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Polishing Anterior Composite Resins

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  • 8/3/2019 Polishing Anterior Composite Resins

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    Why TakE This CoursE?Composite resins are theprimary restorative material oranterior teeth. Patients haveexpectations that when a tooth-colored restoration is placedthat it will be invisible to thoseseeing their smile. Learn thetechniques or fnishing and pol-ishing anterior composite resinsto achieve a highly aestheticresult or your patients.

    PaTiEnT CarEThe trend isto simpliy fnishing and polishing

    composite restorations. Patientsneed to value the attention to de-tail that is required to place highlyaesthetic restorations.

    ConvEniEnCEContinueyour education without traveling,taking time away rom work andamily or paying high tuition, reg-istration and material costs.

    CE CrEdiTsSuccessulcompletion o this course earnsyou 2 Continuing Dental Edu-cation Units.

    high QualiTyAuthored ordental proessionals, by dentalproessionals, Dental U con-tinuing education courses areengaging, concise, anduser riendly.

    Who should TakE ThisCoursE?Dentists, Dental Assistants, andDental Hygienists.

    Tese courses have been designed specifcally tomeet the needs o busy proessionals like yoursel,who demand eciency, convenience and value.Begin your Benco educational experience withthis course today, and watch the mail or live CEevents in your area.

    ACCEPTED NATIONAL PROGRAMPROVIDER FAGD/MAGD CREDIT

    Cet Ccept f Pate Cmpte re

    2 CONTINUING EDUCATION CREDITS

    Howard E. Strassler, DMD, FADM, FAGD, Professor

    Division of Operative Dentistry

    Department of Endodontics, Prosthodontics, and Operative Dentistry

    University of Maryland Dental School

    650 West Baltimore Street, Baltimore, Maryland 21201

    410-706-7551

    Email: [email protected]

    suPErvisEd sElF-sTudy CoursEs FroM BEnCo dEnTal

    CoursE oBjECTivEs

    At the completion o this program the partici-pant will be able to: Describe the choices in composite resin re-

    storative materials Describe the principles o polishing com-

    posite resins List and describe instruments used or n-

    ishing and polishing composite resins List the step-by-step procedure or nish-

    ing and polishing composite resins

    CoursE sPonsorBenco Dental is the course sponsor. BencosADA/CERP recognition runs rom Novem-

    ber 2009 through December 2013. Pleasedirect all course questions to the direc-tor: Dr. Rick Adelstein, 3401 RichmondRd., Suite 210, Beachwood, OH 44122. Fax:(216) 595-9300. Phone: (216) 591-1161.email: [email protected]

    sCoring & CrEdiTsUpon completion o the course, each partici-pant scoring 80% or better (correctly answer-ing 16 o the 20 questions) will receive a certi-cate o completion veriying two ContinuingDental Education Units. Te ormal continu-ing education program o this sponsor is ac-

    cepted by the AGD or FAGD/MAGD credit.erm o acceptance: November 2009 throughDecember 2013. Continuing education creditsissued or participation in this CE activity maynot apply toward license renewal in all states. Itis the responsibility o participants to veriy therequirements o their licensing boards.

    CoursE FEE/rEFundsTe ee or this course is $54.00. I youare not completely satised with thiscourse, you may obtain a ull reund

    by contacting Benco Dental in writing:

    Benco Dental, Attn: Education Department,295 CenterPoint Boulevard, Pittston, PA 18640.

    ParTiCiPanT CoMMEnTsAny participant wishing to contact the authorwith eedback regarding this course may doso through the course director: Dr. Rick Adel-stein, 3401 Richmond Rd., Suite 210, Beach-wood, OH 44122. Fax: (216) 595-9300. Phone:(216) 591-1161. email: [email protected]

    rECord kEEPingo obtain a report detailing your continuingeducation credits, mail your written requestto: Dr. Rick Adelstein, 3401 Richmond Rd.,Suite 210, Beachwood, OH 44122. Fax: (216)595-9300. Phone: (216) 591-1161. email:[email protected]

    iMPorTanT inForMaTionAny and all statements regarding the ecacyor value o products or companies mentionedin the course text are strictly the opinion othe authors and do not necessarily reectthose o Benco Dental. Tis course is not in-tended to be a single, comprehensive sourceo inormation on the given topic. Rather, it is

    designed to be taken as part o a wide-rang-ing combination o courses and clinical ex-perience with the objective being to developbroad-based knowledge o, and expertise in,the subject matter.

    CoursE assEssMEnTYour eedback is important to us. Please com-plete the brie Course Evaluation survey at theend o your booklet. Your response will helpus to better understand your needs so we cantailor uture courses accordingly.

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    Cet Ccept f P ate Cmpte re

    Te aesthetic appearance o composite resin is based

    upon shape, color and gloss o the restoration achieved by

    nishing and polishing. When composite resins were rst

    introduced in the late 1950s and early 1960s, they were sel-

    cured and macrolled with large ller particles in the 25-50 micrometer range. In most cases the ller was made o

    quartz. Tese composite resins, once contoured, had little

    surace gloss and the patient sensed they were rough when

    their tongue touched the restoration. Te introduction in

    the late 1970s o visible light-cured composite resins with

    smaller ller particles made rom synthetic, soer glasses

    made composites more polishable with improved tooth-

    like translucency. Tese restoratives allowed the clinician

    the ability to provide patients with more natural and es-

    thetic tooth-like restorations in the anterior region. Visible

    light-cured composite resins had changes in the polymer-ization chemistry that improved the color stability. Light

    activation in most cases was initiated when a blue wave-

    length light with a peak o 460-480 nm was absorbed by a

    photoinitiator usually camphoroquinone (CQ). Te use o

    CQ combined with an organic amine allowed the chemical

    reaction to progress so the composite resin hardened. Tis

    light-activated reaction eliminated the need or tertiary

    amines that contributed to unaesthetic color changes o the

    earlier sel-cured composite resins.

    In the last decade and a hal, manuacturers have in-

    troduced a wide variety o composite resins with varied

    applications in both the anterior and posterior region. Foranterior restorations microlled composites and hybrid

    composite resins have become accepted as the standard.

