Evolving Restorative Dentistry with Flow Plus

Evolving Restorative Dentistry with Flow Plus

A mere 20 years ago, 4th generation adhesives revolutionized restorative dentistry by offering a predictable technique for bonding to both enamel and dentin1. Less than 5 years later, advances in ionomer and resin technologies provided clinically successful dentin and enamel replacement. In 2003, the first selective preparation burs that could differentiate healthy and unhealthy dentin were introduced2. These were all revolutionary innovations that significantly altered the practice of dentistry. Within a decade, adhesive-resin and composites had displaced amalgam as the mainstream restorative materials.

The intervening years have seen the development of improved 5th and 7th generation adhesives3,4, microhybrid and nanohybrid composites, LED curing lights, soft tissue lasers5,6,7, and a host of other adjunct technologies that make dental treatment better, easier, faster8, and more predictable9,10. These innovations have been evolutionary, rather than revolutionary, building upon the existing science by gradual improvement and facilitation.

The three major clinical concerns encountered by practitioners in recent years have included:

  1. The end-point of cavity preparation (how to differentiate between infected and affected dentin and how much tooth structure must be removed to assure long-term operative success?) 11, 12, 13
  2. The disinfection of the prepared dentinal tissue (how to eliminate the remaining bacteria to prevent redecay?) 14, 15
  3. The facilitation and simplification of the restorative protocol (how to reduce the numerous steps and technique sensitivities that arise in the restoration of function and form?)
  4. Recent technological advances have done much to allay these concerns and to move dental practice towards ever greater clinical predictability.

Preparation End-Point

Second generation Smartburs II (SSWhite, Lakewood New Jersey) are self-limiting polymer burs that have been developed to address the clinical problem of preparation endpoint: the removal of infected dentin (softened tooth structure that cannot be remineralized) 16 but the conservation of affected dentin (infected tooth structure that can be healed and remineralized). FIG A The slow speed Smartbur II relies on tooth structure hardness, and not tissue staining, to scientifically determine the endpoint. Its specifically designed Knoop hardness (harder than diseased dentin but softer than healthy dentin) allows the bur to selectively remove soft carious dentin while not cutting the harder healthy dentin.

Using flow plus for the preparation of restorative and conservative dentistry to treat tooth caries

A carbide or diamond bur can inadvertently penetrate through the thin remaining dentin into the pulp FIG B,C: the Smartbur II, on the other hand, is degraded by healthy dentin and ceases to cut FIG D,E. Smartburs II are used after the initial caries access preparation has exposed the deep, underlying caries. In cases where the caries is exposed FIG F, these instruments can typically be utilized without the need for local anesthetics because they do not traumatize or open healthy dentinal tubules FIG G.







Cavity Disinfection

It is well established that some bacteria remain in the prepared tooth structures, no matter how thorough the preparation process, and despite a tactile firmness and non-stained appearance. It is now possible to greatly decrease the likelihood of viable bacteria beneath the restoration by chemo-therapeutic methods that can penetrate as far as 2-3mm into the remaining enamel or dentin. These techniques effectively destroy bacterial viability and permit the subsequent remineralization of compromised tooth structures.

The technologies that have been shown to be effective surface bactericidals are:

– Aseptim Plus (SciCan, Toronto ON) Photo-Activated Disinfection System.17 FIG H
This compact unit utilizes tolonium chloride to specifically stain liposomes in bacterial cell walls. The stain is subsequently targeted by a red diode light that releases oxygen ions. FIG I These ions break open the liposomes, rupturing the cell walls, and killing the bacteria.

– Healozone X4 (Curozone, Wiesbaden, Germany). FIG L The ozone ions are generated remotely and introduced to the tip-sealed tooth surface through a handpiece. The ions are immediately, and selectively, toxic to bacteria. A very low level of ozone concentration is required for a comprehensive bactericidal effect. 18, 19, 20

– The high concentration of ozone is very effective in bacterial wall disruption and destroys them within 20-40 seconds. 21, 22, 23, 24 FIG M





Simplification of the Restorative Protocol

Most restorative protocols require numerous materials, each selected for particular beneficial properties, numerous steps, and a cumulatively complex description of the specific sequence that must be followed exactly. For example, microhybrid composites have excellent compressive strength for occlusal surfaces BUT they may not flow and adapt to margins and undercut areas of the preparation and can be difficult to sculpt. Flowable composites can adapt readily to the micro-anatomy of the tooth surface and are very polishable BUT cannot withstand the masticatory forces of direct occlusal contact.
Beautifil Flow Plus (Shofu, San Marcos CA) introduces a new category of restorative material: the “injectable” flowable composite resin. Fig N Based on Giomer chemistry, it is neither a conventional composite nor a flowable resin; Flow Plus is a unique blend of these materials with the benefits of both. Its high strength resin matrix is densely packed by fillers optimized to 67%.

