GC America) was injected through the small opening above the abutment, followed by a translucent A3 flowable resin compos-ite. The resin composite mix was cured through the clear matrix on the occlusal, buccal, and lingual aspects for 40 seconds each using an LED curing light.Fig 29 Biointegration of the provisional composite crown with the peri-implant architecture after 3 months.Fig 30 Final results after placement of the implant-supported restoration, revealing optimal hard and soft tissue integration. QDT 2020 251The Injection Resin Technique: A Novel Concept for Developing Esthetic RestorationsCASE 5Restoring Anatomical Form and Color (Figs 31 to 41)31 32 3334 35 36Fig 31 Preoperative facial view of the maxillary anterior segment of a 47-year-old patient who presented with cosmetic concerns regarding his smile. The patient requested a conservative esthetic enhancement without orthodontic treatment.Fig 32 A clear polyvinyl siloxane matrix was fabricated to replicate the diagnostic wax-up using a non-perforated tray. A small opening was made above the lateral incisor that was to be restored using a tapered diamond bur (6847, Brasseler USA). It is important to clean the internal surfaces with a microbrush to prevent silicone debris incorporating into the flowable material.Fig 33 After intraenamel preparation and adhesive protocol, the clear silicone matrix was placed over the maxillary arch and an opacious shade A1 flowable resin composite (G-aenial Universal Flo, GC America) was initially injected through a small opening above the preparation, followed by mixing with a shade B1 flowable resin composite (injection layering technique). The resin composite was cured through the clear resin matrix on the incisal, facial, and lingual aspects for 40 seconds, respectively.Fig 34 The completed resin composite veneer with optimal anatomical form.Fig 35 At the following appointment, the final restoration was completed by using a composite cutback technique. The artificial enamel layer of the composite veneer was removed and a corrugated chamfer 0.3 mm in depth was placed around the entire margin with a long, tapered diamond. Fig 36 The entire composite surface was etched with 37.5% phosphoric acid (Gel Etchant) for 15 seconds and rinsed for 5 seconds. Etching of the existing composite cleans the surface. TERRY ET ALQDT 202025238a 38b 38c37Figs 38a to 38c Internal characterization was performed according to the appearance of the contralateral tooth and a shade-mapping diagram. A diluted gray tint (Renamel Creative Color, Cosmedent) was placed along the incisal edge and proximal regions with a size 08 endodontic file and light cured for 40 seconds. A diluted white tint (Renamel Creative Color) was placed along the incisal edge, proximal regions, and in the body with a size 08 endodontic file, and light cured for 40 seconds to stabilize the color and prevent mixing of the tints. A diluted yellow tint (Renamel Creative Color) was placed at the cervical and in the incisal third with a size 08 endodontic file and light cured for 40 seconds. It is the color variation from these modifiers and tints that creates the three-dimensional effect and the nuances within the incisal edge.Fig 39 A new clear silicone matrix fabricated after the connective tissue surgical procedure was placed over the anterior segment of the maxillary arch, and a clear translucent flowable resin composite (Amaris Flow HT, VOCO) was injected through a small opening over the artificial dentin layer.Fig 37 Silane was applied to the composite surface and lightly air dried. An adhesive was applied to the composite surface and allowed to dwell for 10 seconds, air dried for 5 seconds, and light cured for 10 seconds using an LED curing light.39 QDT 2020 253The Injection Resin Technique: A Novel Concept for Developing Esthetic RestorationsFig 40 The resin composite was cured through the clear resin matrix on the facial and incisal aspects for 40 seconds each. Fig 41 Three-year follow-up of the composite resin veneer with an ideal anatomical form and color. Note the nuances in the incisal edge created by using the composite cutback technique. 