    Microlled composites oer high polishability with tooth-

    like translucency, but unortunately are radiolucent. Te

    high polishability and the ability to maintain their luster o

    microlled composites is due to the use o a 0.04 microm-

    eter colloidal silica particles that can be within the polymer

    matrix (homogenous microll) or mixed with the polymer

    matrix, light cured and crushed to make a prepolymer ller

    that is loaded as an organic ller within the microlled

    composite (heterogenous microll). Te small llers andresin-rich surace allow or high polishability. Microlled

    composites are generally loaded to 32-50% by volume, have

    greater polymerization shrinkage, higher water sorption

    and a higher coecient o thermal expansion and contrac-

    tion than hybrid composites.(1)

    Hybrid composite resins combine microller particles

    (0.04 micrometer umed silica) with microne glass llers

    with an average particle size diameter o less than 2 microm-

    eters. ypically these composites are loaded to 58-75% by

    volume and are radiopaque. Tis mixture o llers accounts

    or the excellent physical properties with high polishability

    when compared to macrolled composites.(2)

    Regrettably,

    one problem with hybrid composite resins is their inabil-

    ity to maintain their gloss when exposed to toothbrushing

    with toothpaste and prophylaxis pastes.(3-6)Although microlled composites maintained their

    gloss, in high stress-bearing areas, microlled composites

    they were more susceptible to racture.(7)

    Tere was a need

    or a highly polishable composite resin with optimal physi-

    cal properties or use in the anterior and posterior regions.

    Recently, a new generation o hybrid composite

    resin has been introduced. Tese composites have been

    categorized as nanolled with ller particles with a di-

    ameter ranging rom 0.005-0.1 micrometers. Te in-

    troduction o nanollers allows manuacturers to cre-

    ate hybrid composite resins with physical propertiesequivalent to the original hybrid composite resins, good

    handling characteristics and higher polishability.(8-12)

    Tese nanolled composites oer an alternative to mi-

    crolled composites in their ability to be highly polish-

    able with toothlike translucency.(10-13)

    Many nanolled

    hybrid composite resins have not only the basic shade

    selection, but oer an extended range o opacities,

    translucencies with dentin, enamel, incisal shades to

    allow or building and stratiying a restoration to have

    a more toothlike appearance. With the current genera-

    tion o nanolled composites or anterior and posterior

    restorations, the clinician can expect good color stabil-ity, stain resistance, low wear, excellent polishability and

    luster retention.(2,8 10-12, 15)

    With the introduction o these composites, manu-

    acturers have also introduced specialized shade guides

    and recipes to help the clinician choose the mix o

    shades to use in specialized circumstances like the

    building on Class IV incisal edge ractures rom the in-

    side out and stratied building o completed acial ve-

    neers or esthetic bonding. Tese stratied composite

    resin placements, using the recipe consisting o the den-

    tin, enamel body shades and incisal shades can be usedto restore anterior and posterior teeth. Examples o this

    philosophy o adhesive bonded composite resin resto-

    ration include Filtek Supreme PLUS (3M-ESPE) which

    includes a comprehensive shade selection wheel that is

    used once the basic shade is selected rom a Classic Vita

    Shade Guide (Vident) classical shade guide; IPS Em-

    press Direct (Ivoclar-Vivadent) which utilizes rue-to-

    Nature shades with ve dierent levels o translucency

    and natural uorescence to mimic a natural tooth in ap-

    pearance. Shades are selected using the IPS Empress Di-

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    rect autoclavable shade guide. Esthet-X HD (Dentsply

    Caulk) uses a similar approach by providing the clini-

    cian with a comprehensive shade guide with expanded

    shades (bleaching shades and some darker shades than

    the traditional Classic Vita guide) and receipes on theback o the shade guide to select enamel, dentin and

    incisal shades. Nanohybrid composites are the current

    state-o-the-art universal anterior and posterior com-

    posite resins. Tese advanced composite resins have

    been ormulated to be more sculptable with minimal

    slump and very little tackiness or ease o placement.

    Te nal esthetic appearance o any composite resin

    will be based upon the artistic abilities o the clinician in

    choosing the correct shade or shades o composite resin

    to mimic the color and appearance o the teeth and in

    shaping and contouring the restoration. Te restorationsability to imitate in appearance the tooth and/or adjacent

    teeth will be based upon the proper use o abrasives to

    nish and polish the restorative to its highest luster. Re-

    search has shown that the technique or polishing com-

    posite resin to its optimal smoothness and gloss is prod-

    uct specic and composite resin specic.(10-27)

    Regardless

    o composite type, using discs sequentially rom coarsest

    to smoothest produced the smoothest suraces.

    Te principles governing the polishing o compos-

    ite resins are similar to those o dental metals. Unlike

    metals that have homogeneous alloyed suraces with

    a uniorm hardness, composite resins have a variablecomposition o resin matrix and ller particles. In some

    cases the resin matrix and llers have dierent hard-

    nesses. Metals, due to hardness and composition use

    dierent abrasive systems and while composite resin

    nishing systems can be used on metals, metal nishers

    and polishers should not be used or composites in or-

    der to avoid undesirable staining and discoloration. Te

    abrasive particles used to polish composites are material

    specic. Similar to metal polishing, the sequence o pol-

    ishing or composite resin progresses rom the coarsest

    abrasive to the smoothest. Finishing and polishing de-vices and instruments can be classied as:

    1. coated abrasives, e.g., abrasive nishing disks and strips;

    2. rotary cutting devices, e.g., carbide nishing burs;

    3. rotary submicron particle diamond nishing abrasives;

    4. reciprocating abrasive tips, e.g., laminated abrasive at

    paddles

    5. rubberized embedded abrasives, e.g., rubber or silicone

    rotary points;

    6. hand instruments;

    7. abrasives suspended in a polishing paste.

    No matter which abrasives are selected, the rule o

    coarsest to smoothest and then physically debriding the

    surace with a moist cotton roll between abrasives must be

    ollowed. For a complete listing o the wide variety o n-

    ishing and polishing burs, diamonds, abrasives, strips andpastes or composite resin reer to the Benco Dentist Desk

    Reerence as your resource or these instruments.

