A clinical case by our Community member Dr. Alessandro Colella
Bulk-filling techniques have become more widely used thanks to the development of high-viscosity bulk composites. Improved curing, controlled polymerization contraction stresses and satisfying aesthetics allow dentists to perform satisfactory restorations in a short time. Working as a consultant often means to go fast. In this case two deep cavities were treated in a 16 y.o. young man at his first dental appointment, in only one hour, testing with my hands for the first time a new bulk composite (DMG Ecosite Bulk Fill; Shade Universal).
This young patient came to my observation complaining about an increase in dental sensitivity in the third quadrant. Clinical and X-ray examination showed two decayed teeth (II class 3.6 – 3.7) and poor oral hygiene, especially on the lingual surface.
Rubber dam isolation was performed in order to have a dry and more comfortable working field and maximum tissue retraction. A plastic wedge (MyWedge – Polydentia) was put in place so as to protect the interproximal tissue and rubber dam.
Despite the initial occlusal aspect, the caries had progressed really deep into the dentin.
Cavities were properly cleaned. Enamel edges were finished with fine-grained burs to prevent unsupported enamel prisms from chipping, thus causing micro-leakage. A slot was performed on the mesial wall of 37 in order to preserve the marginal ridge (2.5 mm thick) and not to lose anatomical information for further occlusal modeling. Because of the depth, a conventional II class should have been executed as well.
Due to the considerable depth and the proximity to the pulp, a selective-etching strategy was preferred to reduce postoperative hypersensitivity.
A universal adhesive was applied on a dry cavity, in a self-etching mode, using a microbrush for 20 seconds. Excess was removed and the solvent evaporated by gently blowing air on the cavity.
Light-curing for 40 seconds for each cavity.
All the exposed dentin was covered with a 0.5 mm flowable composite layer in order to protect the pulp, increase the degree of conversion of the bonding agent, counteract the negative C factor of deep class I and II cavities, and reduce the cavity size for a subsequent faster filling.
The cavity size was measured with a probe, so that I could verify if a single bulk restoration was a viable option. Cavity depth measurement with a periodontal probe is a mandatory step in this case.
High-viscosity bulk composite (DMG Ecosite Bulk Fill; Shade Universal) was chosen for a single shade restoration on both teeth.
Slot cavity on 37 was filled first. Then a sectional matrix was placed (Lumicontrast, Polydentia) to build the distal wall of 36. Using black matrices is important to evaluate and achieve the right thickness of the interproximal wall. MyRing Classico easily ensures an optimal adaptation of the sectional matrix.
The contact area seems to be adequate.
A single increment of composite for each tooth was enough to complete the fillings easily and quickly.
Some stains were used to give the restorations more volume.
It was an optional step to test this new material and its chromatic properties.
Immediately after rubber dam removal and bite check, some occlusal adjustments were needed to remove some small premature contact on disto-lingual cusp.
At one month check-up, the integration is satisfactory.
Using this strategy, the number of increments required to fill a cavity is reduced, compared with traditional incremental filling techniques. Instead of 2 mm increments recommended for conventional resin composites, we can apply up to 5 mm increments of the bulk-fill resin composites.
It means significant time saving that could be spent for finishing and polishing procedures, real key steps in long term longevity of a composite restoration.
Easy handling, also on the first use – like in this case that I performed – good aesthetic properties, in association with the right modeling technique can be the right recipe in the hands of anyone to achieve acceptable results in a very short time.
1) van Dijken JWV, Pallesen U. Bulk-filled posterior resin restorations based on stress-decreasing resin technology: a randomized, controlled 6-year evaluation. Eur J Oral Sci. 2017 Aug;125(4):303-309.
2) 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) Ilie N. Sufficiency of curing in high-viscosity bulk-fill resin composites with enhanced opacity. Clin Oral Investig. 2019 Feb;23(2):747-755.
4) 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.
5). Prager M, Pierce M, Atria PJ, Sampaio C, Caceres E, Wolff M, Giannini M, Hirata R. Assessment of cuspal deflection and volumetric shrinkage of different bulk fill composites using non-contact phase microscopy and micro-computed tomography. Dental Materials Journal, 37(3), 393-399.
6) Chiodera G. Essential Lines. Styleitaliano.org