The dental hygienist plays an important role in maintainingcosmetic restorations; therefore, it is imperative that she orhe understands the properties and maintenance protocolsof each restoration material. Culp et al reviewed the prop-erties of ceramic materials used in cosmetic dentistry in aprevious issue of the Journal (Culp L, McLaren EA, Ritter RG,Roberts M, Trinkner T. Selection of Ceramic Materialsfor Aesthetics and Function. J Pract Hyg 2002;11[2]:13-16).This article addresses the care of ceramic restorations as wellas that of resin-based materials. It is determined that by uti-lizing proper finishing and polishing techniques for bothcomposite resin and porcelain, the aesthetic hygienist con-tributes greatly to the success of cosmetic dentistry.

IntroductionIn cosmetic dentistry, it is imperative to understand howto create the correct aesthetic end results (Figure 1). Long-term success with cosmetic dental restorations, however,is dependent upon the understanding of the importanceof proper maintenance of resin and porcelain bondedrestorations by the entire clinical team.

Commitment to long-term success commences beforethe actual treatment is started. The patient must be informedof 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.

Figure 1A. Pretreatment smile shows lack of good propor-tion in the smile. 1B. Posttreatment shows correction ofthe aesthetic problems with gingival sculpting andconservative porcelain veneers.

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

restorative dentistry in Honolulu, Hawaii. He may be reached

at his website at: www.cosmeticdentistryhawaii.com.

Aesthetic Maintenance Protocolin Cosmetic Dentistry

Wynn H. Okuda, DMD

September/October 2002 31

CECONTINUING EDUCATION

5

Depending on their periodontal/hygiene requirements, thepatient is educated on the frequency and type of recarevisits necessary. At the recare visit, the aesthetic hygienistand the cosmetic/restorative clinician can provide aesthetic/restorative maintenance procedures in addition to routinehygiene care.

In caring for cosmetic restorations, it is important fordental professionals to know the difference in materialsemployed. There are profound differences in restorationsthat are resin-based as compared to porcelain substrate-based. In addition, within the family of resins, there aredifferent types of composite resins based on type andamount of filler particle within the resin-based restorations.Each of these materials needs to be maintained differently.

A

B

Resin-Based Aesthetic RestorationsResin-based restorations—such as anterior direct compositeresin Class III, IV, V, as well as Class I and II posterior directcomposite resin restorations—need more attention to main-tenance during their life span. In comparison to porcelain,direct composite resin-based restorations lack strength.Because of this, chipping, staining, and marginal integritybreakdown are all inevitable outcomes (Figure 2). Withproper technique and proper selection of finishing andpolishing mediums, however, resin restorations can berefurbished and maintained for about three to nine years.

Prior to the initiation of aesthetic maintenance proce-dures, it is important to know what type of compositeresin was originally utilized to restore the tooth. There arebasically three categories, depending on the filler size andcontent, in which practically all resin restorative materialscan be grouped: microfill resins, hybrid resins, and micro-hybrid resins.

Microfill ResinsMicrofill resins (eg, Renamel Microfill, Cosmedent, Chicago,IL; Micronew, Bisco, Schaumburg, IL; Amelogen Microfill,Ultradent Products, South Jordan, UT; Matrixx Microfill,

Aesthetic Maintenance Protocol

32 The Journal of Practical Hygiene

Figure 2. Increase in stain is evident along existing anteriorhand-sculpted composite veneers.

Figure 3. Silicon carbide impregnated polishers, such asJiffy brushes (Ultradent), can be effective to polish alongmost contours without abrading composite restorations.

CECONTINUING EDUCATION

5

Discus Dental, Culver City, CA) are microparticle-basedresins. Due to their minute particle size, microfills easilyregain surface luster when utilized in proper polishing pro-tocol. Microfills are primarily used for Class III restorations,Class V restorations, diastema closures, and hand-sculptedcomposite veneers.

Although microfills recapture a high shine uponpolishing, they are also easy to “ditch” or scratch uponremargination or at the area where the restorative mater-ial meets the tooth. As a result, a high level of care isneeded during aesthetic maintenance procedures. Utilizinga sequence of finishing disks and finishing strips (Table 1),chips and stains on all existing composite restorationscan be modified. In addition, marginal integrity can berecaptured utilizing these products. Thereafter, polishing themicrofill restorations with rubber polishing cups, wheels,and points (eg, Astropol, Ivoclar Vivadent, Amherst, NY;FlexiWheels, Cosmedent, Chicago, IL; Jiffy Polishing Cups/Brushes, Ultradent Products, South Jordan, UT) can recre-ate a high shine (Figure 3).