    Te goal or placement o any composite resin is mini-

    mal nishing and polishing. While this is not dicult with

    routine anterior restorations (Class IIIs and Class Vs) or

    larger more involved restorations (Class IVs and complete

    acial veneering especially or multiple teeth) there will be

    signicantly more contouring and nishing involved. ypi-

    cally or these larger restorations, the sequence or nish-

    ing and polishing involves gross contouring, shaping with

    nishing burs and submicron nishing diamonds witha high-speed handpiece ollowed by additional nishing

    with abrasive discs and/or rubber points. For long incisal-

    gingival restorations, narrow, long nishing burs or dia-

    monds with sae-tipped ends aord the ability to establish

    esthetic orm to curved suraces. While nishing burs and

    diamonds can be used either wet or dry, these authors pre-

    er using them dry with the dental assistant suctioning the

    composite dust during the procedure. Working with a dry

    eld and a light touch allows me or better visualization o

    shape and contour o the composite resin surace. Judicious

    use o coarse and medium grit nishing disks using only

    small sections o the disk allows the same level o control.Most disks today have smaller metal hubs to avoid marring

    the composite surace by accidentally hitting the compos-

    ite with the metal hubs o the disk. Some manuacturers

    (Shou and Brasseler) have placed their disks on silicone

    sheaths that slip over the metal mandrel, totally eliminating

    the potential o marring the composite resin surace. Ad-

    ditional nishing o acial and lingual suraces can be ac-

    complished with specialized rubberized polishers in ame,

    disk and cup shapes. Tese shapes provide access to the

    varied contours o the tooth. Tese are used on a latch-type

    contra-angle handpiece. It is important whenever usingabrasive systems that the surace o the composite resin be

    physically debrided o composite debris and abrasive de-

    bris with a damp cotton roll or gauze. I only an air-water

    spray is used, some o the abrasive debris will remain on

    the restoration surace and interere with attaining the

    smoothest polish nest abrasive grit with the next step-

    down instrument.

    Interproximal nishing and polishing is accom-

    plished with gapped nishing and polishing strips cov-

    ered with aluminum oxide abrasive particles or metal

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    Fe 1a: Smile

    view o discol-

    ored maxillary

    anterior teeth

    due to enamel

    demineralizationoccurring dur-

    ing orthodontic

    trewatment.

    Fe 1B:

    Retracted view o

    maxiallary anterior

    teeth.

    Fe 2: Long,

    thin composite

    resin fnishing bur

    (Brasseler) trim-

    ming the acial

    surace

    Fig. 1a

    Fig. 1B

    Fig. 2

    strips covered with submicron diamond particles. Oc-

    casionally, even with the use o a matrix strip, the resto-

    ration may bond to the adjacent teeth, literally splinting

    them together. In these cases, there are specialized acces-

    sories that allow the clinician to separate the teeth with-

    out damaging the restoration. One can saw the teeth apart

    using an ultra-thin stainless steel saw blade mounted in

    a handle (Cerisaw, Den-Mat). Tis mini-hacksaw and

    handle allows or total control o the instrument while

    gently sawing through the interproximal resin. When us-

    ing a saw, a gingival wooden wedge should be placed to

    protect the gingival papilla when sawing through. Axis

    Dental combines a gapped diamond containing metal

    nishing strip with saw teeth on the strip. Den-Mat uses

    the same concept as the CeriSaw by placing saesideddiamond strips in their CeriSaw handle to nish resin

    and ceramic veneer interproximal suraces. Another

    useul aid to help get through interproximal contacts or

    access with placement o matrix strips or gapped nish-

    ing strips is the Contact Disc (Centrix). Tis thin, rigid

    disk can be inserted rom the incisal, occlusal or acial

    suraces to orce the teeth apart with rapid tooth separa-

    tion. I there is excess composite resin present, the disk

    will create space to place a matrix strip or restoration

    without taking the risk o causing bleeding that a gingival

    wooden wedge would cause to perorm the same task. In

    the presence o excess composite resin interproximally,

    the disk will break away excess resin without damaging

    the restoration. Premier Dental Products has developed

    a diamond-impregnated thin disk, CompDisk, that not

    only creates space with rapid separation but can also be

    used or interproximal nishing or cleaning interproxi-

    mal suraces beore the bonding procedure.

    Tere are times aer placement o the composite res-

    toration, that margination is best accomplished with a

    hand instrument or by using a specialized reciprocating

    handpiece with a at abrasive paddle. Carbide-tipped hand

    instruments (Brasseler), restorative knives (Hu-Friedy) or

    scalpel blades with shapes that allow or access to the res-

    toration margin allow the clinician to remove overhangingrestorative material in a more controlled way than with ro-

    tary burs or diamonds.(17, 28)

    Carbide carvers are especially

    useul or marginating composite resin restorations where

    slight excesses exist. In hard-to-reach areas such as the

    interproximal surace at the gingival margin, specialized

    instruments and devices, e.g., a reciprocating handpiece,

    Pron (Dentatus) with a at Lamineer abrasive tip can

    be used.(28, 29)

    Lamineer tips come in a variety o submicron

    abrasives or nishing and polishing cervical margins o the

    restoration. Te at tips can also be used to nish and shape

    acial suraces and incisal embrasures.

    Final polish o the composite resin surace to itsmost lustrous nish can accomplished using disks with

    the nest aluminum oxide abrasive. Using a disk will

    not only smooth the resin surace, but it also heats the

    surace creating a high luster. Tis heating o the surace

    causes the polymer matrix to reach its glass transition

    temperature. Tis phenomenon gives the composite

    resin a glassy appearance. Also, a composite resin can

    be polished with specialized composite resin polishing

    pastes which contain either very ne aluminum oxide

    abrasive particles or diamond particles. Tis is best ac-

    complished with with oam cups, elt mounted on disksor ne goats hair brushes. I the surace o the restora-

    tion is smooth with no acial lobular orm, disks work

    well. For acial suraces o composite resins that have

    anatomic variation o lobular orm or striations, com-

    posite polishing pastes work best.

