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Cosmetic Dentistry

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Finishing and polishing criteria for minimally


invasive composite restorations
Brian LeSage, ddS, Fagd, FaaCd

to achieve the benefits that composite restorations can provide, it technique- and material-sensitive. this article describes the
is incumbent on dentists to understand the importance of proper proper composite material placement considerations, as well as
finishing and polishing techniques and how to incorporate them finishing and polishing techniques and materials, for providing
appropriately into everyday practice. a smooth surface finish is highly esthetic, long-lasting restorations. By incorporating such
clinically necessary because the presence of surface irregularities protocol into their everyday practices, dentists can increase the
from poor finishing and polishing can lead to staining, plaque long-term esthetic and plaque-resistant predictability of direct
retention, gingival irritation, recurrent caries, abrasiveness, wear composite restorations.
kinetics, and tactile perception by the patient. However, finishing received: may 27, 2011
and polishing procedures for direct composite restorations are accepted: June 24, 2011

C
ompared to earlier generations composites for direct restorations reduction in roughness and scratches
of direct restorative materials, helps to minimize some of these typically created by finishing instru-
todays composite resins pro- risks and eliminates those associated ments.6,7 Properly finishing and pol-
vide improved strength, resistance with mercury in amalgam.4,5 ishing composite restorations offers
to wear, and esthetics, and have Further, the newer composite many benefits that ultimately lead
revolutionized the concept of mini- formulations demonstrate high pol- to a predictable, long-lasting, and
mally invasive dental treatment.1 ishability for maintenance over the highly esthetic result.6,7 Regardless of
One of the most versatile materials, life of the restoration. In addition the cavity class or location, a smooth
composites can be used for direct to contributing to esthetic value surface finish is clinically necessary
restorations, build-ups, cementation, and appearance, optimal surface because the presence of surface
diagnostic mock-ups, gingival stabili- polishability has been proven to irregularities from poor finishing
zation, provisionals, and prototypes.2 reduce staining and plaque accu- and polishing can lead to staining,
Composites are available in many mulation while minimizing wear.3,6 plaque retention, gingival irritation,
forms, including hybrid, microfill, Studies have shown that improper recurrent caries, abrasiveness, wear
and nanofilled/nanohybrid formula- finishing and polishing can lead kinetics, and tactile perception by
tions, and the materials have evolved, to gingival irritation, recurrent the patient.6,7
with the science behind them solving caries, abrasiveness, and tactile For example, in the oral environ-
many of the problems experienced perception.6,7 Therefore, to obtain ment, bacterial survival depends
with materials of the past.1 the added benefits that composite on the ability of bacteria to attach
Earlier generations of composite restorations can provide, clinicians to hard surfaces like teeth, filling
materials presented challenges, such must understand the importance materials, dental implants, and
as polymerization shrinkage and the of proper finishing and polishing prostheses.8 Clinical studies have
potential for marginal leakage result- techniques and how to incorporate demonstrated that surface roughness
ing in the development of secondary them into everyday practice. greatly impacts the initial adhesion
caries.3 The benefits of newer formu- and retention of microorganisms
lations also eliminate many prob- Finishing and polishing on hard surfaces; surfaces that are
lems associated with amalgam.4,5 composites rougher typically retain more plaque
Historically, amalgams could result By definition, finishing is gross than those that are smoother.8
in cusp fractures, increased rates contouring or reduction to obtain Additionally, it has been suggested
of secondary caries, and potential the required anatomy for a restora- that the threshold surface rough-
toxicity from mercury.4,5 Using tion, while polishing refers to the ness where no further reduction

