Louis Mackenzie
Adrian CC Shortall and FJ Trevor Burke
Figure 1. (a, b) Occluso-lingual restoration of a lower second molar in Clearfil Majesty (Kuraray, Japan).
DentalUpdate 71
RestorativeDentistry
Figure 2. (ac) Preventive resin restorations in an upper second molar using X-Flow (Dentsply International, Inc York, PA, USA).
Figure 3. (ac) Occlusal restoration of an upper molar in APX (Kuraray, Japan). Unsupported enamel can be retained, after preparation, if composite is
selected.
72 DentalUpdate
RestorativeDentistry
Figure 4. (ac) Disto-occlusal restoration of a lower premolar in Clearfil Majesty (Kuraray, Japan).
b
Figure 6. (a, b) Cosmetic replacement of an occlusal amalgam using Filtek Silorane (3M ESPE, St Paul,
MN, USA).
74 DentalUpdate
Case selection
Patients should have an
acceptable level of oral hygiene, as
restorations formed in resin composite
have been considered to attract greater
levels of pathogenic bacteria than amalgam
restorations.11 Occlusal contact(s) on enamel
may be considered desirable and, ideally,
all cavity margins should be in enamel. In
this respect, a superior prognosis can be
expected from a restoration bonded to an
uninterrupted enamel margin.18
Contra-indications
RestorativeDentistry
Figure 7. (ac) Direct composite (Clearfil Majesty Kuraray, Japan) used to relieve symptoms of a cracked lower molar.
RestorativeDentistry
Figure 8. (ac) Examples of two surface restorations in Synergy Duo (Coltne-Whaledent, Switzerland) 79 years post-placement. Despite excellent handling
and aesthetic properties, this material has been superseded by a new nano-technology product.
Packable composites
Unfortunately, manufacturers
may be driven by market forces to launch
new composites regularly.5 Accordingly, by
the time independent research has revealed
deficiencies, these products may have
been withdrawn.5 Even more annoyingly,
composites with proven excellent long-term
clinical performance may be discontinued
in favour of further innovative materials and
concepts5 (Figure 8).
Even the best laboratory research
is only partially capable of predicting clinical
performance.12 Clinical trials are the ultimate
tool for evaluation, but poor quality data
and lack of standardization can make results
difficult to interpret.12 It has therefore been
recommended that efforts should be made
to meet published standards for improving
the quality of randomized trials,12 as it is
the patient and dentist who will face the
consequences of an underperforming
material.5 It has also been recommended
that, prior to marketing, it is desirable
to evaluate a dental restorative material
76 DentalUpdate
RestorativeDentistry
Cavity preparation
March 2009
DentalUpdate 79
RestorativeDentistry
Figure 12. MODB restoration of an upper premolar (Filtek Silorane, 3M ESPE, St Paul, MI, USA) displaying
anatomically correct proximal contour.
Matrices
Figure 14. Sectional matrices (top 3: Garrison
Dental Solutions, Springlake, MI, USA; bottom:
TrioDent, New Zealand).
Tunnel restorations
80 DentalUpdate
RestorativeDentistry
DentalUpdate 83
RestorativeDentistry
Etching
84 DentalUpdate
Improvements in modern
materials and adhesive technology have
overcome many of the historical problems
associated with posterior composites,4,6,8
such as poor wear resistance, as well as
practical, technical difficulties, such as contact
formation. Many of the remaining problems
associated with posterior composites are a
direct or indirect result of polymerization
shrinkage.34 On setting, all composites shrink
(on average 2-3% by volume)13 as the matrix
monomer converts to polymer. On shrinking,
stresses are invariably generated within the
material and at the margins; the magnitude
of this stress depends on the composition of
the composite and its ability to flow before
solidification, which in turn is related to the
cavity configuration.35 The Configuration
Factor (C-factor) is the ratio of bonded to
free cavity surfaces. Narrow/deep occlusal
cavities, with only one unbonded surface,
have the greatest C-factor and are therefore
subject to an increased potential for stress
development. 24 The larger the increment of
composite, the greater the total shrinkage
will be; this will again increase the potential
for stress formation.
RestorativeDentistry
Despite improvements in
materials and techniques, post-operative
sensitivity following placement of posterior
composites may arise4,11 if care is not
taken to avoid the problems caused by
polymerization contraction shrinkage or
March 2009
DentalUpdate 87
RestorativeDentistry
Open sandwich
Composite placement
Figure 27. (a) Adhesive applied to an occlusal cavity in a lower first molar: (b) mesio-lingual increment; (c) disto-lingual increment; (d) disto-buccal increment;
(e) centro-buccal increment; (f) mesio-buccal increment.