    CasE rEPorT:

    A 18-year-old emale presented with concerns about

    the appearance o her maxillary anterior teeth. She had

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    completed orthodontic treatment to align her permanent

    dentition. Unortunately, during treatment, the diculty

    in cleaning adjacent to the bonded brackets resulted in de-

    mineralization. Although remineralization therapy with a

    prescription uorides (Prevident 5000 Plus, Colgate) andthe use o a casein phosphopeptides-amorphous calcium

    phosphate paste (CCP-ACP, MiPaste, GC America, Alsip,

    IL) was eective, the discolorations on the acial suraces o

    #6-11 were aesthetically unacceptable to the patient and her

    mother.(Figure 1)

    During the restorative treatment consultation the pa-

    tient was presented with two minimally invasive treatment

    choicesporcelain veneers or direct placement composite

    resin. Based upon the age o the patient, the recommenda-

    tion or minimally invasive porcelain veneers was discour-

    aged because o the potential or the anterior teeth to haveadditional eruption and changes in the height o the ree

    marginal gingiva due to the patients age. Te patient and

    her parents ollowed this clinicans recommendation or

    direct bonded composite resin veneers or #6-11. A diag-

    nostic wax-up was not needed because the tooth align-

    ment and tooth shapes were aesthetically acceptable or the

    patient. In other cases where the patient desires to change

    tooth shape and position adhesive bonding with composite

    resin and ceramic veneers can be used as a successul alter-

    native treatment or esthetic correction o the tooth malpo-

    sition in the anterior area.(30, 31)

    When the patient accepted

    treatment, she was scheduled or restoration with a directplacement optimized particle nano-hybrid composite resin

    (NDurance, Septodont) to aesthetically veneer the maxil-

    lary incisors and canines.

    Te choice or NDurance was based upon this clini-

    cians experience with patients that have mouth breath-

    ing and leave the surace o the composite resin dry dur-

    ing their normal activities. Te desire to have a high luster

    when the restoration was dry and good polish retention is

    oered by the unique monomer chemistry o NDurance

    based upon dimer acid monomers that signicantly reduce

    polymerization shrinkage, shrinkage stresses and increasedthe initial double bond concentration o the monomer and

    the degree o double bond conversion achieved during po-

    lymerization.(32, 33)

    With NDurance, the use o optimized

    nano-llers o Ytterbium Fluoride, Barium glass and silica

    make this composite easy to distinguish in radiographs and

    provide or wear resistance similar to existing nano-lled

    composites.(34-36)

    With this signicantly lower volumetric

    shrinkage and non-stick ormulation with NDurance,

    well-adapted composite resin restorations are more eas-

    ily achievable. Side benets o this new chemistry include

    extremely low water sorption and solubility which contrib-

    utes to color stability (no color shiing), marginal integrity

    and stain resistance o the composite. A clinical research

    study evaluating the NDurance to restore anterior teeth

    demonstrated excellent clinical results in all the categoriesevaluated at one year.

    (37)

    CliniCal ProCEdurE

    Beore tooth isolation, a shade was selected with a Clas-

    sic Vitapan shade guide (Vident, Brea, CA). Te patient

    wanted the teeth to be slightly lighter in appearance. Shade

    selection nalization was achieved by placing an increment

    o composite resin in the lighter shade on the right central

    incisor, shaping it and light curing that increment. Like

    many o the new generation o nano-lled composite res-

    ins, NDurance has shade choices o regular shades, trans-lucent shades and bleaching shades. Although NDurance

    has very little color shi when light cured, some com-

    posite resins change their shade signicantly when light

    cured. Tis color shi occurs during light curing due to the

    chemistry o the polymerization process. By exposing the

    composite resin to the light source, a bleaching out o the

    orange-yellow colored photoinitiator, camphoroquinone,

    occurs and the material reaches its nal shade. Accurate

    shade selection is a critical step when placing anterior com-

    posite resins. Te patient was pleased with the lighter shade

    and was ready or treatment.

    Te teeth were isolated using lip retractors. Sincethe tooth shape and alignment were acceptable, as well

    as, a minimally translucent shade o NDurance was

    selected to block out the enamel discolorations, only a

    minimally invasive preparation o the acial suraces o

    #6-11 was needed. Te teeth were minimally prepared

    leaving enamel to a depth o 0.3 mm using the a me-

    dium grit ame shaped diamond (Revelation 653-016,

    SS White Burs) on a high-speed handpiece with water

    spray. Since there was no need or incisal edge length

    changes, the incisal edges were not changed.

    While there are many dierent techniques to restore #6-11 with direct composite veneers, I have ound that the ol-

    lowing sequence gives me excellent control o the compos-

    ite shape and widths during reehand sculpting. Te teeth

    were restored, two teeth at a time to control tooth shape and

    contour. Te sequence o restoration was the maxillary cen-

    tral incisors, the right maxillary lateral incisor and canine,

    and then the le maxillary lateral incisor and canine. Be-

    ore acid etching, dead so stainless steel metal matrix,

    thickness 0.001 inch thick (Pulpdent) was placed as a

    matrix. For the maxillary central incisors, my experi-

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    Fe 3: Coarse XT Soex disk (3M-ESPE) shaping incisal edge. Fe 4: Coarse XT Soex disk (3M-ESPE) shaping incisal

    embrasure. Fe 5: For another case Vision Flex disk (Brasseler) shaping acial and incisal embrasures.Fe 6: For another

    case Profn with S type Lamineer tip (Dentatus) shaping acial embrasure.Fe 7: For another case sae sided Lamineer tip

    on Profn reciprocating handpiece, shaping gingival interproximal embrasure.Fe 8: Enhance (Dentsply Caulk) fnishing cup

    smoothing acial surace o composite resin.

    Fig. 3

    Fig. 6

    Fig. 4

    Fig. 7

    Fig. 5

    Fig. 8

    ence has been that using aofemire stainless steel rigid

    matrix (0.002 inch thick) cut into a small rectangular

    strip placed between the central incisors provides or

    the correct orientation o the midline to the interpupil-

    lary plane. Following the plan or restoration two teeth

    at a time, the acial tooth suraces and slightly over the

    incisal edge were etched or 15 seconds with a 32 per-

    cent phosphoric acid etchant and then rinsed with an

    air-water spray or 15 seconds. Te etched tooth surac-

    es were dried, leaving a slightly rosty appearance to the

    enamel. A 5th-generation adhesive (Septobond, Sep-

    todont) was painted on the acial surace o the etched

    enamel and then light cured or 10 seconds with a high

    intensity LED curing light (BluePhase 20i, Ivoclar-Viva-

    dent). Te nano-hybrid composite resin (NDurance)

    was placed on the acial suraces o both central incisorsand sculpted with a thin, broad plastic lling instru-

    ment (PFIAB1, HuFriedy). Tis instrument allows or

    smooth shaping o the broad acial areas o incisors. Te

    instrument was lightly wetted with a coating o adhesive

    resin to prevent the composite resin rom sticking to the

    instrument and pulling away rom the enamel surace.

