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Aesthetic Maintenance Protocol in Cosmetic Dentistry
Aesthetic Maintenance Protocol
in Cosmetic Dentistry
Wynn H. Okuda, DMD
The dental hygienist plays an important role in maintaining Depending on their periodontal/hygiene requirements, the
cosmetic restorations; therefore, it is imperative that she or patient is educated on the frequency and type of recare
he understands the properties and maintenance protocols visits necessary. At the recare visit, the aesthetic hygienist
of each restoration material. Culp et al reviewed the prop- and the cosmetic/restorative clinician can provide aesthetic/
erties of ceramic materials used in cosmetic dentistry in a restorative maintenance procedures in addition to routine
previous issue of the Journal (Culp L, McLaren EA, Ritter RG, hygiene care.
Roberts M, Trinkner T. Selection of Ceramic Materials In caring for cosmetic restorations, it is important for
for Aesthetics and Function. J Pract Hyg 2002;11:13-16). dental professionals to know the difference in materials
This article addresses the care of ceramic restorations as well employed. There are profound differences in restorations
as that of resin-based materials. It is determined that by uti- that are resin-based as compared to porcelain substrate-
lizing proper finishing and polishing techniques for both based. In addition, within the family of resins, there are
composite resin and porcelain, the aesthetic hygienist con- different types of composite resins based on type and
tributes greatly to the success of cosmetic dentistry. amount of filler particle within the resin-based restorations.
Each of these materials needs to be maintained differently.
In cosmetic dentistry, it is imperative to understand how
to create the correct aesthetic end results (Figure 1). Long-
term success with cosmetic dental restorations, however,
is dependent upon the understanding of the importance
of proper maintenance of resin and porcelain bonded
restorations by the entire clinical team.
Commitment to long-term success commences before
the actual treatment is started. The patient must be informed
of his or her responsibilities to the new cosmetic restora-
tions prior to the start of treatment. It is important to estab-
lish protocols so that proper patient education is provided.
Wynn H. Okuda, DMD, is an accredited member and National
President of the American Academy of Cosmetic Dentistry.
He is also the Aesthetic Dentistry Expert to the National Dental
Expert Advisory Board of the Academy of General Dentistry,
accomplished author and international lecturer, and a Fellow
of the International College of Dentists. Dr. Okuda has been
the editor of numerous award-winning professional dental
publications, including the Journal of the American Academy
of Cosmetic Dentistry. He practices cosmetic, implant, and Figure 1A. Pretreatment smile shows lack of good propor-
tion in the smile. 1B. Posttreatment shows correction of
restorative dentistry in Honolulu, Hawaii. He may be reached the aesthetic problems with gingival sculpting and
at his website at: www.cosmeticdentistryhawaii.com. conservative porcelain veneers.
September/October 2002 31
Aesthetic Maintenance Protocol CE 5
Figure 2. Increase in stain is evident along existing anterior Figure 3. Silicon carbide impregnated polishers, such as
hand-sculpted composite veneers. Jiffy brushes (Ultradent), can be effective to polish along
most contours without abrading composite restorations.
Resin-Based Aesthetic Restorations Discus Dental, Culver City, CA) are microparticle-based
Resin-based restorations —such as anterior direct composite resins. Due to their minute particle size, microfills easily
resin Class III, IV, V, as well as Class I and II posterior direct regain surface luster when utilized in proper polishing pro-
composite resin restorations —need more attention to main- tocol. Microfills are primarily used for Class III restorations,
tenance during their life span. In comparison to porcelain, Class V restorations, diastema closures, and hand-sculpted
direct composite resin-based restorations lack strength. composite veneers.
Because of this, chipping, staining, and marginal integrity Although microfills recapture a high shine upon
breakdown are all inevitable outcomes (Figure 2). With polishing, they are also easy to “ditch” or scratch upon
proper technique and proper selection of finishing and remargination or at the area where the restorative mater-
polishing mediums, however, resin restorations can be ial meets the tooth. As a result, a high level of care is
refurbished and maintained for about three to nine years. needed during aesthetic maintenance procedures. Utilizing
Prior to the initiation of aesthetic maintenance proce- a sequence of finishing disks and finishing strips (Table 1),
dures, it is important to know what type of composite chips and stains on all existing composite restorations
resin was originally utilized to restore the tooth. There are can be modified. In addition, marginal integrity can be
basically three categories, depending on the filler size and recaptured utilizing these products. Thereafter, polishing the
content, in which practically all resin restorative materials microfill restorations with rubber polishing cups, wheels,
can be grouped: microfill resins, hybrid resins, and micro- and points (eg, Astropol, Ivoclar Vivadent, Amherst, NY;
hybrid resins. FlexiWheels, Cosmedent, Chicago, IL; Jiffy Polishing Cups/
Brushes, Ultradent Products, South Jordan, UT) can recre-
Microfill Resins ate a high shine (Figure 3).