4041The Injection Resin Technique: A Novel Concept for Developing Esthetic RestorationsCONCLUSIONIn the past, with the use of conventional resin composites and the direct bonding technique, the clinician had to com-bine the hybrid and the microfill because of the inequities of the materials of the time. However, polychromatism was achieved from this early concept of anatomic stratification with successive layers of different restorative composites of varying refractive indexes, shades, and opacities.52–57 This development of the polychromatic restoration from the inequities of the different composite resin systems (hy-brid and microfill) stimulated scientists, researchers, clini-cians, and manufacturers to explore and develop restorative materials that are not only applied in relationship to the natural tissue anatomy, but that have similar physical, me-chanical, and optical properties to that of tooth struc-ture.53,58 Today, these highly filled formulations of injectable composite materials can be used to improve adaption and color integration as a result of internal adaptation and the mixing of colors. As we compare the old and the new in history, only the material of the time with the proper tech-nique can provide optimal natural esthetic restorations. Knowledge of a concept of the past and a desire to create are limited by the materials clinicians have available to them for restorative procedures. Advancements in resin composite technology continue to improve the practice of dentistry. Continuing technological breakthroughs allow the clinician not only to comprehend the building blocks of the ideal composite restoration but also to implement and maximize the potential of new materials to attain more pre-dictable and esthetic results.Although new ideas and concepts continually flood the marketplace, one should not discount the power a new biomaterial may have on planning, design, or procedure. These developments promise to simplify the clinical appli-cations for esthetic and restorative techniques and ulti-mately improve the level of health care provided for the contemporary dental patient. Only the passage of time can determine the long-term benefits of these new flowable resin formulations.1 The clinical applications provided in this article demonstrate the potential of these flowable nanoparticle composite formulations to expand treatment options for a wider range of clinical situations. TERRY ET ALQDT 2020254REFERENCES1. Terry DA. Restoring with Flowables. Chicago, IL; Quintessence Pub-lishing: 2016.2. Terry DA, Geller W. Esthetic and Restorative Dentistry, ed 3. Chicago, IL: Quintessence Publishing, 2018.3. Bryce DM. Plastic Injection Molding: Manufacturing Startup and Management, vol V. Dearborn, MI: Society of Manufacturing Engi-neers, 1999.4. Terry DA. Developing a functional composite resin provisional. Am J Esthet Dent 2012;2:56–66.5. Terry DA, Powers JM. A predictable resin composite injection tech-nique, part I. Dent Today 2014;33:96,98–101.6. Terry DA, Powers JM, Mehta D, Babu V. A predictable resin compos-ite injection technique, part 2. Dent Today 2014;33:12.7. Terry DA, Leinfelder KF, Geller W. Provisionalization. In: Aesthetic and Restorative Dentistry: Material Selection and Technique. Houston: Everest, 2009.8. Heymann HO. The artistry of conservative esthetic dentistry. J Am Dent Assoc 1987:14E–23E.9. Gürel G. The Science and Art of Porcelain Laminate Veneers. Berlin: Quintessence, 2003.10. Baratieri LN. Esthetics: Direct Adhesive Restoration on Fractured Anterior Teeth. São Paulo: Quintessence, 1998.11. Donovan TE, Cho GC. Diagnostic provisional restorations in restor-ative dentistry: The blueprint for success. J Can Dent Assoc 1999; 65:272–275.12. Preston JD. A systematic approach to the control of esthetic form. J Prosthet Dent 1976;35:393–402.13. Yuodelis RA, Faucher R. Provisional restorations: An integrated ap-proach to periodontics and restorative dentistry. Dent Clin North Am 1980;24:285–303.14. Saba S. Anatomically correct soft tissue profiles using fixed detach-able provisional implant restorations. J Can Dent Assoc 1997;63: 767–768, 770.15. Terry DA, Geller W. Esthetic and Restorative Dentistry: Material Se-lection and Technique, ed 2. Chicago: Quintessence, 2013. 