    Te composite resin was light-cured or 20 seconds. A-

    ter placement o the composite resin on the central inci-

    sors, the other teeth were were restored ollowing the

    sequence described and the same protocol.

    Finishing and Polishing:

    Many manuacturers provide kits containing nishing

    burs, diamond abrasives, rubberized abrasives and disks

    that provide the clinician with an orderly arrangement o

    nishing and polishing instruments. In these authors ex-

    periences all these kits have merit. Tere is certainly no

    one way to nish and polish composite resin but no matter

    what set o instruments are selected the operator does need

    to ollow the order o coarsest to nest to attain the best

    nish and polish or composites. For this case, the acial

    suraces were contoured using a long, narrow, sae-ended,

    multiuted nishing bur (E-9F, Brasseler) (Figure 2) but

    a submicron diamond abrasive with a similar shape could

    also be used. Te gingival margin was contoured and mar-

    ginated with a shorter, thin, needle-shaped nishing bur.

    Other popular choices or shaping acial suraces o veneersand Class IVs are the Sae-ended series o nishing burs

    rom SS White Burs and nishing burs rom Axis Dental.

    Te choice o nishing bur and diamond abrasive is usually

    a decision made by the practitioner based upon his or her

    ability to control the instrument without notching the res-

    toration. Finishing burs can have as ew as 8 and 12 blades

    or gross reduction. For ner nishing, 16-bladed and

    30-bladed nishing burs are available. Diamond composite

    nishers usually have diamond particle sizes o approxi-

    mately 30-40 microns or ne grit, 15 microns or extra-ne

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    Fe 9: Egg-

    shaped fnishing

    bur (SSWhite Burs)

    marginating and

    shaping lingual

    surace o composite

    restoration.

    Fe 10: Goat's

    hair polishing brush

    (Ultradent) with

    composite polishing

    paste bringing the

    composite resin to

    a highly polished

    surace.

    Fe 11: Complet-

    ed restorations smile

    view (N'Durance

    Dimer Nano-hybrid,

    Septodont)

    Fig. 9

    Fig. 10

    Fig. 11

    grit and 8 microns or ultra-ne grit. A thin, brand-new n-

    ishing bur can cut too aggressively into a acial surace. I

    have ound that a composite resin nishing bur dulls appro-

    priately aer two sequences o autoclaving, thus enhancing

    control. o urther marginate and nish the gingival mar-

    gin a ame-shaped ne nishing diamond (862-016, SS

    White Burs) was used because it allows or better access to

    the gingival margin without marring the root surace o the

    tooth. Te acial surace was also shaped with a coarse X

    Soex disk (#2381C , 3M-ESPE).

    Te incisal edge was shaped and the length determined

    using a pop-on mandrel with a coarse disk (Soex X disk,

    3M-ESPE)(Figure 3). Te best technique or shaping the

    incisal edge is to have the patient seated in an upright posi-

    tion that mimics how the incisal edges are visualized. Te

    disk should be oriented with a slight lingual inclinationollowing the chisel shape o the incisal edge o an intact

    incisor. Te incisal embrasures and acial embrasures were

    established using a the same disk. (Figure 4) Tin, exible

    diamond disks can also be used, e.g., the Vision Flex Disc,

    Brasseler) (Figure 5) Tese areas can also be shaped with

    a reciprocating handpiece, Pron, and an S series knie

    edge Lamineer tip (Figure 6). Once shaped the areas were

    nished using successively smoother disks rom a medium

    to ne and to nest grit.

    One o the most dicult areas to access when nish-

    ing any aesthetic restoration is the gingival interproxi-

    mal margin. Finishing strips do not work well due to thediculty o attempting to access these margins. In this

    case, the Pron with a Lamineer tip was used in the

    gingival interproximal areas because it aorded a ne

    control that the reciprocating handpiece allows with its

    back and orth motion to saely nish and polish the

    root suraces without ear o notching. (Figure 7) Fin-

    ishing burs on a high-speed handpiece, i not used cor-

    rectly, can easily notch a root surace. Even the thinnest

    o nishing burs or submicron diamonds are rounded

    and can notch root suraces. Te Lamineer tips are sae

    sided and come in decreasing diamond abrasive grits tonish and then polish the gingivoproximal suraces.

    Tere are times when a rotary instrument or even

    a reciprocating instrument does not have complete

    access to the interproximal surace. For these special

    situations, a hand instrument allows or ne control,

    precision placement and eective removal o excess

    composite resin. Hand instruments or this use include

    carbide-tipped composite instruments (with specialized

    shapes to access dierent tooth suraces), composite

    carving knives and a #12 scalpel blade.(28)

    Te nishing and polishing o the interproximal sur-

    aces o composite resin restorations require the same

    attention given to accessible suraces. Care should be

    taken not to aggressively nish interproximal suraces

    by removing excessive composite resin, resulting in an

    open proximal contact. Interproximal strips can be used

    to shape and contour the interproximal contact thus

    maintaining the proximal contact. When using nish-

    ing strips, always proceed rom medium abrasive grit to

    ne grit to the nest grit strips. Gapped nishing strips

    work best as they allow the operator ease o placement

    between the teeth. I there is diculty getting the strip

    through the contact, this can be accomplished using a

    plastic lling instrument to rapidly separate the teeth

    and then sliding the nishing strip below the interproxi-

    mal contact area. I the operator wants to use a diamond-abrasive gapped strip, (e.g.,Open centered lightening

    strips, Miltex), additional care must be taken to not re-

    move tooth structure when nishing the interproximal

    areas. Tese diamond impregnated strips work well in

    removing stain on interproximal tooth suraces beore

    the bonding procedure.