88 DentalUpdate
March 2009
RestorativeDentistry
RestorativeDentistry
Figure 29. (a) Isolation. (b) Pre-operative impression of the occlusal surface (silicone putty is used here). (c) Impression must record morphology accurately. (d)
Access to lesion. (e) Cavity preparation complete. (f) Incremental restoration up to ADJ. (g) Final increments of composite applied and silicone index seated
over the unset material. (h) Minimal excess to be removed before curing. (i) Finished restoration requires no occlusal adjustment.
90 DentalUpdate
A multitude of specialized
instruments are now available for use with
posterior composites, designed to simplify
placement and shaping.13
It is vital that they are kept
spotless and unscratched, in order to prevent
RestorativeDentistry
Light curing
Figure 30. (a) P.K.T 2 (b) P.K.T 3 (both instruments are available from many dental and technical suppliers).
(c, d) Multi-function composite instrument (Garrison Dental Solutions, Springlake, MI USA).
Shaping/finishing/polishing
Figure 31. Bertolotti Top-Spin diamonds (Pollarddental, CA, USA). Specialized composite finishing
burs for accurate shaping of fissures and fossae.
RestorativeDentistry
14.
15.
16.
Figure 33. Super-snap finishing and polishing discs (Shofu Dental Corporation, San Marcos, CA, USA).
a
Acknowledgment
References
1.
2.
3.
4.
5.
6.
c
7.
8.
9.
10.
11.
12.
Conclusion
Posterior composites, while time
consuming and demanding, can yield great
patient and dentist satisfaction. Learning and
mastering techniques is well worth the effort.
94 DentalUpdate
13.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
March 2009
RestorativeDentistry
29.
30.
31.
32.
33.
34.
35.
March 2009
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
DentalUpdate 95
Anterior composites
Magnification
Loupes (+ light) (2.4-2.5 x magnification) www.orascoptic.com
Photography
Intra-oral camera
Digital SLR:
Macro lens / Ring flash / Mirrors / Retractors / Contraster
www.dentalphotographyinpractice.com
Anaesthesia
Topical anaesthetic www.optident.co.uk
Articaine LA (Septanest) www.septodont.co.uk
Tooth preparation
Aquacut quattro (Air abrasion) www.velopex.com
Intracoronal brushes www.optident.co.uk
FenderWedges www.directadental.com
Microprep burs www.kometdental.co.uk (West one dental)
Pear-shaped diamond bur (cavity prep) www.diatech.com
Rose-head stainless steel burs various
T.C burs Jet 1169/170 www.claudiusash.co.uk
End cutting diamond burs www.diatech.com
Hand excavator LM 63-64/65-66 Xsi www.js-davis.co.uk
Enamel hatchet (various)
Gingival margin trimmers www.js-davis.co.uk
Mesial 1.2 LM 125-126 XSi / Distal 1.2 LM 121-122 XSi
Matrix systems
Composi-tight 3D Sectional matrix kit www.optident.co.uk
Pin Tweezers (matrix removal) www.triodent.com
SuperMat Matrix kit www.kerrdental.co.uk
SuperMat Matrix bands (2182) www.kerrdental.co.uk
Trimax contact forming instrument www.optident.co.uk
Perform contact forming instrument www.optident.co.uk
Materials
Vitrebond (RMGI) (indirect pulp cap) www.3M.co.uk
Etch and rinse adhesive (XP Bond) www.dentsply.co.uk
Self-etching primer and adhesive (SE Bond) www.js-davis.co.uk
Universal adhesive (ScotchBond Universal) www.3M.co.uk
Fissure sealant (Fissurit) (Voco) www.voco.com
Majesty Flow www.js-davis.co.uk
Majesty esthetic (Hybrid)(Kuraray) www.js-davis.co.uk
SDR (Bulk-fill flowable composite) www.dentsply.co.uk
SonicFill (Bulk-fill) www.kerrdental.co.uk
Biscover - Composite sealant www.optident.co.uk
Fibreposts (Radix Fibrepost kit) www.dentsply.co.uk
Biodentine (direct pulp cap) www.septodont.com
Shaping & Finishing
Garrison composite instrument TN009 www.optident.co.uk
Composite shaping instrument CW 102 www.coltene.com
Bertolotti Top-spin diamonds Size T2/T3 (F/ SF/UF)
(Phone USA) 001(805) 495-5222
Composite finishing burs 860 (bullet) 852 (short needle) 801
(small round) www.diatech.com
Isolation
Hygenic rubber dam kit www.coltene.com
Rubber dam (Blue/med/non-latex) www.perfectionplus.com
Rubber dam clamps (12A/13A) www.coltene.com
Plastic rubber dam frame DTE20/5554 www.qedendo.co.uk
Dam stabilizing cord (Wedjets) www.coltene.com
Amalgam
Amalgam removal bur FG S1158 XY www.trihawk.com
