Fig.1
This 18-years-old patient presented a restoration with carious infiltration in correspondence with the mesial wall of 1.6 and a D1 lesion in the distal portion of 1.5, complaining, here, food impaction.

Fig.2
After injecting the anesthesia, I isolated the operating field with the rubber dam and proceeded to place a wooden wedge in the working area to protect the dam from any lacerations and to obtain a slight distalization.

Fig.3
Once the old restoration was removed on tooth 16, the carious lesion was evident and really deep in dentin.

Fig.4
The distal wall of 15 was also affected by a carious lesion that required a treatment.

Fig.5
The II Class Cavity on 16 was properly cleaned. Enamel was finished with fine-grain burs to prevent the detachment of unsupported enamel prisms and micro-leakage.

Fig.6
A slot was performed on the distal wall of 15 in order to preserve the marginal ridge and not to lose anatomical information for further occlusal modeling.

Fig.7
A piece of teflon tape was placed on 16 to protect it from etching procedure on tooth 15.

Fig.8
A universal adhesive (Ecosite-Bond – DMG) was applied on the dried cavity, in a self-etching mode, using a microbrush for 20 seconds. Excess was removed and the solvent evaporated by blowing air.

Fig.9
All the exposed dentin was covered with 0.5 mm flowable composite.
Subsequently, using a flexible spatula (LM Arte Applica), the outline of the tooth was restored by exploiting the residual anatomical information of the distal wall, applying a layer of dentin (DMG – Ecosite Elements Pure A2) and layer of enamel (DMG – Ecosite Elements Layer EM).

Fig.10
The slight over-hang of the final restoration could be easily corrected using a reciprocating handpiece. The restoration was then polished before proceeding with the restoration of the adjacent tooth.

Fig.11
A sectional matrix (Lumicontrast, Polydentia) and again a wedge were then placed.

Fig.12
Selective etching of the enamel with orthophosphoric acid was performed for 30 seconds.

Fig.13
As before, a universal adhesive was brushed for 20 seconds in the cavity and then polymerized.

Fig.14
The interproximal wall was layered by using an enamel shade (DMG – Ecosite Elements Layer EM) in two increments, in order to reproduce a more natural anatomy. For the same reason, the top of a small accessory ridge was added using the same material. Using black matrices is important to evaluate and achieve the right thickness of the interproximal wall.

Fig.15
Before removing the sectional matrix, the dentin was immediately sealed with a flowable composite, and then a build-up of the dentin (DMG – Ecosite Elements Pure A2) was carried out.

Fig.16
Before layering the occlusal surface, the outline of the restoration was finished with an abrasive disc in order to minimize modeling mistakes and subsequent occlusal pre-contacts. After finishing, it is necessary to wet the composite particles with some universal adhesive and blow before starting to model again.

Fig.17
To obtain a realistic anatomy, only one enamel shade (DMG – Ecosite Elements Layer EM) was used. First, the enamel mass was layered following the inclination of the residual ridges.

Fig.18
Then a brown stain was placed (DMG – Ecosite Elements Highlight Brown) in the sulcus, and left uncured.

Fig.19
As a last layer, the enamel mass was placed onto the uncured stain and modelled for a very natural appearance.

Fig.20
The same procedure was performed to complete the modeling of the occlusal surface.

Fig.21
As you can see in the picture, this composite’s capacity to keep the shape allows for a detailed anatomy. The combination of an enamel and a dentin shade, suggested by a special scale (Ecosite Elements Shade Guide), gives a realistic result.

Fig.22
The final restoration required minimal finishing and polishing. This procedure was quickly and easily carried out with a simple polishing rubber tip, used dry and at low speed. The contact area seemed adequate.

Fig.23
Immediately after rubber dam removal and bite check, no occlusal adjustments were needed.

Fig.24
Follow up picture after 7 weeks.

Conclusions

The integration of a direct restoration depends on a few key factors, especially morphological and chromatic ones. Thanks to this composite, it is possible to obtain satisfactory results in terms of shape because each increment, once placed, maintains its position stably, thus allowing the clinician to give the restoration depth and volume. In terms of color, it is possible to stratify two shades following a specific colour scale. The choice of staining is optional, but can be an additional expedient to obtain a highly esthetic restoration. Lastly, the composite requires a very fast polishing which is maintained over time, as is evident from the follow-up picture.

Bibliography

1. Fruits TJ, Knapp JA, Khajotia SS. Microleakage in the proximal walls of direct and indirect posterior resin slot restorations. Oper Dent. 2006 Nov-Dec;31(6):719-27.
3. Fronza BM, Abuna GF, Braga RR, Rueggeberg FA, Giannini M. Effect of Composite Polymerization Stress and Placement Technique on Dentin Micropermeability of Class I Restorations. J Adhes Dent. 2018;20(4):355-363. doi: 10.3290/j.jad.a40987.
5. Chiodera G. “Mind the Neighbor Teeth: 5 rules to follow” – www.styleitaliano.org