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    Intermediate nishing o the acial surace was ac-

    complished with a cup-shaped, rubber nisher, e.g,

    Astropol, Ivoclar-Vivadent; Jazz, SS White Burs, and

    Enhance, Dentsply-Caulk. For this case, a cup shape

    (Enhance) aords access to the gingival acial margin

    and contours to the acial surace.(Figure 8) I lobularacial orm is desired in the restoration, this can be ac-

    complished once the acial surace has been smoothed

    by using a disk-shaped rubberized abrasive. Te lingual

    surace was nished with an egg-shaped nishing bur (SS

    White Burs)(Figure 9). Te surace was then smoothed

    with a ame shaped point (Jazz, SS White Burs). Occlu-

    sion was checked beore the nal polish was completed.

    Te nal polish was accomplished with a composite

    resin polishing paste (Sparkle, Pulpdent) using a goats

    hair polishing wheel (Jiy Goat Brush, Ultradent) (Fig-

    ure 10). Foam cups (Luminescence, Premier Dental

    Products and Enhance oam cups, Dentsply-Caulk) can

    also be used eectively with composite resin polishing

    pastes. Another technique or attaining a smooth, high

    luster is using the nest grit aluminum oxide disk avail-

    able or the nest grit o rubber polishing point. Running

    the nest abrasive disk or rubber point above 18,000

    RPM creates a highly lustrous surace. Tis is due to

    both the polishing eect o the disk and the act that the

    disk heats the resin surace, creating a glassy appearance.

    Interproxmal areas can be urther polished with small

    width gapped ne abrasive nishing strips or composite

    resin polishing paste on a Lamineer plastic polishing tip(Dentatus) with the reciprocating handpiece. Te patient

    was pleased with the nal result. (Figure 11)

    disCussion:

    Te clinical success o nishing and polishing tech-

    niques can best be seen during the recall appointments

    o patients restorations. While the current generation

    o composite resins is highly polishable, this may not

    hold true or all cases. Te highly polished surace o

    resin-rich microlls are still prone to staining(38)

    . Te

    potential staining o composite resin suraces is direct-

    ly related to a patients oral habits including a patients

    diet (coee, iced tea, wine and other alcoholic bever-

    ages, cola beverages, tea), as well as other habits (smok-

    ing, chew tobacco, and the use o alcohol-containing

    mouth rinses). Te staining due to coee, tea and

    smoking arises rom the deposition o stain rom the

    oending agent. Alcoholic beverages and high percent-

    age alcohol-containing mouth rinses cause composite

    staining by soening the resin matrix o the composite

    resin.(39-42)

    Tis soened polymer matrix allows the pa-

    tient to abrade away the matrix leaving exposed ller

    particles and a slightly roughened composite resin sur-

    ace susceptible to staining. It has also been demon-

    strated that acidulated uorides can have an etching e-

    ect on glass ller particles leaving composites rougheras well.

    (43, 44)

    Oral maintenance o restorations and oral health can

    also have an impact on the appearance o composite res-

    ins. As stated earlier, high concentration alcohol mouth

    rinses can soen the resin matrix, leaving the compos-

    ite susceptible to toothbrush with toothpaste abrasion.

    Even without alcohol mouthrinses, toothpastes can a-

    ect composite smoothness.(3-5)

    For patients with signi-

    cant staining, some hygienists use air powder abrasive

    instruments to remove stain. Te sodium bicarbonate

    abrasive powder used to remove tooth stains can sig-

    nicantly roughen composite resin restorations.(45)

    Care

    must be taken when using these devices.

    Te gloss o the composite resin contributes to the

    overall aesthetic appearance o the restoration. It is

    possible that even ollowing all the recommendations

    or nishing and polishing composite resins to their

    highest luster, that outside inuences can have deleteri-

    ous eects on the smooth composite surace. Because

    o these potential adverse eects, composite resin res-

    torations need to be reassessed or repolishing at every

    recall. Te dental hygienist needs to be aware o poten-

    tially damaging eects o the pastes and stain removaldevices they use. Also, the dental hygienist should be

    instructed with techniques or repolishing composite

    resin restorations using ne abrasive aluminum oxide

    composite resin polishing pastes and disks.

    ConClusion:

    During the last several years, more polishable nano-

    lled composite resins have become available with the

    physical properties o hybrid composite resins. With

    these new composites have come new polishing sys-

    tems to include rubberized abrasives. Many o the

    instruments previously used to nish composite res-

    ins are still very useul with the newer composites. In

    order to attain the optimal nish or composite resins,

    it is important to ollow manuacturers recommenda-

    tions. Using a systematic technique rom nishing burs

    and diamonds, abrasive disks, rubberized abrasives and

    composite resin polishing paste, you should be able to

    impart an enamel-like luster to your composite resins.

    Care must be taken to reevaluate these restorations at

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    RefeRences1. Powers JM. Composite restorative materials. In Restorative Dental Ma-

    terials edited by Craig RG and Powers JM. Edition 11, Mosby Publish-

    ing, 2002 ; p. 232-258.

    2. Strassler HE, Polishing composite resins. J Esthet Dent, 1992; 4:177-179.

    3. Strassler HE, Mott W. Te surace texture o composite resin aer pol-ishing with commercially available toothpastes. Compend Contin Educ

    Dent 1988; 8:826-830.

    4. Serio FG, Strassler HE, Litkowski L, et al. Te eect o polishing pastes

    on composite resin suraces. J Periodont 1988; 59:838-840.

    5. Roulet JF, Roulet-Mjehrens K. Te surace roughness o restorative

    materials and dental tissues aer polishing with prophylaxis and polish-

    ing pastes. J Periodont 1982; 53:257-266.

    6. Neme AL, Frazier KB, Roeder LB, Debner L. Eect o prophylactic

    polishing protocols on the surace roughness o esthetic restorative ma-

    terials. Oper Dent 2002; 27:50-58.

    7. Goldman M. Fracture properties o composite and glass ionomer dental

    restorative materials. J Biomed Mater Res, 1985; 19:771-783.

    8. CRA Newsletter 2003; 27(1):1-2.

    9. Peyton JH. Direct restoration o anterior teeth: review o clinical

    technique and case presentation. Pract Proced Aesthet Dent 2002;

    14(3):203-210.10. Senawongse P, Pongprueksa P. Surace roughness o nanol and nana-

    hybrid resin composites aer polishing and brushing. J Esthet Restor

    Dent. 2007; 19:265-73.

    11. Almeida GS, Poskus L, Guimaraes JG, da Silva EM.

    12. Sensi LG, Strassler HE, Webley W. Clinical materials review: direct com-

    posite resins. Inside Dent. 2007; 3(7):76-79.

