A clinical case by our Community member Dr. Ahmed Saad
This article and its content are published under the Author’s responsibility as an expression of the Author’s own ideas and practice. Styleitaliano denies any responsibility about the visual and written content of this work.
In the posterior region, many cavities are located in the deep proximal zone due to the challenges patients face in cleaning these areas.
Both direct and indirect approaches are viable treatment options for such cases, depending on various parameters. However, even with an indirect approach, direct dentin substitution is essential. The advantages of this technique include:
- Biological protection of dentin.
- Optimization of cavity design, avoiding undercuts (for indirect restorations).
- Elevation of deep proximal margins, eliminating the need for crown lengthening.
Various materials have been proposed to meet biological and clinical requirements, but newly introduced injectable composites with Giomer technology offer added benefits due to their bioactive and mechanical properties.
This article will explore the use of injectable composites with Giomer technology for margin elevation and the indirect approach for large posterior restorations.
Fig.1
A 33-year-old female patient presented with a complaint of a fractured restoration, which was attributed to the absence of a proper contact point.
Fig.2
This diagram illustrates the workflow for managing deep margin cases in posterior restorations, providing a structured approach for optimal outcomes.
Fig.3
The X-ray reveals the presence of deep proximal caries in tooth #36, along with recurrent caries beneath an old amalgam restoration.
Fig.4
A rubber dam was placed to ensure optimal isolation of the deep margin.
Fig.5
The procedure started with tooth #36, where the old restoration was removed along with the caries on the mesial side. The buccal cusp was reduced to facilitate dentin sealing and prepare for further coverage.
Fig.6
An extra seal was applied using Teflon to prevent leakage, and a matrix was placed for margin elevation.
Video.7
This video demonstrates the margin elevation protocol using a 2-step self-adhesive system and injectable composite.
Fig.8
The margin was elevated, and the tooth was temporized for the next session.
Fig.9
In the next session, rubber dam application was performed after the temporary restoration was removed. The old restoration was removed, and the mesial caries tissue was addressed.
Fig.10
During the removal of the old restoration, pinpoint exposure was encountered, so it was sealed using MTA and covered with RMGI.
Fig.11
Dentin seal and undercuts were blocked using injectable composite F00, followed by the final tooth preparation.
Fig.12
Retraction cord was placed, and the tooth is now ready for scanning.
Fig.13
Final scan.
Fig.14
The cementation visit began with rubber dam application and an extra seal using Teflon to ensure ideal bonding steps.
Fig.15
The diagram illustrates the tooth surface treatment steps before cementation, ensuring optimal adhesion and a secure bond.
Fig.16
The diagram illustrates the surface treatment of hybrid ceramics before cementation, outlining the necessary steps for optimal bonding and durability.
Fig.17
Cementation was performed using heated composite to enhance the flow and ensure a secure bond.
Fig.18
Excess cement was carefully removed to ensure a clean and precise restoration.
Fig.19
A buccal view was taken to check the adaptation of the restoration.
Fig.20
Final result after cementation.
Fig.21
Before and after X-rays were taken to assess the outcome and ensure the proper fit and integrity of the restoration.
Conclusions
Adhesive posterior restorations are among the most common treatments in everyday dental practice. Simplification and standardization are essential for the dentist, particularly in these procedures.
Several risk factors must be considered when choosing between direct and indirect approaches:
- Residual Tooth Structure: Direct restoration requires the tooth to have intact, non-undermined coronal walls.
- Molar Considerations: Function, periodontal status, tooth location, and the number of adjacent teeth all influence the decision.
- Additional Factors: Parafunctional habits, gender, age, and dietary habits should also be considered.
Finally, for indirect cases, don’t forget the crucial steps of deep margin elevation, dentin substitution, and cavity optimization to ensure optimal results.
Bibliography
- Magne P. Immediate dentin sealing: a fundamental procedure for indirect bonded restorations. J Esthet Restor Dent. 2005;17(3):144-54; discussion 155.
- Sarfati A, Tirlet G. Deep margin elevation versus crown lengthening: biologic width revisited.
- Int J Esthet Dent. 2018;13(3):334-356.
- Koubi S, Raskin A, Dejou J, About I, Tassery H, Camps J, Proust JP. Effect of dual cure composite as dentin substitute on the marginal integrity of Class II open-sandwich restorations. Oper Dent. 2010 Mar-Apr;35(2):165-71.
- Koubi GF, Koubi S, Brouillet JL. The Composite Up Technique:a simple approach to direct posterior restorations. Ad in Op Dentistry 2001.
