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Posterior composites: A practical guide revisited

Article  in  Dental update · April 2012

DOI: 10.12968/denu.2012.39.3.211 · Source: PubMed

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 RestorativeDentistry

Louis Mackenzie

FJ Trevor Burke and Adrian CC Shortall

Posterior Composites: A Practical

Guide Revisited
Abstract: Direct placement resin composite is revolutionizing the restoration of posterior teeth. Compared to amalgam, its use not only improves
aesthetics but, more importantly, promotes a minimally invasive approach to cavity preparation. Despite the benefits, the use of composite to
restore load-bearing surfaces of molar and premolar teeth is not yet universally applied. This may be due to individual practitioner concerns over
unpredictability, time and the fact that procedures remain technique sensitive for many, particularly with regard to moisture control, placement
and control of polymerization shrinkage stress. New materials, techniques and equipment are available that may help to overcome many of these
concerns. This paper describes how such techniques may be employed in the management of a carious lesion on the occlusal surface of an upper
molar.
Clinical Relevance: Direct posterior composite is the treatment of choice for the conservative restoration of primary carious lesions.
Dent Update 2012; 39: 211–216

Detection and diagnosis

A Class I carious lesion (ICDAS
3)1 was detected in the mesial pit of an upper
second molar (Figure 1). The lesion was
diagnosed as active with respect to enamel
cavitation exposing dentine. In addition the
patient’s dietary habits, oral hygiene measures
and the presence of active lesions elsewhere
indicated the need for operative intervention.

Isolation
Figure 1. A cavitated Class I carious lesion in an
Placement of direct restorations
upper second molar. Figure 2. Isolation.
in the molar regions can present difficulty
with regard to moisture control. Use of rubber
dam with a single hole and a versatile winged
was completed (Figure 2) by flossing the dam left the occlusal surface virtually intact, in
molar clamp (Hygenic 12A, Coltène-Whaledent,
through the mesial contact point. The speed this case a template was used to facilitate
Switzerland)) provided rapid isolation, which
with which this technique achieves isolation provision of an anatomically accurate final
and promotes a comfortable experience for restoration. Fabrication of a template
Louis Mackenzie, BDS, General Dental the patient and a predicable outcome for may be achieved using a pre-operative
Practitioner and Clinical Lecturer, the operator cannot be overemphasized. impression gained by injecting a small
FJ Trevor Burke, DDS, MSc, MGDS Although the vast majority of practitioners do amount of a clear polyvinyl siloxane material
FDS RCS(Edin), FDS RCS(Eng), FFGDP not routinely use rubber dam,2 the isolation of (Memosil 2, Heraeus Kulzer, Germany) onto
FADM, Professor of Primary Dental Care, a single tooth for an occlusal restoration is a the occlusal surface3,4 (Figure 3). After
Primary Dental Care Research Group and perfect starting point for those wishing to learn waiting for the material to partially set, finger
Adrian CC Shortall, BDS, DDS, Reader and refine rubber dam techniques. pressure (Figure 4) was applied to accurately
in Restorative Dentistry, University of capture the occlusal morphology. Once set,
Birmingham School of Dentistry, St the template was removed (Figure 5) and
Chad’s Queensway,Birmingham B4 6NN, Occlusal template the mesial surface marked with a felt pen to
UK. As carious demineralization had assist orientation when reapplied later.
April 2012 DentalUpdate 211
 RestorativeDentistry

Figure 3. Template material injected on to the

occlusal surface. Figure 6. Access to lesion.
Figure 9. Etched cavity after washing/drying.

undercut cavity forms. Etching was further

optimized by agitating the etchant with an
appropriate instrument.

Wash and dry

After 15 seconds the etchant was
thoroughly washed off. The cavity was then
Figure 4. Template material adapted to capture
occlusal morphology. Figure 7. Cavity preparation complete. dried with gentle airflow, taking care not to
desiccate the dentine. The aim is to achieve a
visibly moist dentine cavity floor (and walls)
with no obvious pooling of water.9 When total
etch adhesive systems are employed, careful
control of dentine moisture is essential for
optimization of adhesion and prevention of
post-operative sensitivity. While the ‘frosty’
appearance of enamel walls is a reassuring
sign that a predictable enamel bond (and
thus marginal seal) will be achieved (Figure
9), it may also signal an increased likelihood
of over dry dentine. If dentine desiccation is
Figure 5. Pre-operative template. suspected it may be rehydrated with water,9
Figure 8. Acid etch applied. applied using an appropriate brush.