    13. Stanord WB, Fan PL, Wozniak W, Stanord JW. Eect o nishing on

    color and gloss o composites with dierent llers. J Am Dent Assoc

    1985; 110:211-213.

    14. Da Costa J, Ferracane J, Paravina RD, et al. Te eect o dierent polish-

    ing systems on surace roughness and gloss o various resin composites.

    J Esthet Restor Dent. 2007; 19:214-24.

    15. Korkmaz Y, Ozel E, Attar N, Aksoy G. Te inuence o one-step polish-

    ing systems on the surace roughness and microhardness o nanocom-

    posites. Oper Dent. 2008; 33:44-50.

    16. Barghi N. Surace polishing o new composite resins. Compend Cont

    Educ Dent 2001; 22:918-924.

    17. Duke ES. Finishing and polishing techniques or composite resins.

    Compend Cont Educ Dent 2001; 22:392-396.

    18. Barghi N. A guide to polishing direct composite resin restorations.

    Compend Cont Educ Dent 2000; 21:138-144.

    19. Ozgunaltay G, Yazici AR, Gorucu J. Eect o nishing and polishing

    procedures on the surace roughness o new tooth-coloured restor-

    atives. J Oral Rehabil 2003; 30:218-224.

    20. Reis AF, Giannini M, Lovadino JR, dos Santos Dias C. Te eect o six

    polishing systems on the surace roughness o two packable resin-based

    composites. Am J Dent 2002; 15:193-197.

    21. Pratten DH, Johnson GH. An evaluation o nishing instruments or an

    anterior and a posterior composite. J Prosthet Dent 1988; 60:154-158.

    22. Jeeries SR, Barkmeier WW, Gwinnett AJ. Tree composite nishing

    systems: a multisite in vitro evaluation. J Esthet Dent 1992; 4:181-185.

    23. Barkmeier WW, Cooley RL. Evaluation o surace nish o microlled

    resins. J Esthet Dent 1989; 1:139-143.24. Hoelscher DC, Neme AM, Pink FE, Hughes PJ. Te eect o three nishing

    systems on our esthetic restorative materials. Oper Dent 1998; 23:36-42.

    25. Setcos JC, arim B, Suzuki S. Surace nish produced on resin compos-

    ites by new polishing systems. Quintessence Int 1999; 30:169-173.

    26. Botta AC, Duarte Junior S, Paulin Filho PI, Gheno SM, Powers JM. Sur-

    ace roughness o enamel and our resin composites. Am J Dent. 2009;

    22:252-4.27. de Maraies RR, Goncalves L de S, Lancellotti AC, et al. Nanohybrid

    resin composites: nanoller loaded materials or traditional microhybrid

    resins. Oper Dent. 2009; 34:551-7.

    28. Strassler HE. Interproximal nishing o esthetic restorations. MSDA

    Journal 1997; 40(3):105-107.

    29. Strassler HE, Brown C. Periodontal splinting with a thin high-modulus

    polyethylene ribbon. Compend Contin Educ Dent 2001; 22:696-702.

    30. Helvey GA. Using pressable ceramics to achieve orthodontic correction.

    Pract Period and Aesthet Dent 2002; 14:223-227.

    31. Lowe RA. Instant orthodontics: an alternative esthetic option. Dent

    Prod Report 2002; 36(7):50-52.

    32. Ge J, Lemon M, Lu H, Stansbury JW. Dimer acid-der ived dimethac-

    rylates as diluents monomers in restorative resins. J Dent Res (Special

    Issue A); 2005; 84: abstract no. 1470.

    33. Lu H, Newman SM, Bowman CN, Stansbury JW. Dimer acid derived

    dimethacrylate or ternary dental restorative resins. J Dent Res (SpecialIssue A). 2006; 85:abstract no. 32.

    34. Bracho-roconis C, Rudolph S, Boulden J, Wong N, et al. Characteriza-

    tion o a new dimer acid based resin nano-hybrid composite. J Dent Res

    (Special Issue A). 2008; 87: abstract no. 81.

    35. Bracho-roconis C, Rudolph S, Garnhart A, Boulden J. New low-

    shrinkage dimer acid based microhybrid composite physical properties.

    J Dent Res (Special Issue A). 2007; 86: abstract no. 1290.

    36. Burgess J. Comparison polishing o nanolled composites. Compend

    Contin Dent Educ (Supplement). 2010; 31(2):9-11.

    37. Ritter H, Lee SS. Clinical evaluation o NDurance nano-dimer con-

    version technology dental composite J Dent Res. 2009; 89(Special Issue

    IADR Abstracts): Abstract 1006.

    38. Luce MS, Campbell CE. Stain potential o our microlled composites. J

    Prosthet Dent 1988; 60:151-154.

    39. McKinney JE, Wu W. Chemical soening and wear o dental compos-

    ites. J Dent Res 1985; 64:1326-1331.

    40. Settembrini L, Penugonda B, Scherer W, Strassler H, Hittelman E. Al-

    cohol containing mouthwashes: eect on composite color. Oper Dent

    1995; 20:14-17.

    41. Penugonda B, Settembrini L, Scherer W, Hittelman E, Strassler H. Alco-

    hol-containing mouthwashes: eect on composite hardness. J Clin Dent

    1994; 5:60-62.

    42. Almeida GS, Poskus L, Guimaraes JG, Da Silva EM. Te eect o

    mouthrinses on salivary absorption, solubility and surace degradation

    o a nanolled and a hybrid resin composite. Oper Dent. 2010; 35:105-

    11.

    43. Kula K, Nelson S, Kula , Tompson V. In vitro eect o acidulated

    phosphate uoride gel on the surace o composite with dierent ller

    particles. J Prosthet Dent 1986; 56:161-167.

    44. Soeno K, Matsumura H, Atsuta M, Kawasaki K. Inuence o acidulated

    phosphate uoride agent and eectiveness o subsequent polishing on

    composite material suraces. Oper Dent 2002; 27:305-310.

    45. Cooley RL, Lubow RM, Patrissi GA. Te eect o an air-powder abrasiveinstrument on composite resin. J Am Dent Assoc 1986; 112:362-364.

