A clinical case by our Community member Dr. Tarek Hammad
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.
Large direct posterior composite restorations present significant clinical challenges, particularly in cases involving cusp reduction, weakened residual tooth structure, or missing occlusal margins. The loss of anatomical reference points complicates the reconstruction of accurate occlusal morphology and functional harmony.
Following rubber dam isolation and composite build-up, clinicians frequently encounter occlusal discrepancies and high spots after polymerization. Conventional adjustment using articulating paper is subjective and time-consuming often leading to unnecessary removal of restorative material and compromising the carefully sculpted anatomy.
Although digital dentistry has introduced intraoral scanning and digital articulation for occlusal analysis, its integration into direct composite workflows remains limited. Most occlusal corrections are still performed after final curing, when modifications become subtractive rather than corrective. The technique presented in this article proposes a digitally guided workflow that incorporates pre-operative occlusal mapping, cavity design analysis and real-time occlusal verification while the composite remains in a pre-cured state. This approach aims to minimize post-polymerization adjustments, preserve occlusal anatomy and improve clinical efficiency in large direct composite restorations.
Fig.1
A 26-year-old male patient presented with a defective composite restoration with recurrent caries in the lower first molar, seeking replacement with a new direct composite restoration. After history taking and clinical examination, the tooth was confirmed to be vital.
Fig.2
Pre-operative intraoral scan of the lower quadrant taken by Dexis is 3700 intraoral scanner.
Fig.3
Pre-operative intraoral scan of the upper quadrant.
Fig.4
Pre-operative digital bite registration.
Fig.5
Pre-operative occlusal heat map demonstrating occlusal contact approximation.
Fig.6
Rubber dam isolation.
Fig.7
In this step, we used the lock feature in Dexis ScanFlow software to secure the entire quadrant and prevent the scanner from overwriting existing data during rescanning with the rubber dam in place. The first molar (area of interest) and the second premolar (used as a reference for scanner tracking) were excluded, and the area of interest was then trimmed to allow rescanning after cavity preparation.
Fig.8
Removal of the defective restoration revealed recurrent caries underneath.
Fig.9
Using caries detector dye, caries removal was completed followed by cavity design optimization.
Fig.10
The prepared cavity was captured using the intraoral scanner, followed by digital occlusal analysis.
Video.1
Cavity design analysis was performed to evaluate the residual cusp thickness and determine the need for cuspal coverage.
Fig.11
Cavity design analysis evaluating residual cusp thickness and determining the need for cuspal coverage.
Fig.12
Selective enamel etching.
Fig.13
Immediate dentin sealing and resin coating using OptiBond Universal 360 and SimpliShade Bulk Fill Flow (Kerr).
Fig.14
Matrix placement of the distal margin using a saddle matrix to achieve optimal marginal seal.
Fig.15
Distal marginal ridge built using universal body shade composite (OptiShade Medium, Kerr).
Fig.16
Another view of the marginal ridge demonstrating optimal adaptation and contour.
Fig.17
Uncured foundational layer of the restoration placed before the final layer, with cuspal outlines defined.
Fig.18
The foundational layer was scanned before polymerization to assess occlusal proximity.
Fig.19
Occlusal proximity was detected on the middle buccal cusp ridge.
Fig.20
The middle buccal cusp was sectioned digitally from the scan, refined intraorally, and rescanned.
Fig.21
Occlusal scheme illustrating contact points of the finished yet uncured mesiobuccal, middle buccal, and distolingual cusps, demonstrating the absence of premature contacts.
Fig.22
Uncured final layer showing three premature contacts requiring adjustment before final polymerization.
Fig.23
Final layer after occlusal adjustments, prior to curing.
Fig.24
Fully polymerized anatomical restoration.
Fig.25
Final clinical outcome after rubber dam removal, finished and polished, and double-checked with articulating paper for premature contacts.
Fig.26
Final scan.
Fig.27
Before and after.
Conclusions
The proposed digitally guided technique integrates pre-operative occlusal analysis, cavity evaluation, and real-time articulation verification into the direct restoration workflow. By identifying and correcting occlusal discrepancies prior to final polymerization, this approach minimizes post-curing adjustments, preserves planned occlusal anatomy and enhances clinical efficiency in large restorations.
The incorporation of digital articulation into direct restorative procedures may represent a predictable and time-saving strategy for achieving accurate functional outcomes. Further clinical studies are recommended to evaluate its reproducibility and reliability. Although the technique requires experience and precision, once mastered it significantly reduces chair time and facilitates the delivery of functionally accurate, anatomically precise posterior direct composite restorations.
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