Direct Posterior Composites: A Predictable Approach
A 25-year-old healthy male presented for comprehensive treatment planning. Intraoral exam showed occlusal caries on teeth Nos. 30 and 31. The patient was shown the active caries with different imaging modalities and educated about the disease process. Following a discussion about the benefits and potential complications of treatment as well as treatment alternatives, the patient opted for direct composite restorations. Posterior composites pose a difficulty to the clinician because they are technique sensitive, subjected to greater occlusal forces, and can potentially exhibit higher rates of wear. Therefore, certain careful clinical parameters should be taken into account to ensure a successful and predictable result such as isolation, bonding protocol, and material handling. Many composite types exist on the market for a variety of purposes in this clinical application, including the bulk fill. However, inadequate curing is a common cause of failure facilitated by insufficient light energy penetrating the full depth of material and excess polymerization shrinkage common with large increment placement. The outlined protocol has shown reliable results in form, function, and esthetics. Patient education and understanding of home care is equally important to maintain the restorations.
The patient was shown the affected teeth first with the CamX Polaris (Air Techniques) to visualize the problem, then with the CamX Spectra caries detector (Air Techniques) to show tooth structure with numerical values. These were explained to the patient and aided in patient acceptance and understanding of the procedure. Caries were excavated and the teeth were restored under rubber dam isolation. Both preparations were cleaned with chlorhexidine gluconate, followed by 1 mm increment placement of TheraCal LC (BISCO) with a 20-second cure time. This liner is used under all restorations to help prevent any postoperative symptoms and create an alkaline anti-microbial environment. Because TheraCal LC is hydrophilic, a moist environment is necessary for placement and ensuring success. The clinician may also choose to place the liner first and then etch, which is common; regardless of order, the clinician must maintain a moist, non-desiccated environment. This will also aid in a predictable bond strength by keeping dentinal tubules open and decreasing postoperative sensitivity. The cavosurface margins were selectively etched, followed by application of bonding agent. An initial layer of heavy flowable composite (GrandioSO Heavy Flow, VOCO) was placed on the pulpal floor to adapt to any irregularities. The teeth were restored free-hand incrementally in layers with GrandioSO (VOCO) of varying shades to restore form and function. This 89% filler by weight universal nano-hybrid composite shows excellent polishability, wear resistance, and low polymerization shrinkage. The small increments also aid in having full control over re-creating anatomy and adaptation. Polishing burs with copious irrigation on a high-speed handpiece were used to finish.