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    ConTinuing EduCaTion TEsT QuEsTions

    test questions

    1. Usully h phiii us lih-cucpsis is

    a. silane

    b. glass llersc. camphoroquinoned. Bis-GMA

    2. micll cpsis f hih plishbiliywih h-lik sluccy, bu uuly iluc. T hih plishbiliy hbiliy ii hi lus icllcpsis is u h us cllil silicpicls h c b wihi h ply ix(hus icll) ix wih hply ix, lih cu, cush k pply ll h is l s

    ic ll wihi h icll cpsi(hus icll). T ll picl siz h cllil silic picls is

    a. 0.04 micrometersb. 0.4-0.9 micrometersc. 1-3 micrometersd. 5-15 micrometers

    3. a w clss ll cpsi sisf h cliici cbii ipvphysicl ppis

    a. better ow to adapt to marginsb. higher polishabilityc. expanded shades or improved shade selection

    and the ability to match incisal, enamel anddentin shades.

    d. b and c

    4. nll cpsis hv ll picls wih i i

    a. 0.005-0.1 micrometersb. 0.5-5 micrometersc. 5-10 micrometersb. 20-50 micrometers

    5. all h llwi ll cpsi

    sis eXCePt:a. IPS Empress Directb. Esthet-X HDc. NDuranced. Smoothy

    6. T sis biliy ii i ppch h / jc h will b bsup h pp us bsivs ish

    plish h siv is hihs lus.rsch hs shw h h chiqu plishi cpsi si is pilshss lss is puc spcic cpsi si spcic.

    a. Both statements are trueb. Te rst statement is true, the second statement is

    alsec. Both statements are alsed. Te rst statement is alse, the second statement is

    true

    7. all h llwi isus

    vics ish plish cpsisis eXCePt:a. coated abrasives, e.g, abrasive nishing disks and

    stripsb. ultrasonic scaling tipsc. carbide nishing bursd. submicron diamond abrasives

    8. gss ishi cui c sily bccplish wih

    a. nishing bursb. submicron nishing diamondsc. coarse and medium grit disksd. all the above

    9. T is wh plci icpsi si h xcss h iivlipxil i s b v. Tisxcss c b v usi

    a. a Pron reciprocating handpiece with a Lamineertip abrasive tip

    b. a nishing diskc. #12 scalpel bladed. a and c

    10. iishi ipxil sucs s

    scib i his icl iclu ll hllwi eXCePt:

    a. gapped nishing and polishing strips covered withaluminum oxide abrasive particles

    b. metal strips with submicron diamondsc. dental oss with zirconia abrasive

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    ConTinuing EduCaTion TEsT QuEsTion

    CUTALONGD

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    LINE

    11. occsilly, wh plci ipxilsis wih cpsi sis, h jch y b h. a chiqu scib i

    h icl sp h h usi ila. jackhammerb. routerc. sawd. hammer

    12. t chiv h hihs lus cpsisi, h h l sp plishiwul b

    a. nishing burb. submicron nishing diamondc. composite resin polishing pasted. air abrasion

    13. il plish h cpsi si suc iss lusus ish c ccplish usi iskswih h s luiu xi bsiv. Usi isk will ly sh h si suc, bu ils hs h suc ci hih lus. Tishi h suc cuss h ply ix ch is_______________________________.Tis ph ivs h cpsi si lssy ppc.

    a. waxed smoothnessb. glass transition temperaturec. ller mosaic polishd. polymer matrix interstitial exure

    14. T pi wih ic shic bi ihis icl h h iscli u

    a. tetracycline stainingb. demineralization due to bacterial plaque retained by

    orthodontic bracketsc. endodontic stainingd. hypoplastic white spots

    15. T chic cpsi si s hi h h pi i h cs pis lw shik cpsi wih hih

    ubl b cvsi h hs uiqucpsi chisy bs up

    a. dimer acid monomersb. glyomonersc. resinomersd. pleobisphenol dimethacrylate

    16. T ii piiz lls wh ypk nduc cpsi si sy isiuishi iphs pvi w sisc.

    a. Ytterbium uorideb. barium glassc. silicad. all the above

    17. T pil sii cpsi si sucs isicly l pis l hbis iclui pis i (cf, ic , wi h lchlicbvs, cl bvs, ), s wll s h hbis(ski, chw bcc, h us lchlcii uh iss). T sii u cf, ski iss h psii si h fi .

    a. Both statements are trueb. Te rst statement is true, the second statement is alsec. Both statements are alsed. Te rst statement is alse, the second statement is true

    18. alchlic bvs hih c lchl-cii uhiss c k cpsi sisuscpibl sii bcus hy

    a. cause loss o ller particles through chemicaldissolution

    b. soen the polymer matrix o the composite resinmaking them more susceptible to wear and suraceroughening

    c. cause microractures in the composite resin suraced. cause a change in chemical polarity o the composite

    surace making it more susceptible to attract stain

    19. dui l pphylxis ppis, h lhyiis c uh cpsi si sucski h suscpibl sii by

    a. using prophylaxis pastes with a prophylaxis cupb. using an air-powder (sodium bicarbonate abrasive

    particle) abrasion to remove surace stainsc. using an acidulated uoride that can etch glass ller

    particlesd. all the above

    20. T l hyiis c hlp ii h lus plish cpsi sis by

    a. polishing the surace with prophylaxis pastes.b. polishing the composite restorations with ne abrasive

    aluminum oxide composite resin pastes and disks.c. cleaning the composites with diamond air abrasion

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    Cet Ccept f P ate Cmpte re

    ansWEr kEy Course Order Number [4235-169]

    name: _________________________________________________________________

    title: (circleone) dds dmd rdh cdh rda cda efda

    address: ______________________________________________________________

    city:__________________________state: _________zip: ______________________

    telephone: home ( )________________office ( ) _______________________

    Mailing insTruCTions:When you fnish reading the course text, use the orm to submit your an-swers to the sel test. Fill in the correct box or each question indicating your answer. Pen or pencil may beused. There should be only one correct answer or each question. Upon completion o the course, mail theanswer sheet to: Benco Dental, Attn: Education Department, 295 CenterPoint Boulevard, Pittston, PA 18640

    noTE: We recommend that you photocopy your answers beore mailing this course. This will ensurethat you have a record o your course completion in case o loss due to postal system error.

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    o Please check i you would like to receive your score with your certifcate o completion.