16. Bayne SC, Thompson JY, Swift EJ Jr, Stamatiades P, Wilkerson M. A characterization of first-generation flowable composites. J Am Dent Assoc 1998;129:567–577.17. Labella R, Lambrechts P, Van Meerbeek B, Vanherle G. Polymeriza-tion shrinkage and elasticity of flowable composites and filled adhe-sives. Dent Mater 1999;15:128–137.18. Tabassian M, Moon PC. Filler particle characterization in flowable and packable composites [abstract 3022]. J Dent Res 1999;79:213. 19. Baroudi K, Silikas N, Watts DC. Edge-strength of flowable resin- composites. J Dent 2008;36:63–68.20. Ikeda I, Otsuki M, Sadr A, Nomura T, Kishikawa R, Tagami J. Effect of filler content of flowable composites on resin-cavity interface. Dent Mater J 2009;28:679–685.21. Irie M, Tjandrawinata R, E L, Yamashiro T, Kazuomi S. Flexural perfor-mance of flowable versus conventional light-cured composite resins in a long-term in vitro study. Dent Mater J 2008;27:300–309.22. Estafan AM, Estafari D. Microleakage study of flowable composite resin systems. Compend Contin Educ Dent 2000;21:705–708.23. Attar N, Tam LE, McComb D. Flow, strength, stiffness and radiopacity of flowable resin composites. J Can Dent Assoc 2003;69:516–521.24. Gallo JR, Burgess JO, Ripps AH, et al. Clinical evaluation of 2 flow-able composites. Quintessence Int 2006;37:225–231.25. Duki´c W, Duki´c OL, Milardovi´c S, Vindakijevi´c Z. Clinical comparison of flowable composite to other fissure sealing materials: A 12 months study. Coll Antropol 2007;31:1019–1024.26. Baroudi K, Saleh AM, Silikas N, Watts DC. Shrinkage behavior of flowable resin-composites related to conversion and filler-fraction. J Dent 2007;35:651–655.27. Celik C, Ozgünaltay G, Attar N. Clinical evaluation of flowable resins in non-carious cervical lesions: Two-year results. Oper Dent 2007;32: 313–321.28. Kubo S, Yokota H, Hayashi Y. Three-year clinical evaluation of a flow-able and a hybrid resin composite in non-carious cervical lesions. J Dent 2010;38:191–200.29. Turner EW, Shook LW, Ross JA, deRijk W, Eason BC. Clinical evalua-tion of a flowable resin composite in non-carious class V lesions: Two-year results. J Tenn Dent Assoc 2008;88:20–24; quiz 24–25.30. Xavier JC, Monteiro GQ, Montes M. Polymerization shrinkage and flexural modulus of flowable dental composites. Mater Res 2010;13: 381–384.31. Gallo JR, Burgess JO, Ripps AH, et al. Three-year clinical evaluation of two flowable composites. Quintessence Int 2010;41:497–503.32. Yu B, Lee YK. Differences in color, translucency and fluorescence between flowable and universal resin composites. J Dent 2008;36: 840–846.33. Clelland NL, Pagnotto MP, Kerby RE, Seghi RR. Relative wear of flowable and highly filled composite. J Prosthet Dent 2005;93:153–157.34. Karaman E, Yazici AR, Ozgunaltay G, Dayangac B. Clinical evaluation of a nanohybrid and a flowable resin composite in non-carious cervi-cal lesions: 24-month results. J Adhes Dent 2012;14:485–492.35. Ilie N, Hickel R. Investigations on a methacrylate-based flowable composite based on the SDR technology. Dent Mater 2011;27:348–355.36. G-aenial Universal Flo: Editor’s Choice. Dent Advisor 2011:19.37. Sumino N, Tsubota K, Toshiki T, Shiratsuchi K, Miyazaki M, Latta M. Comparison of the wear and flexural characteristics of flowable resin composite for posterior lesions. Act Odontol Scand 2013;71:820–827.38. Rocha