422 November/December 2011 General Dentistry www.agd.org


in bacterial accumulation can be smooth and feel as natural as the The literature indicates that
obtained is 0.2 .9 However, surface surrounding dentition.6 nanofilled composites have been
roughness above this threshold has Overall, proper finishing and successfully polished using respec-
been correlated with an increase in polishing allows clinicians to tive combinations consisting of
plaque retention, as well as the inci- achieve proper marginal adaptation 40 m diamonds, 42 m silicon
dence of secondary caries, gingival of the restorations and maintain carbide polishers, 6 m silicon car-
irritation, and loss of esthetics due to natural surface luster and contours bide polishers, and polishing paste.20
discoloration.8,9 In cases of patients necessary to mimic the surrounding Additional research suggests that
with poor oral hygiene, these issues dentition.13 However, finishing and diamond polishing points, diamond
often are exacerbated and can lead polishing procedures are technique- paste, and urethane-backed alumi-
to the onset of subclinical or clinical and material-sensitive. Just as num oxide disks also produce clini-
gingival inflammation.8 classes of composite materials dem- cally acceptable levels of smoothness
Proper finishing and polishing onstrate different esthetic qualities during the polishing process.21
also reduces the incidence of wear and tensile strengths, polishability
and marginal breakdown as well and maintainability in the long- Composites
as preventing the buildup and term can vary, based on inherent Adhesively bonded composite
retention of plaque and promoting particles and filler size.7,17 restorations demonstrate esthetically
the oral health of the soft tissues Research has demonstrated that acceptable results that conserve
surrounding the restorations.9,10 composite filler size and the systems sound tooth structure and offer the
Studies have shown that unpolished used to finish and polish restora- potential for tooth reinforcement.
restorations demonstrate increased tions influence surface roughness The least invasive and most predict-
incidences of friction and, therefore, and staining. Study results indicate able restoration of teeth to normal
increased wear of opposing enamel that composites polished with form and function, tooth-colored
on occlusal contact areas.11,12 Con- finishing systems from the same composites provide patients and
tributing to this wear, improper manufacturer exhibit less surface dentists with cost-effective and long-
finishing and polishing could cause roughness and staining.17 Hybrid lasting solutions for a variety of indi-
topographical changes and can composite resinswhich contain cations. There are, however, certain
introduce subsurface microfractures matrix and filler particles of varying criteria that composites must meet.
in the composite.13-15 For example, hardness, as well as a combination In general, composites should
when finishing composite restora- of large and small particlesachieve mirror natural tooth structure in
tions, carbide-laminated burs a smooth, flat surface when finished color and translucency, withstand
and regular grit diamonds do not with 12- or 30-fluted carbide function in high stress-bearing
produce the marginal integrity that burs.18,19 Using diamond burs could areas over time, have seamless or
fine, extra-fine, and ultra-fine finish- lead to crazing, composite loss, and undetectable margins, and allow
ing diamonds do; coarse diamonds surface irregularities that can affect for a polish that can be maintained
can remove excess composite mate- a restorations wear resistance.16,18 over the life of the restoration.
rial and could result in composite Polishing hybrid composite restora- Now available in a variety of
surface crazing or cracking.14,16 tions is best accomplished with formulations for different indica-
The manner in which direct aluminum oxide polishing pastes.18 tions, todays composites provide
restorations are finished and Microhybrid composites achieve the many added benefits, specifically in
polished also affects patient com- smoothest surface when polished finishing and polishing, compared
fort.6 An improperly finished and with silicone polishing systems.7 to the conventional materials of the
polished surface remains rough Microfill composites can suffer past. For example, hybrid or micro-
and negatively affects the patients fractures and other damage when hybrid compositesuniversally
tactile perception of a restoration.6 finished with carbide burs. Micro- referred to as microhybridsare
Research has shown that a change filled composites are more appro- heavy-loaded materials that dem-
in surface roughness of only 0.3 m priately finished with wet finishing onstrate high strength and opacity
can be detected by the patient with diamonds.18 Restorations created similar to that of natural dentin
the tip of the tongue.6 Therefore, with these composites are ideally and enamel.22,23 Additionally,
to ensure patient comfort with the polished with 1 m grit aluminum microhybrids are less likely to
restoration, the surface should be oxide polishing pastes.18 chip or fracture because they

www.agd.org General Dentistry Special Cosmetic Dentistry Section 423


Cosmetic Dentistry Finishing and polishing criteria for minimally invasive composite restorations

