A clinical case by our Community member Dr. Abdelrahman Mohammed Elgamal
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Not every clinical case presents a simple or straightforward solution. In many situations, achieving proper functional contacts and anatomical form can be highly challenging, requiring careful analysis, a well-structured treatment plan, and a systematic sequence of steps to ensure a predictable outcome.
While it is essential to respect and replicate natural tooth anatomy, it is equally important to avoid inadvertently altering the patient’s existing occlusion. This balance becomes particularly critical in complex cases.
In this report, an unusual yet frequently encountered clinical scenario is presented: a patient with tilted teeth, specifically the second premolar and second molar, resulting from the childhood extraction of the first molar. A conservative approach was explored to restore both function and esthetics while strictly preserving biological integrity.
Fig.1
The preoperative clinical image demonstrates a fractured amalgam restoration on a severely mesially tilted second premolar, secondary to the prior extraction of the first molar. A large existing amalgam restoration is also evident on the second molar.
Additionally, the image captures the preoperative occlusal evaluation performed using 40-micron articulating paper. This step allows precise mapping of the existing occlusal contact points prior to treatment, ensuring their accurate replication postoperatively in accordance with a confirmative occlusal approach.
Fig.2
Another view.
Fig.3
The preoperative radiograph illustrates the mesial tilting of both the second premolar and second molar, along with the extent and depth of carious involvement affecting the premolar.
Fig.4
Rubber dam isolation was achieved with proper inversion around the cervical margins to ensure optimal moisture control. This was followed by the removal of defective amalgam restorations and associated carious tissue.
A caries detector dye was applied repeatedly to confirm complete caries removal. Subsequently, air abrasion was performed using 29-micron aluminum oxide particles to thoroughly cleanse the prepared surfaces and enhance bonding efficacy.
Fig.5
Another view demonstrating the extension of the cavities buccally.
Fig.6
The adhesive system was applied in two consecutive layers with active agitation to ensure optimal resin infiltration. Following photopolymerization, a thin layer of highly filled flowable composite was placed as a resin coating layer. Deep margin elevation was then performed on the premolar using an injectable composite.
Subsequently, the missing walls were rebuilt freehand with a packable composite resin. This step facilitated proper matrix system placement without band deformation, ensuring adequate proximal contact and natural anatomical contour.
Fig.7
This view demonstrates the reconstruction of the walls by composite resin to mirror the original inclination of the natural tooth prior to preparation.
This highlights the importance of preoperative analysis in successfully restoring the tooth to its original position.
Fig.8
The occlusal anatomy was restored by carefully following the essential anatomical lines of each individual tooth. Respecting the natural cusp inclinations during composite layering helps prevent postoperative high spots and ensures proper functional occlusion.
During the shaping of the premolar, particularly its central groove, it is essential to consider the tooth’s preoperative tilt to maintain harmony with the existing occlusal scheme.
Finally, characterization stains were applied within the grooves to enhance both hygiene by improving plaque guidance and overall esthetics.
Fig.9
After Finishing and polishing.
Fig.10
The postoperative occlusal assessment, performed immediately after polishing and rubber dam removal, demonstrates contact points identical to those recorded preoperatively. This confirmative approach ensures that the restored occlusal anatomy remains fully functional and in harmony with the patient’s existing occlusion.
Fig.11
The postoperative radiograph confirms the success of the restoration, demonstrating proper proximal contact and excellent marginal sealing.
Conclusions
Not all clinical cases follow a typical pattern, which underscores the importance of adopting an individualized approach to treatment. Thorough preoperative analysis is essential to achieving predictable outcomes.
A comprehensive understanding of the existing clinical situation, including the patient’s functional occlusion and any anatomical variations, is critical before initiating treatment. Ultimately, the goal is to deliver restorations that preserve function, esthetics, and biological integrity.
Bibliography
- Hardan L, Sidawi L, Akhundov M, et al. One-Year Clinical Performance of the Fast-Modelling Bulk Technique and Composite-Up Layering Technique in Class I Cavities. Polymers. 2021;13(11):1873.
- Chiodera G, Orsini G, Tosco V, Monterubbianesi R, Manauta J, Devoto W, Putignano A. Essential Lines: A Simplified Filling and Modeling Technique for Direct Posterior Composite Restorations. Int J Esthet Dent. 2021;16(2):168–184.
- Manauta J, Salat A, Devoto W, Putignano A. Layers 2. Direct Composite: The StyleItaliano Clinical Secrets. 2022. Quintessence Publishing.