Microfill resins (eg, Renamel Microfill, Cosmedent, Chicago,
IL; Micronew, Bisco, Schaumburg, IL; Amelogen Microfill, Hybrid Resins
Ultradent Products, South Jordan, UT; Matrixx Microfill, In comparison, hybrid composite resins are the most
difficult to polish and to regain a high finish during
maintenance procedures. Hybrid resins are composed of
Table 1 large particle fillers of varying types. The filler particles
Tools for Aesthetic Maintenance of
Microfill Resin Restorations
Type Product Manufacturer Table 2
Finishing Disks FlexiDisc Cosmedent, Chicago, IL
Super-Snap Shofu, San Marcos, CA
Polishing Pastes for
Microhybrid Resin Restorations
Sof-Lex Disks 3M, St. Paul, MN
Finishing Strips FlexiStrip Cosmedent, Chicago, IL
Epitex GC America, Alsip, IL
Extra Fine Dentsply/Caulk, Milford, DE
Sof-Lex 3M, St. Paul, MN
Enamelize Cosmedent, Chicago, IL
Polishing Strips Diamond Polishing Paste Kerr, Orange, CA
32 The Journal of Practical Hygiene
Figure 4. Proper polishing pastes help the clinician regain Figure 5. Proper maintenance by the aesthetic clinician
a high luster in maintaining composite restorations. can provide long-term success in composite resins.
generally consist of glass (1.0 µm – 3.0 µm) and silica To polish all resin-based restorations to a high shine,
(0.04 µm). It is this combination of particles that gives true it is important to finish the polishing protocol with polishing
hybrid composite resins (eg, Herculite XRV, Kerr, Orange, pastes. Although polishing disks, wheels, cups, and points
CA; Renamel Hybrid, Cosmedent, Chicago, IL) the best create a smooth finish, a glass-like finish can only be
strength of all categories of resins. Hybrid resins are attained by utilizing an aluminum oxide or microparticle
commonly utilized for Class IV anterior restorations and diamond polishing paste (Figure 4). Polishing pastes help
Class I or Class II posterior restorations. to remove surface debris and to recapture a high shine
However, these varying large particle sizes make along all surfaces without ditching or scratching (Figure 5)
a high luster polish in hybrid resins the most difficult (Table 2). In addition, carrying the polishing pastes into the
to achieve and maintain. The best polishing system for interproximal areas with floss helps to polish the proximal
both hybrid resin and microhybrid resins are diamond- surfaces without abrading and opening proximal contacts.
impregnated polishers. Various polishing systems (eg, Due to the varying types of composite resins, it is
D-Fine Diamond Polishing, Clinician’s Choice, New understandable that the aesthetic hygienist needs several
Milford, CT; Astropol, Ivoclar Vivadent, Amherst, NY; polishing systems in her or his armamentarium to main-
POGO, Dentsply/Caulk, Milford, DE; Finale, Ultradent tain resin-based restorations. With proper maintenance,
Products, South Jordan, UT; Diacomp, Brasseler, Savannah, resin restorations can reasonably last up to about nine years
GA) are able to help surface-polish these resin materials. (Figure 6).
Microhybrid Resins Porcelain
Microhybrid resins (eg, Renew, Bisco, Schaumburg, IL; Porcelain aesthetic restorations are the longest lasting, cos-
Vit-l-escence, Ultradent Products, South Jordan, UT; Esthet-X, metic bonded restorations in dentistry today. Although the
Dentsply/Caulk, Milford, DE; Point 4, Kerr/Sybron, Orange, life span for porcelain can last beyond 10 years, it must
CA) were created to produce a composite resin that theo- be maintained correctly on a consistent basis. Proper
retically has the best combination of strength and aesthetics. contouring, smoothing, and polishing utilizing the correct
Maintenance procedures are fairly simple for these restora-
tions, as long as the proper polishing materials are utilized.
Once again, diamond-impregnated polishers are the best
choice to polish and maintain microhybrid resins.
Porcelain Abrasive Systems
Dialite Brasseler, Savannah, GA
Ceramiste Silicone Points Shofu, San Marcos, CA
Revitalizer Cosmedent, Chicago, IL Figure 6. Anterior four composite resin veneers maintained
for six years.
September/October 2002 33
Aesthetic Maintenance Protocol CE 5
Figure 7A. Without the proper maintenance of porcelain, Figure 8. Posterior aesthetic resin restorations can
the surface glaze can be irreversibly affected leaving be maintained for years with a proper aesthetic
dull, unaesthetic restorations. 7B. Re-restoring with maintenance protocol. 8A. Preoperative view.
porcelain veneers #5 –10 helps to regain the enamel-like 8B. Postoperative view
finish similar to the surrounding dentition.
abrasive systems is necessary to maintain a high luster in silicone carbide, these rubber finishing disks, cups, wheels,
porcelain restorations. and points are able to gradually smooth the porcelain
Without proper maintenance, roughness of the porce- surface. A variety of porcelain abrasive systems are currently
lain along the occlusal surfaces develops, thereby increas- available (Table 3).
