Some restorative procedures in posterior teeth require particularly delicate strategies, and flowable composites can be useful, especially in two specific situations. The first, as described in previous articles, is cusp modeling, where pulling a drop of flowable composite can reproduce the dimensions and geometry of a cusp quite accurately.
The second, described in this article, involves situations where the remaining cervical enamel at the margin of a posterior tooth has been undermined. This delicate enamel can be preserved and supported with flowable composite. Using a packable composite in this area may increase the risk of trapping air bubbles or creating voids, whereas a flowable material can be carefully injected into this difficult-to-access space.
In the following clinical report, we will describe these two strategies and show how they can simplify the restorative procedure.
Fig.1
Initial situation. Proximal caries on the distal surface of the mandibular first molar was detected during radiographic examination.
Fig.2
Radiographic analysis of the deep lesion is shown on the left. On the right, the critical area is highlighted in red, indicating caries undermining the gingival margin, while the delicate gingival enamel is highlighted in blue. With conservative and careful treatment, this enamel can be preserved. Losing it would result in a very deep gingival margin, significantly increasing the operative difficulty.
Fig.3
Pre-wedging of the proximal area was performed to initiate tooth separation and apical displacement of the papilla.
Fig.4
Initial cavity access through the marginal ridge. The thin marginal enamel was temporarily preserved to avoid accidental contact between the bur and the adjacent tooth.
Fig.5
The axial opening was made wider than the proximal area to bring the margins into a more clinically accessible position. This provides better control of the margins, facilitates passive matrix insertion and allows better visualization of the matrix anatomy. Caries removal was still incomplete at this stage.
Fig.6
After further widening of the cavity and application of a caries detector, extensive undermined enamel and residual carious tissue were still visible. Cusp coverage was planned, as the subsequent restorative procedure could be simplified using flowable composite.
Fig.7
The cavity after complete caries removal. Note how the cervical enamel was preserved. With an appropriate adhesive technique, this critical area can be supported and incorporated into the restoration.
Fig.8
The preserved peripheral enamel is highlighted in blue. Note the substantial enamel thickness in the cusp area.
Fig.9
Loss of a marginal ridge can substantially reduce the structural resistance of a posterior tooth (up to 40%). The decision to provide cusp coverage depends on the amount and thickness of the remaining tooth structure. With an appropriate direct technique, cusp reconstruction can be kept straightforward.
Fig.10
Without removing the wedge or inserting a matrix, the preserved cervical enamel was first adhesively connected to the restoration using Filtek™ Supreme Flowable OA3 (Solventum). The flowable consistency facilitates placement in this delicate area and helps minimize the risk of void formation. The buccal and lingual cusps were also reconstructed with a more translucent flowable composite, Filtek™ Easy Match Flow Bright (Solventum), selected to better reproduce the external translucency of the tooth.
Fig.11
Once the critical areas had been restored, a sectional matrix and ring were positioned to reconstruct the proximal wall.
Fig.12
The occlusal cavity was restored using the same composite materials, and the fissures were sealed with Clinpro™ fissure sealant (Solventum).
Fig.13
Final restoration showing good integration, cervical margin preservation, optimal and verifiable marginal seal and cusp coverage with well-defined occlusal anatomy. The technique allowed these objectives to be achieved with a straightforward direct restorative workflow.
Conclusions
- Preservation of sound marginal enamel is a valuable strategy whenever the clinical conditions allow it.
- Cusp coverage is not limited to indirect restorations or extremely large cavities.
- Understanding the quantity and quality of the remaining enamel is essential when planning contemporary adhesive restorations.
Bibliography
- Manauta J. Cervical Enamel. StyleItaliano. Published May 11, 2016. Cervical Enamel – StyleItaliano.
- Liebenberg WH. Posterior composite resin restorations: operative innovations. Pract Periodontics Aesthet Dent. 1996;8(8):769–778; quiz 780.
- Manauta J, Salat A, Devoto W, Putignano A. Layers 2: Direct Composites – The Styleitaliano Clinical Secrets. Quintessenza Edizioni; 2022. Chapter 9.
- Massai L. Odontoiatria restaurativa: procedure di trattamento e prospettive future. In: Accademia Italiana di Conservativa. Chapter 13:638–676. Elsevier; 2009.