Beautifil Flow Plus has a higher yield point than other flowables; thus, it is not deformed by the strong occlusal forces placed on the posterior teeth. Due to its excellent physical properties, Beautiful Flow Plus is indicated for restoring both anteriors and posteriors, and it is suitable for the occlusal surfaces of posterior teeth.
Two viscosities are available, a sculptable non-flow (F 00) FIG O and a low-flow (F 03) FIG P, which are used together in the resin Cone Technique. Both are suitable for the occlusal surfaces of posterior teeth. The highly elastic Beautifil Flow F 10 is placed after the adhesive for interface stress relief. Then, the non-flow is injected to form cusps and marginal ridges. It injects smoothly from the syringe, holds its shape, and does not develop a dispensing “horn”. Beautifil Flow Plus is not subject to technique sensitivity, and the Cone Injection Technique offers an important time advantage when compared to the layering technique. Beautifil Flow Plus 03 is placed last to finalize the occlusal anatomy of the restoration and to seal the marginal areas.
Used individually, or preferably together, these innovative techniques and materials provide practical clinical solutions to the concerns listed above. The following demonstration indicates an effective step-by-step protocol that incorporates the latest advances in restorative dentistry.



Clinical Protocol

The rubber dam is punched and lubricated with water soluble Wink (Pulpdent, Watertown MA) FIG Q to facilitate its insertion through interproximal contacts without tearing. The Vita Easyshade Compact (Vident, Brea CA) determines the shade of the restorative material at the beginning of the procedure, either before the rubber dam is placed, or immediately afterwards. FIG R It is important to record the shade while the tooth is still moist; once it is desiccated, the tooth will appear unnaturally chalky and opaque.
The tooth is air-dried and the CarieScan PRO caries indicator (CarieScan, Dundee, United Kingdom) is utilized to confirm the location and the extent of the decay.25, 26, 27, 28 FIG T



Access through the enamel is developed with a Great White Gold #2 carbide 29 FIG U or a TDA #849 diamond FIG V high speed bur (both from SSWhite, Lakewood NJ) 30. Once the deep decay is exposed, The Smartbur II selectively removes the soft carious (infected) dentin. FIG W The structure of the Smartbur II is designed to automatically determine the preparation end-point; any further rotation of the bur in the cavity simply abrades the bur, not the dentin. This leaves the harder, remineralizable (affected) dentin covering the pulp chamber intact. FIG X




The restorative process begins with an optional etching step; 7th generation adhesives do not require a separate etching step. A brief etch, 15 seconds or less, is unlikely to harm the bonding strength of the dental surfaces. Etch-Rite (Pulpdent, Watertown MA) is applied to the enamel first and then the dentin FIG Y and rinsed off with copious water less than 15 seconds later. FIG Z Then, the prepared tooth surfaces are disinfected with the Aseptim Plus, FIG ZA or Healozone. FIG ZC Each of these treatments takes 1 minute or less of chairtime, and offers a greatly improved restorative predictability. Beautibond 7th generation single-component, single-step adhesive (Shofu, San Marcos CA) is scrubbed onto all prepared dentin and enamel surfaces. FIG ZD It is left undisturbed for 10 seconds, and is then completely dried with an oil-free air syringe. FIG ZE The Beautibond is polymerized with a Fusion high power LED curing-light (DentLight, Richardson TX). FIG ZF







Next, the cavity is filled utilizing the innovative resin Cone Technique (as opposed to the more laborious and time consuming layering technique). Sculptable Beautifil Flow Plus F 00 is injected onto the bonded surface of the preparation; FIG ZG the composite is formed into cones at the bases of the buccal cusps FIG ZH as it adapts intimately to the preparation. Since Flow Plus 00 is a non-flow resin, it stays where it is placed until curing. The Beautifil Flow Plus 00 is then injected to form the cones at the bases of the lingual cusps, FIG ZI from cavity floor to the occlusal, until all four cusp bases are restored FIG ZJ. The injected cones are then polymerized with the Fusion curing light. FIG ZK Once the cone build-up is complete, Beautifil Flow Plus F 03 is injected to seal the marginal areas FIG ZL and the valleys between the cones. FIG ZM The BFF F 03 is a low-flow material that can readily be shaped by the Duckhead instrument (Hu-Friedy, Chicago IL) FIG ZN prior to final light-curing. FIG ZO The Duckhead composite instrument minimizes (and in many cases, eliminates) the need for occlusal adjustment and polishing, further improving the efficiency of the restorative protocol. The completed restoration FIG ZP demonstrates the clinical result of the technique and material enhancements that are available to the practitioner today.












Innovations in end-point determination, cavity surface disinfection, and the simplification of restorative techniques have again revolutionized dental practice. Mainstream clinical procedures are better, faster, and easier, and much more predictable in the long-term.


