Fig.1
Preoperative picture of the quadrant to treat, after the anesthesia

Fig.2
First rule: a correct isolation with the rubber dam starts before the cleaning of the caries. You reach a better adhesion without saliva contamination.
TIP #1: use the wooden wedges to protect the rubber dam while cleaning the caries otherwise you will probably break it using the burs on the cervical step, and you will need to change it before the bonding procedures

Fig.3
Second rule: prepare the cavities, cleaning all the caries and refining the enamel with fine grained diamond or multiblade burs, so to have a perfect bonding to the enamel and avoid the detachment of unsupported enamel and micro-leakage.
TIP #2: it could happen that, after removing the wedges, a little bleeding occurs as in distal 24 mesial 25. Pay attention to wash properly to disinfect and to control the wetness before putting in place the matrix and the new wedges
TIP #3: clean the dentin with glycine and disinfect it with clorexidine at 2%

Fig.4
TIP#4: there’s no preference in putting one matrix by one or all together. It depends on what you prefer and are able to do and nobody can say that one way is better than the other. The advantage in putting them all together is that you save time, you don’t contaminate the neighbor cavities and don’t have the need to refine the restorations one by one before putting in place the other matrix. The disadvantage is that you have less control and need a little more experience in doing this.
TIP#5: use a selective etching procedure and a universal (8th generation) adhesive in a self etching mode, for the bonding procedures.

Fig.5
Third rule: start building the interproximal wall first so to change the class II in a class I
TIP#6: before removing the matrix apply a little of flow between the dentine and the interproximal wall you’ve done previously, otherwise you risk to remove the wall while pulling the matrix.

Fig.6
Fourth rule: do not remove the wedges until the end of the layering and modeling work, so to avoid the risk of bleeding from below
TIP#7: use a flow on the adhesive to have a better conversion of the adhesive itself and to counteract the C Factor, before start layering the packable composite

Fig.7
Fifth rule: there’s no best one among layering techniques. You can choose a horizontal, a vertical or an oblique one.
The horizontal one is easier to perform, but keep in mind that what you have to reach is a good result, nothing else, and you can get it with each and every layering technique.

Fig.8
Details after the modeling, before the finishing and polishing procedures.
TIP#8: use an easy modeling technique, no need of reproducing something that in nature doesn’t exist. The essential is more than enough.

Fig.9
Details after finishing and polishing.
TIP #9: use a multiblade bur on composite instead of a diamond one for finishing, it’ll be gentler and it won’t damage the enamel while you are finishing your restorations

Fig.10
Details after polishing procedures
TIP #10: use a supercharged diamond paste to polish your restorations, only one is sufficient. Use it with a brush or with the spirals

Fig.11
Occlusal check: it requires some corrections, that are immediately carried out.

Fig.12
Details of the anatomies after the removal of the rubber dam

Fig.13
Details of the anatomies after the removal of the rubber dam.

Fig.14
Occlusal check at six months.

Fig.15
Details of the anatomy and of the morphological and chromatic integration at six months check.

Fig.16
Details of the anatomies and of the morphological and chromatic integration at six months check.

Conclusions

In modern restorative dentistry it is quite easy to work clean and to perform with good results, even if you are not a “pro”. Use the rubber dam from the start, clean all the decayed tissue, leaving any on the bottom of the cavity, properly finish the enamel, clean and disinfect the dentin, use a modern adhesive in a self etch way. No flights of fancy, no time to lose, no 1000 layers of composite, but a few steps and rules to follow, and… have fun working!

Bibliography

Dietschi D, Spreafico R. Restauri adesivi non metallici. Attuali concetti per il trattamento dei denti posteriori. Scienza e Tecnica Dentistica Passirana di Rho, 1997; br., pp. 215.

Bichacho N. The centripetal build-up for composite resin posterior restorations. Pract Periodontics Aesthet Dent. 1994 Apr

Magne P. IDS: Immediate Dentin Sealing (IDS) for tooth preparations.  J Adhes Dent. 2014 Dec;16(6):594. doi: 10.3290/j.jad.a33324.

Manauta J, Salat A. Layers: An Atlas of Composite Resin Stratification; Quintessence. Print; 2012.