Simplifying Quadrant Dentistry Using a Single-Shade Composite

Matching shades historically has been one of the most significant challenges associated with direct composite restorations,^1-3 especially when utilizing quadrant dentistry for extensive restorative treatment over the course of several weeks. However, direct composite restorations often are the best way to minimize both the invasiveness and cost of the procedure, both of which patients typically prefer to more complex treatment plans involving indirect restorations and/or orthodontic therapy.

Even in cases of amalgam replacement, clinical research indicates that direct resin-based composites offer a reliable and low-cost treatment option.⁴ For Class 5 restorations, specifically, research shows that the occlusal load strength of composite materials is greater than that of glass-ionomer cement.⁵

Strategies for shade matching with direct composites can be labor intensive and technique sensitive. For example, the use of custom shade guides and an intraoral mockup, while reported to be effective, falls into this category.⁶ Digital photography with polarizing filters also can be utilized.⁷ Photography also can be combined with numeric shade quantification.⁸

In recent years, single-shade composites have emerged as a viable, simpler alternative.⁹ Resin composites with increased color and translucency adjustment have been found to potentially simplify shade selection and facilitate challenging and complex color-matching situations.¹⁰

The following case report demonstrates how a single-shade composite was used to simplify the workflow for a case in which direct restorative treatment was provided in each quadrant of the mouth over the course of four visits.

A 62-year-old female patient presented with a complaint about discoloration on all of her teeth. She had undergone chemotherapy and surgery for breast cancer, a hip replacement, and a colon resection for diverticulitis in recent years, and she was taking a number of medications, including anastrozole, metoprolol succinate, pantoprazole, trazodone, and sertraline. A clinical evaluation found multiple carious lesions present throughout her mouth, along with leaky composite restorations (Figure 1 through Figure 3). Radiographs revealed various stages of decay, chipping on teeth Nos. 7 through 10 and 23 through 26, and mandibular anterior crowding. No periodontal or endodontic concerns were identified.

Preserving Tooth Structure

The clinician noted to the patient that orthodontic therapy could position her teeth better, and that veneers or crowns were also an option to correct some of the tooth positions. The patient, however, was not interested in those options because her primary concern was the discoloration. Finances were a concern as well. The clinician acknowledged that addressing the rampant decay was the primary clinical priority and that function was less of a problem. Additionally, indirect restorations could still be an option in the future.

Accordingly, the clinician prioritized preserving tooth structure and improving esthetics in the proposed treatment plan, which entailed restoring all of the carious lesions with direct composite and keeping as much tooth structure as possible. The patient wanted to have the entire treatment accomplished in one visit, but the clinician advised that the procedure would be quite time-consuming and could be too traumatic for her. She subsequently accepted a treatment plan that included four visits, with one quadrant being restored during each visit. Each quadrant in this case was deemed equally problematic, so the clinician chose to start in the maxillary right quadrant and finish in the mandibular left quadrant.

In the past, this strategy would have required the careful recording of numerous details, such as the different opacities and modifiers used and the thickness and location of each layer, in an attempt to match shades from one quadrant to another. Quadrant dentistry can be like painting a house: Purchasing the same shade of paint in two separate visits can result in slight mismatching. Exceptional clinical skills are required to blend different layering techniques for a polychromatic approach to shade matching.

A single-shade composite can alleviate this issue, however. While an understanding of layering techniques, opacities, and translucencies still is important, the restorative process can be significantly simplified and the margin for error minimized with a single-shade composite.^9,10 The author uses a single-shade composite for approximately 95% of the direct restorative cases in his practice now, including very challenging Class 3 and Class 4 restorations. The present case involved mostly Class 5 restorations, so the author was confident it would be successful.

One Quadrant at a Time

Starting in the maxillary right quadrant, the author removed the decay and old restorative material (Figure 4). A retraction cord was placed to control gingival fluid and separate the gingiva from the tooth, improving visibility and access to the immediate area; the author utilizes this strategy for all Class 5 restorations when removing carious lesions.

The restorative materials were placed freehand; no wax-up or preoperative models were necessary before the bonding agent (Tokuyama Universal Bond, Tokuyama Dental, tokuyama-us.com) was applied. A one-shade flowable composite (OMNICHROMA FLOW, Tokuyama Dental) was applied around the margins to ensure they were sealed; in the author's experience, flowable composite reduces the chances of nicking the gingiva and creating bleeding. A one-shade universal composite (OMNICHROMA, Tokuyama Dental) was then utilized for the rest of the restorations (Figure 5).

The author sometimes uses a supplementary resin-based material (eg, OMNICHROMA BLOCKER, Tokuyama Dental) for a lingual layer to prevent shade-matching interference on cases with dark stains or dark dentin, but that was not necessary in this case as the preparations were relatively clean. The single-shade nature of the composites also ensured that the flowable and universal materials matched ideally, with the only difference being consistency.

When the patient returned for the second visit 1 week later, the restorations from her first visit were intact with no staining; the only changes were slightly traumatized gingival areas due to the polishing of the margins, but by the third visit, those areas were completely healed. The process and results for each subsequent quadrant were the same (Figure 6 through Figure 11), with a total of 25 teeth being restored: seven in the mandibular right quadrant and six in each of the others (Figure 12). The clinician checked around the margins for leaks or stains and found no problems. The patient was very happy with both the experience and the results, and she declined any further treatment, such as veneers.

Most, if not all, dentists want to simplify procedures and build efficiency in their practice without sacrificing quality. They also want to identify themselves with beautiful restorations, and regardless of one's innate artistic talent or skill level, a single-shade composite can aid clinicians in achieving excellent esthetic outcomes. Even for the most skilled clinician, a single-shade composite can save valuable time. The shade blending is seamless, and, in the author's experience, the clinical results are outstanding.

The structural color of the single-shade composite utilized in this case combined with the reflected color of the surrounding teeth to attain ideally matched esthetics. The material initially presents as white opaque, which can help identify and eliminate the excess of composite on unwanted areas before curing, which in turn can reduce finishing time. Smart Chromatic Technology (Tokuyama Dental) uses the structural color concept, wherein the material itself weakens or amplifies wavelengths of light to blend with tooth color,¹¹ unlike other composite resin systems that add dyes or pigments to color the material.¹²

Utilizing a single-shade composite also reduces inventory, which in turn can reduce waste as composites have expiration dates. The composite utilized in this case matches all 16 VITA classical tooth shades (VITA North America, vitanorthamerica.com), from A1 to D4, according to the manufacturer as well as the author's experience. The author uses it for nearly all composite cases, including anterior or posterior, simple or complex, Class 5, core buildup, screw-access hole cover-up, and diastema closure. The consistency is also a benefit in terms of handling, as the material's moderate stiffness makes it easy to manipulate, contour, polish, and shine.

Direct restorative quadrant dentistry is likely to remain a central part of most dental practices for years to come, and single-shade composites that simplify shade-matching can make the provision of treatment easier for dentists while improving patients' results.

This article was commercially supported by Tokuyama Dental.

Juan Uribe, DDS
Private Practice, Sioux City, Iowa