Hybrid ResinsIn comparison, hybrid composite resins are the mostdifficult to polish and to regain a high finish duringmaintenance procedures. Hybrid resins are composed oflarge particle fillers of varying types. The filler particles

Table 1Tools for Aesthetic Maintenance of

Microfill Resin RestorationsType Product Manufacturer

Finishing Disks FlexiDisc Cosmedent, Chicago, IL

Super-Snap Shofu, San Marcos, CA

Sof-Lex Disks 3M, St. Paul, MN

Finishing Strips FlexiStrip Cosmedent, Chicago, IL

Epitex GC America, Alsip, IL

Sof-Lex 3M, St. Paul, MNFinishing andPolishing Strips

Table 2Polishing Pastes for

Microhybrid Resin RestorationsProduct Manufacturer

Prisma-Gloss/Prisma-GlossExtra Fine Dentsply/Caulk, Milford, DE

Enamelize Cosmedent, Chicago, IL

Diamond Polishing Paste Kerr, Orange, CA

To polish all resin-based restorations to a high shine,it is important to finish the polishing protocol with polishingpastes. Although polishing disks, wheels, cups, and pointscreate a smooth finish, a glass-like finish can only beattained by utilizing an aluminum oxide or microparticlediamond polishing paste (Figure 4). Polishing pastes helpto remove surface debris and to recapture a high shinealong all surfaces without ditching or scratching (Figure 5)(Table 2). In addition, carrying the polishing pastes into theinterproximal areas with floss helps to polish the proximalsurfaces without abrading and opening proximal contacts.

Due to the varying types of composite resins, it isunderstandable that the aesthetic hygienist needs severalpolishing systems in her or his armamentarium to main-tain resin-based restorations. With proper maintenance,resin restorations can reasonably last up to about nine years(Figure 6).

PorcelainPorcelain aesthetic restorations are the longest lasting, cos-metic bonded restorations in dentistry today. Although thelife span for porcelain can last beyond 10 years, it mustbe maintained correctly on a consistent basis. Proper contouring, smoothing, and polishing utilizing the correct

Okuda

September/October 2002 33

Figure 4. Proper polishing pastes help the clinician regaina high luster in maintaining composite restorations.

Figure 5. Proper maintenance by the aesthetic cliniciancan provide long-term success in composite resins.

Figure 6. Anterior four composite resin veneers maintainedfor six years.

CECONTINUING EDUCATION

5

generally consist of glass (1.0 µm – 3.0 µm) and silica(0.04 µm). It is this combination of particles that gives truehybrid composite resins (eg, Herculite XRV, Kerr, Orange,CA; Renamel Hybrid, Cosmedent, Chicago, IL) the beststrength of all categories of resins. Hybrid resins arecommonly utilized for Class IV anterior restorations andClass I or Class II posterior restorations.

However, these varying large particle sizes make a high luster polish in hybrid resins the most difficult to achieve and maintain. The best polishing system forboth hybrid resin and microhybrid resins are diamond-impregnated polishers. Various polishing systems (eg, D-Fine Diamond Polishing, Clinician’s Choice, NewMilford, CT; Astropol, Ivoclar Vivadent, Amherst, NY;POGO, Dentsply/Caulk, Milford, DE; Finale, UltradentProducts, South Jordan, UT; Diacomp, Brasseler, Savannah,GA) are able to help surface-polish these resin materials.

Microhybrid ResinsMicrohybrid resins (eg, Renew, Bisco, Schaumburg, IL; Vit-l-escence, Ultradent Products, South Jordan, UT; Esthet-X,Dentsply/Caulk, Milford, DE; Point 4, Kerr/Sybron, Orange,CA) were created to produce a composite resin that theo-retically has the best combination of strength and aesthetics.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 bestchoice to polish and maintain microhybrid resins.

Table 3Porcelain Abrasive Systems

Product Manufacturer

Dialite Brasseler, Savannah, GA

Ceramiste Silicone Points Shofu, San Marcos, CA

Revitalizer Cosmedent, Chicago, IL

abrasive systems is necessary to maintain a high luster inporcelain restorations.

Without proper maintenance, roughness of the porce-lain along the occlusal surfaces develops, thereby increas-ing accelerated wear of the opposing dentition. In addition,inadequately maintained margins of porcelain-bondedrestorations are susceptible to staining and caries. Lesseffectively polished margins of porcelain restorations alongthe free gingival margin can cause inflammation and poten-tial periodontal-related challenges. Due to the difficulty inproperly accessing all necessary surface areas, polishingporcelain restorations to a high luster can be challenging.

