Back to Basics: A step by step protocol

The use of the composite materials to restore shape and function of posterior teeth damaged by decay, age or trauma is gaining wide acceptance by the dental community.

The dental practitioner and also the patient have the same desire regarding posterior composite restorations, which is that those restorations has to last many years.

While there are numerous recommendations regarding preparation design, restoration placement, and curing technique, current research indicates that restoration longevity depends on several variables that may be difficult for the dentist to control.

These variables include the patient’s caries risk, tooth position, patient habits, number of restored surfaces, the quality adhesion and the ability of the material to produce a sealed tooth- restoration interface.

So, success of posterior direct restorations strongly relies on the dentist’s procedure and his clinical experience. In this article is described a clinical step by step procedure in order to create and develop a protocol for daily practice. Working with an understandable and clear protocol, the dental clinician can pay attention on many details during composite reconstruction, can prevent the technical errors, can hold the “flow” estate, leading to a better result with every restoration.

styleitaliano style italiano direct posteriors shadeguides restoration composite pre-wedging wedge rubber dam isolation teflon matrix adaptation

Fig.1

The protocol proposed for posterior reconstruction is described in 6 STEPS
1. Diagnostic and initial occlusal check
2. Isolation and pre-wedging
3. Cavity preparation and cavity finishing
4. Proximal wall build-up and occlusal layering
5. Straining (Optional) and finishing
6. Polishing and final occlusal check
styleitaliano style italiano direct posteriors shadeguides restoration composite pre-wedging wedge rubber dam isolation teflon matrix adaptation

Fig.2

The initial situation is showing caries on both premolars and on both molars. Also the first and second molar have old restorations that they have to be change because of poor integration and inadequate morphology and function.
styleitaliano style italiano direct posteriors shadeguides restoration composite pre-wedging wedge rubber dam isolation teflon matrix adaptation

Fig.3

The initial occlusal check was made using a 40 micron articulation paper. This stage is made to help the dental clinician to see the contact points in order to prepare and restore properly.
styleitaliano style italiano direct posteriors shadeguides restoration composite pre-wedging wedge rubber dam isolation teflon matrix adaptation

Fig.4

After the occlusal check, the rubber dam isolation was done. When restoring the posterior region I prefer to isolate al working quadrant. Using this technique can help the dentists and also the dental assistant to have a better view and a better access to all cavity preparations. After isolation a cleaning is made with brushes and paste and also airflow, to remove all the plaque and stains. This step is mandatory to prevent contamination during the adhesive procedure.
styleitaliano style italiano direct posteriors shadeguides restoration composite pre-wedging wedge rubber dam isolation teflon matrix adaptation

Fig.5

Pre-wedging is very important and useful because
1. Protect the proximal rubber to be broken during the cavity preparation
2. Push the rubber and the gingiva more apically
3. Separate the teeth so the proximal preparation is easier
styleitaliano style italiano direct posteriors shadeguides restoration composite pre-wedging wedge rubber dam isolation teflon matrix adaptation

Fig.6

Cavity preparation have 3 steps
1. Access
2. Removal of the caries
3. Finishing of the cavity
The bur that I use most for access is the cylindric-round burr with a diameter of 0,9 mm.
styleitaliano style italiano direct posteriors shadeguides restoration composite pre-wedging wedge rubber dam isolation teflon matrix adaptation

Fig.7

The second step of the cavity preparation is caries removal and I use a round low speed bur.
styleitaliano style italiano direct posteriors shadeguides restoration composite pre-wedging wedge rubber dam isolation teflon matrix adaptation

Fig.8

Finishing the cavity using a fine bur is also very important for a better seal between tooth and restoration. I use for this stage a micromotor mounted Arkansas, at low speed. As a general rule – the cavity preparation starts with high speed and water and finishes with low speed and no water.
styleitaliano style italiano direct posteriors shadeguides restoration composite pre-wedging wedge rubber dam isolation teflon matrix adaptation

Fig.9

The aspects of cavity preparation. The wedges were very helpful for the proximal areas preparations.
styleitaliano style italiano direct posteriors shadeguides restoration composite pre-wedging wedge rubber dam isolation teflon matrix adaptation

Fig.10

The proximal wall is restored using a metallic matrix and a ring. First, I applied the matrix, then the wedge after that. I used two pieces of teflon tape and after that I placed the V-ring. Teflon tape is used for a better fitting of the matrix in contact with the proximal walls.
styleitaliano style italiano direct posteriors shadeguides restoration composite pre-wedging wedge rubber dam isolation teflon matrix adaptation

Fig.11

The matrix in place. Also for this stage the high of the matrix is very important to obtain a nice proximal ridge.
styleitaliano style italiano direct posteriors shadeguides restoration composite pre-wedging wedge rubber dam isolation teflon matrix adaptation

Fig.12

After the proximal wall is restored the ring is removed and the occlusal morphology is created following the anatomy of the tooth.
styleitaliano style italiano direct posteriors shadeguides restoration composite pre-wedging wedge rubber dam isolation teflon matrix adaptation

Fig.13

For the second premolar no ring was used, just a matrix and a teflon tape. The teflon piece fixes the matrix in contact with the proximal walls and also helps the dentist to distribute the proximal space with the mesial cavity of the molar.
styleitaliano style italiano direct posteriors shadeguides restoration composite pre-wedging wedge rubber dam isolation teflon matrix adaptation

Fig.14

Both premolars reconstructed. At this stage any finishing procedure can be made before starting the molar restoration.
styleitaliano style italiano direct posteriors shadeguides restoration composite pre-wedging wedge rubber dam isolation teflon matrix adaptation

Fig.15

The matrix for molar. The high of the matrix regarding the proximal ridge of the premolar is very important for a very nice restoration.
styleitaliano style italiano direct posteriors shadeguides restoration composite pre-wedging wedge rubber dam isolation teflon matrix adaptation

Fig.16

The aspect of the proximal ridges just after matrix and ring removal.
styleitaliano style italiano direct posteriors shadeguides restoration composite pre-wedging wedge rubber dam isolation teflon matrix adaptation

Fig.17

styleitaliano style italiano direct posteriors shadeguides restoration composite pre-wedging wedge rubber dam isolation teflon matrix adaptation

Fig.18

For finishing I prefer to use the same Arkansas bur, a no. 12 blade and a rubber wheel. After finishing if the dentist prefer he can stain the occlusal surface. Brown stain was used for pits and fissures.
styleitaliano style italiano direct posteriors shadeguides restoration composite pre-wedging wedge rubber dam isolation teflon matrix adaptation

Fig.19

The occlusal check using the 40 micron articulating paper. The occlusal check should be made in static and also in dynamic positions.
styleitaliano style italiano direct posteriors shadeguides restoration composite pre-wedging wedge rubber dam isolation teflon matrix adaptation

Fig.20

The final aspects of the restorations. The polishing step is made with a cotton wheel and aluminum oxide and water. Nice polish can be achieved using this protocol.
styleitaliano style italiano direct posteriors shadeguides restoration composite pre-wedging wedge rubber dam isolation teflon matrix adaptation

Fig.21


The final aspect of the restorations.

Conclusions

A daily protocol understand by the dentist and also by the dental assistant can provide very good posterior restorations with every patient.

Bibliography

1. Bohaty BS, Ye Q, Misra A, Sene F, Spencer P. Posterior composite restoration update: focus on factors influencing form and function

2. Hassan K, Khier S. Composite resin restorations of large class II cavities using split-increment horizontal placement technique

3. Ferraris F. Adhesion, Layering, and Finishing of Resin Composite Restorations for Class II Cavity Preparations

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