Adhesive
Access excavation5,6,7 (Figure 7). Adhesive (XP Bond, Dentsply
Using a small round bur, access Removal of only irreversibly International Inc, York, PA,USA) was applied to
to the carious lesion was gained through demineralized tooth tissue is a fundamental the whole cavity and just beyond the margins,
the cavitated pit and extended only to allow aim of contemporary caries management,5–7 using a Microbrush (Microbrush international
visualization and assessment of underlying as it maximizes the amount of residual healthy Grafton, US). Gentle airflow was then used
dentinal caries. (Figure 6). tooth tissue5–9 and improves the prognosis for until no ripples were evident. This reduced the
long-term pulpal health by minimizing trauma likelihood of adhesive pooling and confirmed
to the dentine/pulp complex.5–7 that the solvent had evaporated. The adhesive
Minimally invasive preparation was then light-cured for 40 seconds with the
Using appropriate burs, peripheral Etching light tip as close to the cavity as possible. The
caries excavation was carried out to remove Phosphoric acid (37% ) was used cavity was inspected to ensure that a uniform
soft carious dentine and fragile overhanging to etch the whole cavity and 1mm beyond the glossy/shiny adhesive layer coated the entire
enamel only. Pulpal caries was then excavated margins (Figure 8). cavity9 (Figure 10).
using a hand excavator and extended only Etch 37 (Bisco Inc, Schaumburg,
until there was moderate resistance to gentle IL, USA) was chosen as it flows easily into
212 DentalUpdate April 2012
 RestorativeDentistry

one increment has a significant time-saving

benefit;11
 The technique is easy to learn and simple
to use;11
The SDR™ layer was then light-
cured for 20 seconds.

Placement (‘Enamel layer’)

A single increment of a traditional
hybrid composite was then placed over the
Figure 13. ‘Enamel’ increment of hybrid
layer of SDR™, which is not designed to restore
composite applied. right up to the occlusal surface as a result of:
Figure 10. Adhesive applied.
 Inferior optical properties conveyed by the
material’s translucency;
 Wear resistance lower than that of a
conventional hybrid composite.
Care was taken to apply just the
right amount of hybrid material (Figure 13) to
minimize excess and prevent under fill that
would increase the tendency for poor marginal
adaptation and void formation.

Use of the template

Figure 11. Bulk-fill restoration of ‘dentine layer’ Figure 14. Template re-applied to adapt final
To facilitate adaptation and
using SDR™. composite increment. shaping of the final increment, the pre-
operative occlusal template was applied to the
unset material (Figure 14). The light tip was
then firmly applied to the translucent template
during a (minimum) 60 second light cure
(Figure 15).
This technique has three main
benefits:4
 Application of the template may reduce
the potential for oxygen inhibition of the
polymerization reaction occurring on the
surface of the restoration;
 The morphology of the original occlusal
surface is accurately reproduced;
Figure 15. Composite light-cured through
 A significant amount of time may be saved
Figure 12. SDR™ compule. template
when this technique is employed. (Although
this may be cancelled out by the time taken to
make the template3).
property optimizes marginal adaptation into
Placement (‘dentine layer’) undercut cavities;
In this case, the entire ‘dentine  Cannula delivery obviates the need for
Light cure
layer’ was restored in one increment, using instrumentation, thus reducing the tendency Once the template was removed
a flowable composite designed for this for marginal voids and layers between the restoration received a further 60 seconds
purpose ( SDR™, Smart Dentine Replacement, increments; light-cure to maximize polymerization
Dentsply International Inc, York, PA, USA)  Translucency of the material facilitates (Figure 16).
(Figure 11). depth of cure up to 4 mm in one increment;
SDR™ (Figure 12) is an innovative  Reported low polymerization shrinkage
flowable posterior composite offering a stress10 reduces the risk of post-operative
Excess removal
number of potential benefits with regard to sensitivity that is usually associated with bulk- The restoration was inspected
reducing placement technique sensitivity: fill techniques; for marginal excess (Figure 17), which was
 Flowable consistency and ‘self-levelling’  Restoration of the majority of the cavity in easily removed from unetched enamel using a

April 2012 DentalUpdate 215

 RestorativeDentistry

With patient consent,

photographic images taken before, during
and after operative procedures may be
used as a powerful motivational tool to
help explain the disease process when
encouraging patients to reduce their caries
risk and to demonstrate the benefits of
modern minimally invasive dentistry.

References
1. Diniz M, Lima L, Eckert G, Zandona AF,
Figure 16. Further light-curing. Figure 19. Completed restoration.
Cordeiro R, Pinto LS. In vitro evaluation of
ICDAS and radiographic examination of
occlusal surfaces and their association with
treatment decisions. Oper Dent 2011 Mar-
Apr; 36(2): 133–142.
2. Gilbert GH, Litaker MS, Pihlstrom DJ,
Amundson CW, Gordan VV. Rubber dam
use during routine operative dentistry
procedures: findings from the Dental PBRN.
Oper Dent 2010 Sep-Oct; 35(5): 491–499.
3. Hamilton JC, Krestik KE, Dennison JB.
Evaluation of custom occlusal matrix
technique for posterior light-cured
Figure 17. Minimal excess for removal. Figure 20. Review. composites. Oper Dent 1998; 23: 303–307.
4. Geddes A, Craig J, Chadwick RG.
Preoperative occlusal matrix aids the
development of occlusal contour of
Review posterior occlusal resin composite
restorations – clinical rationale and
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techniques. Br Dent J 2000 May; 188(9):
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Figure 18. Occlusal check. Discussion
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216 DentalUpdate April 2012

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