ing accelerated wear of the opposing dentition. In addition, To complete the porcelain maintenance procedure, it
inadequately maintained margins of porcelain-bonded is key to finish with a 1.0-µm diamond polishing paste. By
restorations are susceptible to staining and caries. Less utilizing this type of polishing paste (eg, Diamond Polish,
effectively polished margins of porcelain restorations along Ultradent Products, South Jordan, UT; Porcelize, Cosmedent,
the free gingival margin can cause inflammation and poten- Chicago, IL), a high shine can be regained. Utilizing these
tial periodontal-related challenges. Due to the difficulty in pastes with a prophy cup, Robinson bristle brush, or felt
properly accessing all necessary surface areas, polishing wheel allows the best access to all anatomical surfaces of
porcelain restorations to a high luster can be challenging. the porcelain restorations. To avoid damage to the surface
of the existing aesthetic restoration, proper polishing paste
Aesthetic Maintenance Protocol for Porcelain must be used to sustain long-term success (Figure 7).
In the aesthetic maintenance protocol for porcelain, the
severity of chips and scratches to the existing porcelain Conclusion
restorations are assessed first. If the chips and scratches are Overall, composite resin and porcelain restorations have
determined to be more moderate-to-severe in nature, adjust- the ability to be long-term restorations, provided they are
ments are first performed with finishing diamonds of var- properly maintained (Figure 8). The aesthetic dental hygien-
ious grits (eg, Brasseler Diamond Finishing Burs, Brasseler ist plays a significant role in helping patients preserve their
USA, Savannah, GA) to recontour, remove chipped porce- cosmetic restorations and their beautiful smiles. By utiliz-
lain, and remarginate porcelain margins. Subsequently, by ing the proper finishing and polishing techniques for both
utilizing rubber finishing instruments, coarse scratches are composite resin and porcelain, the aesthetic hygienist con-
smoothed out. Impregnated with diamond particles or tributes greatly to the success of cosmetic dentistry.
34 The Journal of Practical Hygiene
CONTINUING EDUCATION (CE) EXERCISE NO. 5
To submit your CE Exercise answers, please use the answer sheet found within the CE Editorial Section of this issue and complete it
as follows: 1) Identify the Article; 2) Place an X in the appropriate box for each question; 3) Clip the answer sheet from the page and
mail it to the CE Department at Montage Media Corporation. For further instructions, please refer to the CE Editorial Section.
Answers to the 10 multiple-choice questions for this CE exercise are based on the article “Aesthetic Maintenance Protocol in Cosmetic
Dentistry” by Wynn H. Okuda, DMD.
WARNING: The Journal of Practical Hygiene encourages its readers to pursue further education when necessary before
implementing any new procedures expressed in this article. Reading an article in The Journal of Practical Hygiene does
not fully qualify you to incorporate these new techniques or procedures into your practice.
• Determine proper maintenance techniques for ceramic restorations and resin-based materials.
• Review the three categories of resin restorative materials: microfill resins, hybrid resins, and microhybrid resins.
• Exploration of tools and products utilized in cosmetic dental hygiene.
1. Cosmetic bonded restorations do not need 6. Which of the following is the best polishing
to be periodically professionally maintained. system for both hybrid and microhybrid resins?
A. True. A. Diamond-impregnated polishers.
B. False. B. Rubber polishing cups.
2. Long-term success of cosmetic restorations is C. Wheels and points.
dependent on: D. None of the above.
A. Periodic professional cleanings.
B. Daily self care by the patient. 7. Microfill resins are primarily utilized in:
C. Understanding the differences between restorations A. Class I posterior restorations.
that are porcelain substrate versus resin-based. B. Class II posterior restorations.
D. All of the above. C. Class III and V restorations.
D. Class IV anterior restorations.
3. Which of the following is the longest lasting
cosmetic bonded restoration?
8. Which of the following is the most difficult to
A. Hybrid resins.
polish and to regain a high finish during
B. Microfill resins.
C. Microhybrid resins.
A. Hybrid resins.
D. Porcelain restorations.
B. Microfill resins.
4. Improper or inadequate maintenance of C. Microhybrid resins.
porcelain restorations may increase: D. Porcelain restorations.
A. Inflammation and periodontal-related problems.
B. Susceptibility to staining and caries. 9. Hybrid resins are commonly utilized for:
C. Wear of opposing dentition. A. Diastema closures.
D. All of the above. B. Class III and V restorations.
5. Resin-based restorations need more attention C. Class IV anterior restorations.
to maintenance during their life span. In com- D. Hand-sculpted composite veneers.
parison to porcelain, direct composite resin-
based restorations have comparable strength. 10. Which of the following resins theoretically
A. Both statements are true. has the best combination of strength
B. Both statements are false. and aesthetics?
C. The first statement is true, the second statement A. Microfill.
is false. B. Hybrid.
D. The first statement is false, the second statement C. Microhybrid.
is true. D. None of the above.
September/October 2002 35