Bulk flow for Snowplow

Bulk-fill composites (BFCs) are increasingly employed resin-based materials for posterior tooth restoration. Their innovative chemical monomers and fillers enhance translucency, facilitating an optimal degree of conversion even at the cavity base, where achieving a high degree of conversion is challenging. Literature suggests that new flowable BFCs should serve as liners in deep cavities, particularly in extensive class I and class II restorations, followed by a high-viscosity composite cover layer. Studies indicate that flowable liners improve the marginal adaptation of composite restorations and significantly reduce microleakage compared to the incremental layering technique. They can help achieve perfect cervical margin adaptation and fill all internal cavity undercuts. Moreover, the “snowplow technique,” which involves applying a thin layer of non-light-cured flowable liner before the packable composite increment, mitigates shrinkage stress. This clinical case demonstrates the potential of these new materials to simplify class II restorations in a predictable way.

KERR Simplishade bulk fill flow styleitaliano style italiano
KERR Simplishade bulk fill flow styleitaliano style italiano
styleitaliano style italiano occlusal view of proximal caries snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.1
The initial situation revealed an interproximal lesion in the first upper premolar.

styleitaliano style italiano proximal caries of upper premolar snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.2
After the application of the rubber dam, the distal carious lesion became evident due to the retraction of the papilla by the rubber dam.

styleitaliano style italiano cavity opening for class II snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.3
Starting with caries removal, a class II cavity preparation was performed.

styleitaliano style italiano clean class II cavity snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.4
Final appearance after complete removal of dental caries.

styleitaliano style italiano matrix and ring for class II restoration snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.5
The sectional matrix was fixed with plastic wedge and ring. For better adaptation of the matrix to the dental interproximal margin, teflon was inserted.

styleitaliano style italiano snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.6
It’s noteworthy to check the correct adaptation of the matrix on the class II box to obtain a proper contact point and an optimal interproximal shape. After ensuring this, the Snowplow technique was applied.

styleitaliano style italiano snowplow technique direct posterior restoration

Fig.7
As described in the literature, the snowplow technique involves the use of a thin layer of non-light-cured flowable liner placed before applying the increment of the packable composite. Upon dispensing the packable composite, the uncured flowable material further disperses into a very thin layer. The two materials are simultaneously polymerized with a single application of the curing light.

styleitaliano style italiano flowable composite on proximal margin snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.8
After completing the adhesive procedure, a thin layer of flowable bulk-fill composite (SimpliShade™ Bulk Fill Flow by Kerr) was applied to the bottom of the cavity.

styleitaliano style italiano build up of proximal wall snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.9
Immediately thereafter, a packable bulk-fill composite (SimpliShade™ Bulk Fill composite by Kerr) was applied to reconstruct the interproximal wall. The composite was accurately condensed into the cavity, ensuring that if the flowable composite sealed all the undercuts, there would be no space rising coronally. Consequently, any excess flowable material could be eliminated, leaving only the packable composite on the surface.

KERR Simplishade bulk fill flow styleitaliano style italiano
KERR Simplishade bulk fill flow styleitaliano style italiano
styleitaliano style italiano modeling of the proximal wall snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.10
Therefore, any excess flowable material could then be eliminated, leaving only the packable composite on the surface.

styleitaliano style italiano posterior misura for proximal ridge snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.11
The LM Posterior Misura instrument enables the precise measurement and modeling of the composite wall to replicate the height and anatomy of the neighboring tooth, even in the presence of a matrix. Consequently, excess material was easily eliminated using half of the fork, while the second part controlled the height of the restoration.

styleitaliano style italiano cavity after proximal build up and removal of matrix snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.12
Class II was transformed into Class I.

styleitaliano style italiano side view of proximal buildup snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.13
From a lateral point of view, the interproximal walls were at the same level with the same orientation.

styleitaliano style italiano finished class II restoration before polishing snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.14
The cavity was filled by applying only one single mass of the same bulk-fill composite used for the interproximal wall. Subsequently, characterizations were applied to complete the restoration.

styleitaliano style italiano side views of proximal restoration snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.15
Final aspect from different points of view.

styleitaliano style italiano close up of contact point after restoration snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.16
A proper contact point was established, along with the correct ridge inclination.

styleitaliano style italiano restoration after finishing and polishing snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.17
Final aspect of the restoration after finishing and polishing procedures.

styleitaliano style italiano class II restoration after occlusal checkup snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.18
During a second visit, the second premolar was treated due to the presence of a carious lesion on the distal interproximal area. Before beginning the procedure, the occlusion was checked to visualize the contact points.

styleitaliano style italiano class II cavity snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.19
A small class II cavity was obtained after cleaning the decayed tissue.

styleitaliano style italiano restoring proximal cavity snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.20
To restore the cavity, a sectional matrix was placed and properly fixed to the cavity with a plastic wedge and separator ring. Due to the small size of the cavity, the Snowplow technique was employed to finish the restoration, ensuring complete cavity filling and treating it as if it were a class I cavity.

styleitaliano style italiano flowable bulk fill injected on cavity margin snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.21
Therefore, once again, a thin layer of flowable bulk-fill composite (SimpliShade™ Bulk Fill Flow by Kerr) was applied to the bottom of the cavity.

styleitaliano style italiano injected bulk fill composite before modeling snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.22
A single mass of packable composite material was used to completely fill the cavity. Once again, the packable material distributed the flowable composite over the undercuts, effectively sealing the entire class II box. Excess flowable material rose to the coronal margin.

styleitaliano style italiano essential lines for occlusal anatomy snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.23
After removal of the composite excess, the Essential lines were drawn to complete and finalize the restoration.

styleitaliano style italiano finished class II restorations snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Fig.24
Final aspect of the restorations after finishing and polishing procedures. Both premolars were treated by restoring function and aesthetics.

Conclusions

In conclusion, leveraging the superior characteristics of BFCs, various techniques were employed for restoring class II cavity preparations with these materials, aiming to facilitate placement for optimal clinical outcomes. Additionally, the snowplow technique enables better adaptation to the gingival wall, thereby reducing the risk of secondary caries occurrence.

Bibliography

Certainly, here’s a revised version of the references, all in the style of reference number 2:

  1. Ferracane JL, Lawson NC. Probing the hierarchy of evidence to identify the best strategy for placing class II dental composite restorations using current materials. J Esthetic Restor Dent. 2021;33:39-50. doi: 10.1111/jerd.12686.
  2. Putignano A, Tosco V, Monterubbianesi R, Vitiello F, Gatto ML, Furlani M, Giuliani A, Orsini G. Comparison of three different bulk-filling techniques for restoring class II cavities: μCT, SEM-EDS combined analyses for margins and internal fit assessments. J Mech Behav Biomed Mater. 2021 Dec;124:104812. doi: 10.1016/j.jmbbm.2021.104812. Epub 2021 Sep 3. PMID: 34500356.
  3. Sampaio CS, Fernández Arias J, Atria PJ, Cáceres E, Pardo Díaz C, Freitas AZ, Hirata R. Volumetric polymerization shrinkage and its comparison to internal adaptation in bulk fill and conventional composites: A μCT and OCT in vitro analysis. Dent Mater. 2019 Nov;35(11):1568-1575. doi: 10.1016/j.dental.2019.07.025. Epub 2019 Sep 6. PMID: 31500903.
  4. Chiodera G, Orsini G, Tosco V, Monterubbianesi R, Manauta J, Devoto W, et al. Essential Lines: a simplified filling and modeling technique for direct posterior composite restorations. Int J Esthet Dent. 2021;16:168-184.

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