1. Nahabayaski N, Bonding mechanisms of resins and the tooth (in Japanese), Kokubyo Gakkai Zashi, J Stomat Society, Japan 1982 49:410

2. Freedman G, Polymer Preparation Instruments, Dentistry Today, APRIL 2003 22:5 58-62

3. Freedman G, Fifth Generation Bonding Systems: State of the Art in Adhesive Dentistry, J Canadian Dental Assoc June 1997 63:6 347-350

4. Freeman, G Seventh-Generation Adhesive Systems, Dentistry Today NOVEMBER 2002 21:11 106-111

5. Goldstep, F, Diode Lasers For Periodontal Treatment: The Story So Far, Oral Health December 2009 44-46

6. Goldstep F, Soft Tissue Diode Laser : Where Have You Been All MY Life?, Oral Health July 2009 34-38

7. Goldstep F. Diode Lasers For Periodontal Treatment: The Story Continues, Dental Town June 2010 11:6 66-69

8. Freedman G, Goldstep F, Seif, T, Watch and wait is not acceptable treatment – Ultraconservative resin restorations, J Can Dent Assoc 1999, 65: 579-581

9. Freedman G, Leinfelder K, Seventh Generation Adhesive Systems, Dentistry today 2002, 21:106-111

10. Fusayama T, A simple pain-free adhesive restorative system by minimal reduction and tooth etcing, Tokyo Ishiyaku Euro America Inc, 1993

11. Fusayama T, Okuse K, Hosada H, Relationship between hardness, discoloration and microbial invasion in carious dentin, J Dent Res, 1966: 45: 1033-1046

12. Hosoya Y, Marshall SJ, Watanabe LG, Marshell GW, Microhardness of carious deciduous dentin, Oper Dent 2000: 25: 81-89

13. Kutsch VK, Everett M, Process for the removal of soft tooth decay using a unique abrasive fluid stream, United States Patent 5,601,430, United States Patent and Trademark Office, February 11, 1997

14. Lynch E, Baysan A, Ellwood R et al, Effectiveness of two fluoride dentifrices to arrest root carious lesions, Am J Dent, 2000, 13:218-220

15. Nyvad B, Fejerskov O, Scanning electron microscopy of early microbial colonization of human enamel and root surfaces in vivo, Scan J Dent Res, 1987, 95: 287-296

16. Freedman G, Minimally Invasive Dentistry – The Management of Caries (Contributor)-Polymer Cutting Instruments section Quintessence Publishing Co. Ltd Surrey United Kingdom 2007 p 109-110

17. Freedman G, Lynch E, Photo-Activated Disinfection, Oral Health Magazine, December 2009, 19-25

18. Baysan A, Management of Primary Root Caries using Ozone Therapies, PhD Thesis, University of London, 2002

19. Bocci V, Luzzi E, Corradeschi F, et al, Studies on the biological effects of ozone:4 Cytokine production and glutathione levels in human erythrocytes, J Biol Regul Homeost Agents, 1993: 7: 133-138

20. Ericson D, Zimmerman M, Raber H, Gotrick B, Bornstein R, Clinical evaluation of efficacy and safety of a new method for chemo-mechanical removal of caries, Caries Res 1999: 33: 171-177

21. Baysan A, Lynch E, Grootveld M, The use of ozone for the management of primary root carious lesions, In: Albrektsson (ed): Tissue Preservation and Caries Treatment, Quintesssence 2001:3:49-67

22. Baysan A, Whiley R, Lynch E, Anti-microbial effects of a novel ozone generation device on micro-organisms associated with primary root carious lesions in vitro, Caries Res 2000, 34: 498-501

23. Bocci V, Biological and clinical effects of ozone, Has ozone therapy a future in medicine? Br J Biomed Sci 1999, 56: 270-279

24. Bocci V, Ozone as a bioregulator, Pharmacology and toxicology of ozonetherapy today, J Biol Regul Homeost Agents 1996: 10:31-53

25. Pitts N, How Electrical Caries Detection and Monitoring with CarieScan Can Help Deliver Modern Caries Management, Oral Health Magazine, July 2010 34-43

26. Pitts NB and Stamm J, ICW-CCT Statements, Journal of Dental Research 2004 83: Special Issue C 125-128

27. Detection, Assessment, Diagnosis and Monitoring of Caries – Editor NB Pitts, Karger Monographs in Oral Science, Vol 21 ISBN 978-3-8055-9184-3, S Karger AG Basel (Switzerland) 2009

28. Pitts NB, Are we ready to move from operative to non operative/preventive treatment of dental caries in clinical practice? Caries Research 2004: 38:294-304

29. Kimmel K, Optimal selection and use of rotary instruments for cavity and crown preparations. Dent Echo 1993: 63 (2) 63-69

30. Siegel SC, von Fraunhofer JA, Cutting efficiency of three diamond bur grit sizes JADA 2000 131, 1706-1710

By Dr. George Freedman

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