Minimizing Removal, Maximizing Esthetics
With direct, adhesively bonded composite resin, contemporary dentists are able to deliver minimally invasive, esthetic results to patients when restoring
Class I decay. However, intrinsic and extrinsic factors—including prep design, pathological agents, overall caries risk, and moisture control—add to the complexity of these otherwise straightforward composite restorations.
In this case report, a healthy 26-year-old male presented for his routine cleaning and exam. The exam revealed occlusal caries on 6 of his 8 molars (Figure 1), making him a high-caries-risk patient. Estimated sizes of the lesions, age, salivary flow, oral hygiene, and use of a high-strength fluoride treatment were weighed to assist the patient and clinician in deciding on the best treatment outcomes. After reviewing all parameters, we decided to proceed with conservative composite restorations.
With no pain or sensitivity reported, the rational starting point was to treat the deepest decay first—teeth Nos. 18 and 19. In an effort to mitigate risk factors and create a sound, pain-free restoration, the following steps were taken: rubber dam isolation to combat intraoral humidity and the pooling of saliva; biomimetic techniques to reduce stresses created by the high configuration factor of the prep; and a high-quality polishing technique to ensure minimal plaque retention and reduce risk of recurrent decay.
The Procedure
After obtaining profound anesthesia, Nos. 18 and 19 were isolated with the use of a heavyweight rubber dam retained by a #13A clamp on No. 18. Guided by the use of caries detection dye (Figure 2), the occlusal caries were removed using a carbide bur. Caries detection dye was used for appropriate caries end-point removal and establishment of the peripheral seal zone (Figure 3). Completion of the prep included beveling the enamel margins.
The selective-etch technique was completed using 37% orthophosphoric acid (Super Etch, SDI) for 20 seconds before rinsing and drying. Two layers of a universal adhesive (Zipbond Universal, SDI) were applied and each was gently agitated for 30 seconds. A clean microbrush was used to remove pooling of the adhesive in the deepest part of the cavity prep. The adhesive was cured for 20 seconds (Radii Xpert, SDI) and covered with a thin layer (0.5 mm) of flowable composite (Aura Easyflow, SDI), which was cured for 20 seconds. Following a rest period of 5 minutes for bond maturation (Figure 4), an A3 composite (Luna, SDI) was placed at angled increments of 1–1.5 mm, minimizing stresses. Each layer was cured for 20 seconds.
A dark yellow shade modifi er (SDI Shade Modifi cation system) was used to better match the patient’s yellow dentin (Figure 5). The final layer of composite was placed using A2 composite (Luna, SDI). Marginal adaptation was obtained with a composite brush and modeling liquid. Occlusion was adjusted with a fine diamond bur, and polishing was completed with a 3-point polishing system and polishing paste (Figure 6). A fi nal radiograph was taken to confirm proper fill (Figure 7).
Conclusion
With secondary caries cited as the most common reason for retreatment of restorations, proper technique is critical for placing even the most basic direct composites. When the focus is to first control the hostile oral environment, clinical efforts can be centered on the appropriate use of bonding systems, systematic placement of resin materials, and high-quality finishing and polishing protocols. These steps aim to eliminate postoperative sensitivity and augment the longevity of the restorations.