An issue with this class of have illustrated that nanofilled


composite materials, however, materials exhibit the lowest
is their inability to maintain a incidences of roughness and wear
polish; they tend to lose surface after finishing and polishing and
gloss over time and are less stain- on recall when compared to other
resistant than other generations of classes of dental composites.29 This
composite.17,22-24 Filler particles in class of composites demonstrates
microhybrids have been shown to the smoothest polished surface and
Fig. 1. slightly underexposed before showing pluck out during the polishing lowest surface roughness, regard-
the depth of color, chroma, and translucency. process and normal lifespan in the less of the polishing system used.7
oral cavity, and, as a result, restora- Additionally, with a greater resis-
tions can lose gloss or luster over tance to wear, nanofilled materials
time.24 Studies have demonstrated offer the most ideal mechanical
that although it might not be as and optical properties.27,28 Further,
easy to maintain a polish as it is for nanofilled composites display
other classes of composites, hybrids opacity similar to that of natural
tend to be resistant to surface enamel and dentin, with translu-
microfractures during finishing, cency similar to that of enamel.27,28
for reasons that are believed to be Demonstrating high strength,
directly related to the presence of nanofilled composites also are
Fig. 2. putty matrix trimmed to the facial incisal inorganic fillers and their ability to less likely to chip in high-stress
line angle, shown here on tooth No. 8 using a absorb energy.17,25 areas.27,28 The only true disadvan-
customized typodont. In comparison, microfill compos- tage to nanofilled composites is the
ites demonstrate high polishability lack of in vivo long-term studies,
that lasts for the long term.22,23 because the material science is
Many authors have gone so far as relatively new.27-29
to deem the smoothness achieved
with microfill composite materials Composite placement
as permanent.25 A direct effect considerations to enhance
of the inclusion of colloidal silica the finishing and
particles in the polymer matrix, polishing processes
small fillers and a resin-rich surface Using a typodont with denture
promote an excellent and main- teeth (Premium teeth, Heraeus
Fig. 3. putty matrix with first increment of the tainable polish.26 Additionally, Kulzer, Inc.), the following proto-
3-D characterized build-up showing lingual microfills demonstrate a higher col demonstrates proper material
enamel increment. (Note that the preparation resistance to wear and abrasion placement considerations and
to the free gingival margin and removal of the and a translucency that is similar finishing and polishing techniques
incisal edge in this case was performed for to that of natural enamel.22,23 and materials for providing highly
teaching purposes only. rarely would teeth This class of composites lacks the esthetic, long-lasting restorations
need to be prepared this aggressively.) strength required in functional for teeth No. 7 and 8 (Fig. 1). By
areas and often translucency is too incorporating such protocol into
great.22,23 Despite its high polish- everyday practice, dentists can
ability, this class of composites increase the long-term esthetic and
demonstrates a higher susceptibil- plaque-resistant predictability of
demonstrate excellent strength and ity to stain than newer generations direct composite restorations.
the ability to withstand functional of composite.17 After developing a proper
stresses.22,23 Microhybrids blend The newest class of composite treatment plan, including iden-
with the natural dentition to create materials, nanofills have the tification of patients for whom
an esthetic restoration, allowing the potential to maintain greater composite restorations would be
practitioner to mimic dentin and strength, long-term polishability, contraindicated (for example, those
enamel morphology.22,23 and stain resistance.17,27,28 Studies who have occlusal issues or bite

424 November/December 2011 General Dentistry www.agd.org


Fig. 4. Completed 3-D layer achieved to Fig. 5. articulating paper aids with and Fig. 6. Using the detailed finishing and
full contour using Bisco aelite composite confirms correct outline form, line angles, and polishing sequence results in the correct color,
system (all-purpose Body & aelite axial inclination when establishing primary and translucency, luster, and polish.
enamel esthetic). secondary anatomy.