Aesthetic Maintenance Protocol for PorcelainIn the aesthetic maintenance protocol for porcelain, theseverity of chips and scratches to the existing porcelainrestorations are assessed first. If the chips and scratches aredetermined to be more moderate-to-severe in nature, adjust-ments are first performed with finishing diamonds of var-ious grits (eg, Brasseler Diamond Finishing Burs, BrasselerUSA, Savannah, GA) to recontour, remove chipped porce-lain, and remarginate porcelain margins. Subsequently, byutilizing rubber finishing instruments, coarse scratches aresmoothed out. Impregnated with diamond particles or

Aesthetic Maintenance Protocol

34 The Journal of Practical Hygiene

CECONTINUING EDUCATION

5

silicone carbide, these rubber finishing disks, cups, wheels,and points are able to gradually smooth the porcelainsurface. A variety of porcelain abrasive systems are currentlyavailable (Table 3).

To complete the porcelain maintenance procedure, itis key to finish with a 1.0-µm diamond polishing paste. Byutilizing this type of polishing paste (eg, Diamond Polish,Ultradent Products, South Jordan, UT; Porcelize, Cosmedent,Chicago, IL), a high shine can be regained. Utilizing thesepastes with a prophy cup, Robinson bristle brush, or feltwheel allows the best access to all anatomical surfaces ofthe porcelain restorations. To avoid damage to the surfaceof the existing aesthetic restoration, proper polishing pastemust be used to sustain long-term success (Figure 7).

ConclusionOverall, composite resin and porcelain restorations havethe ability to be long-term restorations, provided they areproperly maintained (Figure 8). The aesthetic dental hygien-ist plays a significant role in helping patients preserve theircosmetic restorations and their beautiful smiles. By utiliz-ing the proper finishing and polishing techniques for bothcomposite resin and porcelain, the aesthetic hygienist con-tributes greatly to the success of cosmetic dentistry.

Figure 7A. Without the proper maintenance of porcelain,the surface glaze can be irreversibly affected leavingdull, unaesthetic restorations. 7B. Re-restoring withporcelain veneers #5 –10 helps to regain the enamel-likefinish similar to the surrounding dentition.

A

BFigure 8. Posterior aesthetic resin restorations canbe maintained for years with a proper aestheticmaintenance protocol. 8A. Preoperative view.8B. Postoperative view

A

B

September/October 2002 35

1. Cosmetic bonded restorations do not needto be periodically professionally maintained.A. True.B. False.

2. Long-term success of cosmetic restorations isdependent on:A. Periodic professional cleanings.B. Daily self care by the patient.C. Understanding the differences between restorations

that are porcelain substrate versus resin-based.D. All of the above.

3. Which of the following is the longest lastingcosmetic bonded restoration?A. Hybrid resins.B. Microfill resins.C. Microhybrid resins.D. Porcelain restorations.

4. Improper or inadequate maintenance ofporcelain restorations may increase:A. Inflammation and periodontal-related problems.B. Susceptibility to staining and caries.C. Wear of opposing dentition.D. All of the above.

5. Resin-based restorations need more attentionto maintenance during their life span. In com-parison to porcelain, direct composite resin-based restorations have comparable strength.A. Both statements are true.B. Both statements are false.C. The first statement is true, the second statement

is false.D. The first statement is false, the second statement

is true.

6. Which of the following is the best polishingsystem for both hybrid and microhybrid resins?A. Diamond-impregnated polishers.B. Rubber polishing cups.C. Wheels and points.D. None of the above.

7. Microfill resins are primarily utilized in:A. Class I posterior restorations.B. Class II posterior restorations.C. Class III and V restorations.D. Class IV anterior restorations.

8. Which of the following is the most difficult topolish and to regain a high finish duringmaintenance?A. Hybrid resins.B. Microfill resins.C. Microhybrid resins.D. Porcelain restorations.

9. Hybrid resins are commonly utilized for:A. Diastema closures.B. Class III and V restorations.C. Class IV anterior restorations.D. Hand-sculpted composite veneers.

10. Which of the following resins theoreticallyhas the best combination of strengthand aesthetics?A. Microfill.B. Hybrid.C. Microhybrid.D. None of the above.

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.

Learning Outcomes:• 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.

CONTINUING EDUCATION (CE) EXERCISE NO. 5 CECONTINUING EDUCATION

5