AutoMatrix kit www.dentsply.co.uk
Flexiwedges www.optident.co.uk
Tytin Amalgam www.kerrdental.co.uk
Amalgam condensers www.js-davis.co.uk
1.0-1.5mm LM 340-360 / 1.2-2.0mm LM 350-380 /
1.8-2.5mm LM 370-390
Frahms Carver 62004006 www.dentsply.co.uk
P.K.T 3 burnisher various
Hollenback carver (Flexichange) www.dentsply.co.uk
Discoid-Cleoid Carver LM 731-732 www.js-davis.co.uk
Amalgam burnisher LM 31-32 www.js-davis.co.uk
Panavia F 2.0 luting resin (Bonded amalgam + RBB) (Kuraray)
www.js-davis.co.uk
Resinomer amalgam bonding resin www.optident.co.uk
References
Textbooks www.quintpb.co.uk
Papers
Online CPD
www.dentaljuce.com
RestorativeDentistry
Louis Mackenzie
FJ Trevor Burke and Adrian CC Shortall
Isolation
Placement of direct restorations
in the molar regions can present difficulty
with regard to moisture control. Use of rubber
dam with a single hole and a versatile winged
molar clamp (Hygenic 12A, Coltne-Whaledent,
Switzerland)) provided rapid isolation, which
Louis Mackenzie, BDS, General Dental
Practitioner and Clinical Lecturer,
FJ Trevor Burke, DDS, MSc, MGDS
FDS RCS(Edin), FDS RCS(Eng), FFGDP
FADM, Professor of Primary Dental Care,
Primary Dental Care Research Group and
Adrian CC Shortall, BDS, DDS, Reader
in Restorative Dentistry, University of
Birmingham School of Dentistry, St
Chads Queensway,Birmingham B4 6NN,
UK.
April 2012
Occlusal template
As carious demineralization had
Figure 2. Isolation.
RestorativeDentistry
Access
Using a small round bur, access
to the carious lesion was gained through
the cavitated pit and extended only to allow
visualization and assessment of underlying
dentinal caries. (Figure 6).
212 DentalUpdate
Etching
Phosphoric acid (37% ) was used
to etch the whole cavity and 1mm beyond the
margins (Figure 8).
Etch 37 (Bisco Inc, Schaumburg,
IL, USA) was chosen as it flows easily into
Adhesive
Adhesive (XP Bond, Dentsply
International Inc, York, PA,USA) was applied to
the whole cavity and just beyond the margins,
using a Microbrush (Microbrush international
Grafton, US). Gentle airflow was then used
until no ripples were evident. This reduced the
likelihood of adhesive pooling and confirmed
that the solvent had evaporated. The adhesive
was then light-cured for 40 seconds with the
light tip as close to the cavity as possible. The
cavity was inspected to ensure that a uniform
glossy/shiny adhesive layer coated the entire
cavity9 (Figure 10).
April 2012
RestorativeDentistry
Light cure
Once the template was removed
the restoration received a further 60 seconds
light-cure to maximize polymerization
(Figure 16).
Excess removal
The restoration was inspected
for marginal excess (Figure 17), which was
easily removed from unetched enamel using a
DentalUpdate 215
RestorativeDentistry
References
Figure 16. Further light-curing.
Review
At review (interval based on
caries risk or, as in this case, need for further
dentistry) all aspects of the completed
restoration were studied (Figure 20).
Figure 18. Occlusal check.
Occlusal check
Articulating paper was used
to confirm that the restoration conformed
precisely to the patients pre-existing occlusal
scheme, in both the intercuspal position and
all excursions (Figure 18).
Finished restoration
The restoration was inspected
(Figure 19). At this stage the surface may be
refined, polished or coated with a solventfree surface sealer, depending on operator
preference.9
216 DentalUpdate
Discussion
Direct posterior composite
restorations offer many benefits
to both patient and dentist that
go far beyond the fact that the
restorations are tooth-coloured.
New materials, equipment and techniques
will continue to improve the quality,
predictability and success of direct
composite restorations. Such methods will
also promote minimally invasive caries
management, maximizing the amount of
tooth tissue preserved. This will increase
the longevity, not of just the fillings placed,
but of the teeth that they restore.
Precise notation of the
materials employed during each restorative
procedure will provide each dentist with
an invaluable evidence base for the longterm audit of their successful operative
techniques.
1.