their fingernails), selection of Proper handling


the proper composite class, and Whether the composite material is
evaluation of the patients existing placed on the facial surface, inter-
dentition, utilize the proper tools proximally, or around the gingival
and protocols to ensure the best tissues, the manner in which the Fig. 7. Before image of tooth No. 7 demonstrat-
results. This involves taking steps composite is handled can greatly ing the starburst bevel in the rare instance
during the placement process that affect the appearance of a restora- where preparation might be required to allow
will lead to the least amount of tion. To handle composites properly, for an undetectable restoration.
adjustment to the restoration once ensure that no air voids are present
the composite has been built up. in the increments being placed.
For example, polyvinyl siloxane Further, placing smaller increments
matrixes provide placement limits predictably, instead of placing bulk
in terms of volume of composite quantities of material at once, helps between where the etch-and-bevel
material three-dimensionally and to ensure proper control of the ends. To ensure the best results,
can be used as adjuncts to help material. Sensitivity can be elimi- rubber wheels and polishers should
maintain the proper incisal length nated by completely curing each not be used on the margins,
and edge thickness (Fig. 2 and composite increment and allowing because the rubber tends to become
3).30,31 By doing so, finishing and the restorations to reach their full easily embedded in this area.13,35,36
polishing will be predictable and photocure potential.
much simpler (Fig. 46). Finishing and polishing
Undetectable margins technique considerations
Reduction guides To create undetectable margins Once the composite has been placed,
When creating direct resin restora- in the esthetic zone that are not a proper finishing and polishing pro-
tions, preparation is of the utmost only esthetic but also resistant to tocol ensures a quality restoration. By
importance (Fig. 7). Overly aggres- leakage, a starburst bevel should be understanding the following caveats
sive preparation for the sake of used, followed by etching beyond of composite finishing and polishing,
esthetics often leads to unnecessary the bevel.32-35 The outer layer of a predictable and long-lasting result
loss of tooth structure.32 Although composite must be rolled while can be achieved without concern for
necessary in some extreme cases, this wearing clean gloves to improve recurrent issues and further removal
loss of tooth structure typically can sculptability and prevent voids. The of healthy tooth structure.37
be avoided with the use of a reduc- material should then be placed,
tion guide.32 Further, reduction supercured, and allowed to relax Gross contour (anterior
guides have proven useful in con- for at least five minutes to allow the restorations)
trolling midlines in cases requiring material to settle.33-35 To properly finish composite
diastema closure and when complex Next, the margin should be after successful layering and 3-D
bonding is required.32 addressed and finished back anatomical construction (using an

www.agd.org General Dentistry Special Cosmetic Dentistry Section 425


Cosmetic Dentistry Finishing and polishing criteria for minimally invasive composite restorations

Fig. 8. a red-stripped, flame-shaped, fine Fig. 9. a yellow-stripped, flame-shaped, Fig. 10. a green-stripped, coarse diamond is used with
diamond is used to establish outline form extra-fine diamond further develops the very light pressure and an electric handpiece to place
and facial planes. proper contours. texture in a prepolished direct composite restoration.

