September 2010, Volume 6, Issue 8
Published by AEGIS Communications
Using Tetric EvoCeram for Predictable Posterior Restorations
The material’s filler technology offers many advantages over traditional formulations.
In the dental composite industry, there are many companies and products that claim to provide superior features, innovations, and proven technologies. Although there are many treatment options and materials to choose from, they all do not provide the same results. When dealing with restorations, most products cannot deliver the longevity, esthetics, and functionality desired by patients and practitioners alike. It is important for practitioners to choose products that are proven to accomplish everything they, as well as their patients, seek from their restorations. One such product, Tetric EvoCeram® (Ivoclar Vivadent,http://www.ivoclarvivadent.us), provides innovation and proven results in one complete package. Tetric EvoCeram is an innovative nano-optimized universal hybrid composite that offers many advantageous features that work together to provide excellent esthetics and functionality.
Because Tetric EvoCeram filler technology is composed of nano-sized particles, there are many advantages over the traditional formulations of composite materials. The nano-sized particles promote a smoother surface, which allow practitioners to quickly and easily polish restorations to a high gloss.1 Lower wear allows restorations to last longer than composite materials of the past, decreasing the need for patients to return to the office for replacement of restorations completed with this material.1 Shrinkage rates are also exceptionally low (< 1.6%), promoting better marginal integrity of the restoration.1
Another exciting feature of Tetric EvoCeram is the composite’s high radiopacity. This innovation enables practitioners to clearly see the restoration upon completion and final x-ray.1Because it is radiopaque, practitioners are able to see if the restoration was placed properly and ensure that there are no issues, such as leakage.
Tetric EvoCeram is composed of three different types of nanoparticles, which include fillers, pigments, and a modifier. The various sizes of ceramic fillers promote the aforementioned strength, polishing properties, high gloss, and low wear that one could come to rely on for predictable results. Spherical mixed oxide is the basis for the material’s consistency. This oxide promotes optimal light refraction, which imparts a lifelike translucency to not only the material, but the completed restoration as well.1 Prepolymers, which are also used in the formulation of Tetric EvoCeram, are responsible for the exceptionally low shrinkage rates demonstrated by the composite.1
Ytterbium trifluoride, a patented filler created by Ivoclar Vivadent, is responsible for the exceptionally high radiopacity of the composite. Research shows that high radiopacity is not only useful, but actually essential for a sound diagnosis.2 As previously mentioned, this feature allows practitioners and technicians to clearly distinguish the restoration from natural tooth structures and secondary caries on dental radiographs.2 These combined features create a singular material that presents improved handling properties, a non-sticky consistency, and enhanced stability.1
Additionally, the formulation of this nano-optimized composite creates the ability to blend completely with the tooth’s natural structure and the surrounding natural dentition. With Tetric EvoCeram, practitioners do not have to rush through restorations, as working time is ample. Because of these characteristics, restorations created with Tetric EvoCeram are long-lasting and demonstrate a natural fluorescence.
Tetric EvoCeram is available in syringes, as well as Cavifil injectors (Ivoclar Vivadent). Cavifil single-dose restoratives tend to be a better option, as the use of a spatula or a modeling instrument is not required.3 The longer tips of the injectors allow practitioners to easily and comfortably reach areas in the oral cavity that tend to be difficult to work on, such as molars.3Cavifil can also be turned 360° in the injector, so that no matter what the position of the jaw, a practitioner is able to complete the restoration.3
The high-viscosity material is easily dispensed through Cavifil, because of the high transmission ratio of the injector.3 Even if a variety of shades or opacities are required, the Cavifil is still a great option, as the tips can be easily changed.3 The Cavifil injector is also a cost-effective tool, because even though it was designed to be used primarily with Ivoclar Vivadent products like Tetric EvoCeram, other manufacturers’ products can be dispensed by the Cavifil as well.3
As a result of Tetric EvoCeram’s life-like translucency and ability to match nearly perfectly with the surrounding natural dentition, a high level of esthetics can be achieved with a single shade.1 The product is available in three levels of translucency, which include dentin, enamel, and transparent, providing practitioners with a variety of esthetically pleasing options in both anterior and posterior restorations.1 Tetric EvoCeram syringes and Cavifil follow a color-coded system; the labels of the syringes and the caps of the Cavifil are clearly labeled according to each shade, making identification and selection much easier.1
The patient was a 58-year-old man who wanted to upgrade his old amalgam restorations to bonded composites (Figure 1). The patient also presented with an active underlying immunosuppressive condition, which was discussed during pre-treatment planning. During this planning, the patient asked for “white fillings” to replace the previous amalgams on the lower left first and second molars (Teeth Nos. 30 and 31).
