Restoring with Flowables. Douglas A. Terry

cannot become the only guiding light. It also requires an anatomical morphologic thinking of the individual characteristics of teeth through continued observation of intraoral and extracted teeth. In addition, the personalities of our patients and the importance of their individuality determine natural esthetics. Each patient, like each sunrise, is always unique and exciting.

      I hope that every clinician and technician who reads these pages finds the excitement and fulfillment I have experienced from the pursuit of excellence in dentistry. Although there are different mediums to restore the natural dentition, this book focuses on the use of flowable resin composites to develop natural esthetic restorations. From my travels and hands-on courses around the world, I have realized that this restorative medium has a universal significance. It is not a solution to all restorative considerations, but it can offer an avenue for understanding natural esthetics while providing solutions to many restorative and esthetic challenges. Many clinicians think of restorative materials as a replacement of tooth structure, and composite restorations allow the clinician to understand the importance of the color of the substrate, the optical properties of light, the different restorative materials and their thickness and how this influences color, and even the difference in refractive indices of the materials to tooth structure and how they interrelate. It is by having an understanding of the dimensions of color and developing our senses through observation of nature that we can begin to create more lifelike restorations. We can begin to appreciate and understand the important role of technicians and the information that they need to create natural esthetic restorations on stone models without faces.

      During my career in dentistry, I have researched in the laboratory and chairside, investigated resin composites, and worked with scientists, clinicians, and technicians around the world to develop techniques and materials with different hybrid composites to create natural esthetics. Many years ago, with the influence of Dr Vincenzo Musella and his inverse layering technique, I began a journey with flowable resin composites. Although the initial formulations were disappointing, at that same time, Dr John Burgess and Dr John Powers began studies with a new generation of universal flowables that showed promise. The clinical results in this book are a compilation of my endeavors. At the 3-year point, I was calling the restorations developed with the injectable technique transitional restorations. However, after discussions with Burgess and Powers regarding their clinical and laboratory findings with highly filled flowable resin composites, I learned that these restorations should be considered part of the armamentarium that the clinician can use in everyday practice.

      The purpose of this text is to provide the clinician and technician with information to develop and stimulate their powers of observation, imagination, evaluation, decision-making, and application of flowable resin composites. It provides a detailed presentation of the inverse injection layering technique, which can be used for provisional restorations, pediatric crowns, posterior restorations, provisional restoration repair, resurfacing existing resin restorations, and prototyping during interdisciplinary treatment such as crown lengthening, ovate pontic development, and development of the peri-implant region during implant therapy. The follow-up results shown in this book provide not only the technique and materials to develop natural-looking restorations but also sound evidence that these highly filled flowable materials have significance in improving the practice of dentistry.

      The text provides a detailed and scientific description of the evolution of flowable resin composites and the adhesive design concept and illustrates the same order of development that I use in my restorative procedures with the inverse injection layering technique. A detailed presentation of the various adhesive preparation designs, applications and restorative techniques, adhesive protocols, and finishing procedures is also provided. The scientific data and microscopic illustrations are intertwined to provide clarity and evidence for these procedures. In addition, chapter 2 provides a detailed description of the light-curing unit (by Richard Price) and the significance of understanding its mechanism for proper selection and use, which play an integral role in the adhesive design concept for optimal bonding. The majority of the book demonstrates the information presented in the early chapters through illustrated case presentation. My desire is that these clinical and laboratory procedures may provide another vantage point for the clinician and technician in their pursuit of excellence in restorative dentistry.

      My inspiration for writing this book and sharing photographs of these procedures can be attributed to my dear colleagues and students around the world who have expressed interest during presentations and hands-on courses. Compilation of this information would not have been possible without the dedication, persistence, and relentless hard work and long hours of my dear friend and personal assistant, Melissa Nix, who instilled confidence and offered continual support in writing and organizing this information. My mother’s great ability to persuade patients to return for follow-up photographs along with her support and dinners for the team have allowed us to complete this project. Furthermore, this project would not have seen the light of day without the dedication, relentless organization, persistence, and imagination of the Quintessence team. Also, I would like to express my gratitude to my team—Dr John Powers, Dr Jean-François Roulet, Dr Markus B. Blatz, Dr Alejandro James, Dr Wesam Salha, and technicians Victor Castro, Alex Schuerger, Jungo Endo, August Bruguera, and Olivier Tric—for their patience, commitment, and midnight hours to complete this endeavor. More importantly, I would like to thank my patients without whom this project would not have been possible.

      Of special significance in my life is my teacher, Maestro Willi Geller, whose friendship and early-morning conversations in the cellar have expanded my understanding and vision of esthetic dentistry and, more importantly, of life. And of course I must thank my colleagues in Oral Design for their friendship and brotherhood. Finally, I give special thanks to my Creator who makes me realize that teeth are simple in His hands but so complex in mine.

Contributors

      Scientific Reviewers and Contributors

      Irfan Ahmad, BDS

      Alejandro James, DDS, MSD

      John M. Powers, PhD

      Richard Price, BDS, DDS, MS, PhD

      Jean-François Roulet, DDS, PhD

      Clinical and Laboratory Contributors

      Venkatesh Babu, BDS, MDS

      August Bruguera, CDT

      Victor E. Castro, CDT

      Jungo Endo, RDT

      Kim S. Gee, DDS, MS

      Bassam Haddad, CDT

      Yoshihiro Kida, DDS, PhD

      Usha H. L., BDS, MDS

      Deepak Mehta, BDS, MDS

      Alireza Sadr, DDS, PhD

      Wesam Salha, DDS, MSD

      Ashwini Santosh, BDS, MDS

      Alex H. Schuerger, CDT

      Olivier Tric, MDT

      Hiroyuki Wakatsuki, DDS

      Francisco Zarate, DDS, CDT

Historical Perspective

The year 1996 was an exciting one all over the world. The Dow Jones Industrial Average reached a record high of 6,000; the Nobel Prize in Chemistry was awarded to Robert F. Curl Jr, Harold W. Kroto, and Richard E. Smalley for their discovery of fullerene, a molecule composed entirely of carbon; General Motors launched the first electric car of the modern era; divers discovered the ancient port of Alexandria; eBay opened its doors for business;