handpieces (for example, NSK elec-


tric handpieces, Brasseler USA).
Again, to simplify this process,
the matrix should be used and
the composite should be layered
carefully to ensure accurate and
precise placement.1 At this stage,
Fig. 11. a coarse disc (Bisco Composite Disc system) is used Fig. 12. a medium disc is used to the line angles will become more
to establish transition line angles and incisal edge planes. initiate finishing protocol. well-defined and the clinician
should have a logical, sequential,
and predictable method of finishing
and polishing which ultimately will
lead to a restoration surface that
incisal putty matrix), the restora- yellow-stripped diamond (863EF- will accept and reflect light.12 Fur-
tion should be evaluated for similar 012) (Fig. 8 and 9). Note that ther, the surface should not display
harmony and balanced width and research indicates the lowest inci- voids, defects, stains, or pits.
length across the central incisors, as dence of defective margins occurs Prior to finalizing and mirroring
well as to balance with the laterals when all three types of finishing the natural dentition in luster,
and canines. The flap door facial diamonds (fine, extra-fine, and coarse and medium discs are used
matrix often proves useful in ensur- ultra-fine) are used.14 which, in many cases, will lessen
ing that a proper facial contour has any of the initial texture placed in
been achieved. Texture and anatomy the restoration (Fig. 11 and 12). A
Removal of excess materials and Texture must be imparted on well-polished material can be the
recontouring is performed first. the restoration and the tertiary outcome, so the texture can be reap-
To that end, a variety of finish- anatomy must be fine-tuned plied to play into realism.
ing devices have been proposed, to impart realism. Texture can
including coated abrasive disks, be placed using a multitude of Polishing
carbide burs and stones, fine dia- armamentarium, including gross Achieving the appropriate luster
mond burs, and resin- or silicone- coarse diamonds (for example, and polish on a composite restora-
impregnated burs.7,14 No. 6856L-020, UCLA Anterior tion is crucial because it contributes
Gross contours can be established Aesthetic Restorative Kit) (Fig. 10), to factors other than esthetics. A
using a red-stripped diamond No. 557 cross-cut burs, and rubber proper polish that lasts for the long
(8863-012, UCLA Anterior points and wheels used both term reduces the adhesion of bac-
Aesthetic Restorative Kit, Bras- vertically and horizontally, prefer- teria and plaque to the restoration
seler USA), coarse discs, and a ably and most easily with electric and prevents marginal leakage.

426 November/December 2011 General Dentistry www.agd.org


Additionally, when polished
correctly, composite restorations
demonstrate improved resistance to
staining. The life of the restoration
also will be extended by eliminat-
ing the need for early removal
purely for esthetic purposes.
To complete polishing of esthetic
direct composite restorations, a
system from the same manufac- Fig. 13. a goat-hair brush with composite Fig. 14. 3-D characterized composite, mirroring
turer that incorporates polishing polishing paste is used to achieve and emulating the denture tooth (Heraeus
paste, points, cups, and wheels and appropriate luster. Kulzer, inc.) in contour, color, and luster.
silicone brushes is recommended.17
The use of assorted polishing
instruments has been shown to
produce variations in surface
roughness after polishing.7 To
obtain the final luster and polish, a
goat-hair chamois brush (Brasseler
USA) or a regular chamois brush
with polish paste should be used.
When using goat-hair chamois
brushes, they should be wet and Fig. 15. preoperative view showing the Fig. 16. retracted preoperative view showing
well-coated with polishing paste patients diastema. the diastema and incisal edge wear.
(Enamelize, Cosmedent, Inc.) with
firm pressure initially, then used
dry with adequate polishing paste
at high speed to complete restora-
tion polishing (Fig. 13). Again,
run the brush vertically and hori-
zontally. During this process, fine
or medium discs again might be
needed, after which the goat-hair
brush is used to finalize the polish-
ing protocol (Fig. 14). Fig. 17. Close-up view showing maverick Fig. 18. View of the restorations the day
coloring and polychromicity built into the after completion, showing an improved
Verify occlusion restoration using the nanohybrid composite. esthetic result.
The final step in any direct compos-
ite restoration, occlusion should be
verified one last time after finishing
and polishing.
a nanohybrid universal composite Summary
Case report (Venus Diamond, Heraeus Kulzer, In the case described above, the cli-
A 29-year-old woman came to Inc.) was placed according to a 3-D nician was able to restore function
the clinic unhappy with the characterization layering technique and esthetics by following place-
space between teeth No. 8 and 9 and the finishing and polishing ment and finishing and polishing
(Fig. 15 and 16). With no removal protocol described in detail above protocols noted here. By doing so,
of tooth structure and only an addi- was followed. The final restorations the risk for recurrent issues such as
tive direct technique, composite mirrored each other and the sur- secondary caries, gingival inflam-
restorations were placed to close the rounding dentition enhanced the mation, staining, plaque buildup,
diastema (Fig. 17). Using a matrix, patients smile (Fig. 18). and marginal leakage, among

www.agd.org General Dentistry Special Cosmetic Dentistry Section 427


Cosmetic Dentistry Finishing and polishing criteria for minimally invasive composite restorations

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428 November/December 2011 General Dentistry www.agd.org