Consequently, the old amalgams were removed, and the caries underneath were identified and then excavated (Figure 2). Evidence of leakage was present in the preparation, and some of the grooves were stained. However, the integrity and structure of the teeth were good.
The cavity preparation was prepared with a cleaning solution of hydrogen peroxide and chlorhexidine to remove any debris. After cleaning, the enamel was etched for 10 seconds using an etchant gel (Figure 3). The dentin was then etched for 10 seconds, giving the enamel a full 20 seconds of etching (Figure 4). Once the preparation was etched to satisfaction, a copious amount of water was used to remove all of the etching gel and excess material.
Using a Vivapen, ExciTE F (Ivoclar Vivadent), a bonding agent featuring beneficial fluoride content, was liberally placed in the preparations in an agitating motion for 20 seconds. This was followed by a light air-dry to evaporate the solvent, and then the preparations were light-cured for 10 seconds. This process was also completed at angles around the cavity preparations to cure undercut areas (Figure 5).
It is important to note at this point in the procedure why a bonding agent that used fluoride was placed on the preparation. Research suggests that as a means of protection against recurrent caries, which are typical with restorations such as the one that presented, fluoride-releasing materials are necessary.4 These types of materials offer protection to hard dental tissues and the surrounding areas, decreasing the chance of post-procedure secondary caries.4This is why it was not only important, but necessary to use a composite material that released fluoride when placed on the preparation.4,5
A flowable, light-curing nano-hybrid composite (Tetric EvoFlow, Ivoclar Vivadent) in shade A1 was then placed on the floor of the preparation and light-cured for 20 seconds (Figure 6). The depth of the cavity preparation was only 3 mm, allowing one increment of material. Most light-curing units can cure down to 5 mm, however (Figure 7).
A universal, light-curing radiopaque nano-hybrid composite (Tetric EvoCeram) was then placed in one increment and sculpted with a cylindrical instrument and a flat composite instrument. The preparation was cured for 20 seconds, and Tetric Colour was placed into the grooves to accentuate anatomy. This was followed by a final light-cure and flash removal with fluted carbide finishing burs (Figure 8).
Once final occlusal adjustments were made, a final polish was completed using rubber points, wheels, and brushes (Astropol, Ivoclar Vivadent) (Figure 9). The Astropol brushes were also used for and in the grooves (Figure 10).
Tetric EvoCeram is a nano-optimized universal hybrid composite suitable for anterior and posterior restorations. It is also ideal for replacing failing amalgam restorations (Figure 11 and Figure 12). This is because of the handling characteristics of Tetric EvoCeram, which now enables clinicians to realize greater efficiency and predictability when suggesting and implementing direct composite restorations. In particular, the material handles very well, with little tackiness on the instruments, and it polishes wonderfully. These characteristics also ensure that patients will be happy with the esthetics and function of their restorations.
The author has received an honorarium from Ivoclar Vivadent.
1. Tetric EvoCeram®. 2009. Nano-optimized composite restorative. [Brochure]. Ivoclar Vivadent, Amherst, NY.
2. Tetric EvoFlow®. 2007. Nano-optimized composite restorative. [Brochure]. Ivoclar Vivadent, Amherst, NY.
3. Ivoclar Vivadent USA. Clinical Accessories/Instruments—Cavifil Injector. 2010. Available at:http://www.ivoclarvivadent.us/content/products/detail.aspx?id=prd_t1_1075236776&product=Cavifil+Injector.
4. Gjorgievska E, Nicholson WJ, LastIljovska S, Slipper I. The potential of fluoride-releasing dental restoratives to inhibit enamel demineralization: an SEM study. Prilozi. 2009; 30 (1): 191-204.
5. Chen MH. Update of dental J Dent Res. 2010;[Epub ahead of print] anocomposites. J Dent Res. 2010;[Epub ahead of print]
About the Author
Wilson J. KWong, DMD
Private Practice Vancouver
Vancouver, British Columbia