Gomes Torres C, Rêgo HM, Perote LC, et al. A split-mouth randomized clinical trial of conventional and heavy flowable compos-ites in class II restorations. J Dent 2014;42:793–799.39. Zaruba M, Wegehaupt FJ, Attin T. Comparison between different flow application techniques: SDR vs flowable composite. J Adhes Dent 2012;15:115–121.40. Lokhande NA, Padmai AS, Rathore VP, Shingane S, Jayashanker DN, Sharma U. Effectiveness of flowable resin composite in reducing microleakage: An In vitro study. J Int Oral Health 2014;6:111–114.41. Bayne SC, Taylor DF, Heymann HO. Protection hypothesis for com-posite wear. Dent Mater 1992;8:305–309.42. Turssi CP, Ferracane JL, Vogel K. Filler features and their effects on wear and degree of conversion of particulate dental resin compos-ites. Biomaterials 2005;26:4932–4937.43. Lim BS, Ferracane JL, Condon JR, Adey JD. Effect of filler fraction and filler surface treatment on wear of microfilled composites. Dent Mater 2002;18:1–11.44. Venhoven BMA, de Gee AJ, Werner A, Davidson CL. Influence of filler parameters on the mechanical coherence of dental restorative resin composites. Biomaterials 1996;17:735–740.45. Condon JR, Ferracane JL. In vitro wear of composite with varied cure, filler level, and filler treatment. J Dent Res 1997;76:1405–1411.46. Condon JR, Ferracane JL. Factors effecting dental composite wear in vitro. J Biomed Mater Res 1997;38:303–313. The Injection Resin Technique: A Novel Concept for Developing Esthetic Restorations QDT 202025547. Beatty MW, Swartz ML, Moore BK, Phillips RW, Roberts TA. Effect of microfiller fraction and silane treatment on resin composite proper-ties. J Biomed Mater Res 1998;40:12–23.48. Cadenaro M, Marchesi G, Antoniolli F, Davidson C, De Stefano Dorigo E, Breschi L. Flowability of composites is no guarantee for contrac-tion stress reduction. Dent Mater 2009;25:649–654.49. Yamase M, Maseki T, Nitta T, et al. Mechanical properties of various latest resin composite restoratives [abstract 464]. J Dent Res 2010; 89(special issue A).50. Yahagi C, Takagaki T, Sadr A, Ikeda M, Nikaido T, Tagami J. Effect of lining with a flowable composite on internal adaptation of direct com-posite restorations using all-in-one adhesive systems. Dent Mater J 2012;31:481–488.51. Terry DA. What other restorative material has so many uses: Flow-ables. Int Dent (African Ed) 2012;3:42–58. 52. Terry DA. Natural aesthetics with composite resin. Mahwah, NJ; Montage Media Corporation: 2004. 53. Terry DA. Restoring the incisal edge. N Y State Dent J 2005;71: 30–35.54. Terry DA, McLaren EA. Stratification: Ancient art form applied to re-storative dentistry. Dent Today 2001;20:66–71.55. Terry DA. Dimension of color: Creating high-diffusion layer with com-posite resin. 2003;24(suppl 2):3–13.56. Terry DA. Developing natural aesthetics with direct composite resto-rations. Pract Proced Aesthet Dent 2004;16:45–52, quiz 54.57. Dietshi D. Free-hand composite resin restorations: A key to anterior aesthetics. Pract Periodont Aesthet Dent 1995;7:15–25.58. Rinn LA. The Polychromatic Layering Technique: A practical manual for ceramics and acrylic resins. Carol Stream, IL: Quintessence, 1990:11–30. Register Now! The Superb Clinician Redefined: Acquire the SkillsAvishai Sadan, DMD, MBASillas Duarte, Jr, DDS, MS, PhDThe 26th International Symposium on Ceramics2020SHERATON SAN DIEGO HOTEL & MARINA | JUNE 12–14, 2020Register: www.quintpub.com/ISCSpanish Translation Availableattended by prosthodontists and lab technicians from around the worldFeatured Speakers:Leonardo BacheriniMarkus B. BlatzVictor ClavijoMauro Fradeani Iñaki GamborenaGalip GürelRicardo Mitrani Andrea Ricci Eric Van Dooren... and more!CALL: (800) 621-0387 (toll free within US & Canada) • (630) 736-3600 (elsewhere) 8/19FAX: (630) 736-3633 EMAIL: [email protected] WEB: www.quintpub.comQUINTESSENCE PUBLISHING CO INC, 411 N Raddant Rd, Batavia, IL 60510

Related Articles

Leave A Comment?