Saving time in daily practice. The bulk composite strategy. Part 2

31 Dec 2017

We present a clinical case in which we have to restore a class 2 od on 24, class 1 on 24 with a distal caries and class 2 on 26. 

Fig. 1

Isolation with the dental dam from first molar to central incisor. We always isolate all the quadrant for a better vision. 

Fig. 2

First I cleaned the occluso-distal cavity.

Fig. 3

Before opening the cavity I customized the ring in order to have the perfect fit for this specific situation in which the tooth is rotated and no ring would have been better than the customized one. 

Selective etching of the enamel only for 20-30 seconds (phosphoric acid, 37%). 

Fig. 4

Transforming the class 2 into a class 1 cavity.

Fig. 5

Filling the cavity with only one layer of the bulk composite (Ecosite, DMG). Shaping of the occlusal anatomy is done at the same time.

Fig. 6

Polymerization for 30 seconds. I usually like to treat multiple cavities on the same quadrant in one visit. For a bad planning I almost lost one whole hour (the difference between doing 2 or 3 cavities is small) because if  treated in the same appointment, we only have to perform one same anesthesia, one isolation procedure, and we don’t have to repeat all the steps from the beginning. 

Fig. 7

So here we go, second appointment, anesthesia…

Fig. 8

… placing of the dental dam, this time on the second molar, with a wedge because I knew I would have to open interproximally. 

Fig. 9

I customized the ring with a resin. 

Fig. 10

I cleaned the cavity leaving the proximal wall in order to avoid to touch the neighbouring tooth.

Fig. 11

When the wall is thin enough it usually crumbles. Manual instruments might also help in this situation.

Fig. 12

I start to clean all the enamel, the proximal enamel is cleaned with a special bur with only diamond on the top to avoid touching the neighboring tooth.

Fig. 13

Once the enamel margins are clean I start cleaning the dentin with the aid of a caries detector. 

Fig. 14

We still have caries on the proximal box. 

Fig. 15

Cavities are now clean.

Fig. 16

We first restore the premolar and then, with only one sectional matrix and the custom ring we were ready to start the molar restoration.

Fig. 17

Adhesive steps. selective etching with 37% phosphoric acid for 30 seconds and adhesive agent.

Fig. 18

A thin proximal wall was created with perfect adaptation thanks to the custom ring. Then the same procedure of the first appointment was followed using a bulk composite (Ecosite, DMG) in two increments, due to depth of  the cavity in the mesial area.

Fig. 19

After removing the dental dam

Fig. 20

After removing the dental dam

Fig. 21

Control appointment

Fig. 22

Control appointment. 

 

Conclusions

In my practice, I have always been reaching for excellence trying to do my best in each step. Because in every clinic in the world time is a key factor, protocols that help us decrease the treatment total time are really appreciated for everybody (including the patient).

Stratification times decrease using the Bulk materials and with the essential lines, the technique to model the anatomy of the final occlusal layer in posteriors (which will be described very soon in a Styleitaliano article)

Before, I was afraid of using Bulk composite on the outer part of the restoration as they are “worse” than hybrid conventional composites mechanically speaking. On the other hand, some bulk composites have improved in many senses. I am very satisfied with this new material which is really good optically, mechanically and with a good handling, easy to use and easy to finish and polish. What else? 

Bibliography

  • A. Van Ende, J. De Munck, K.L. Van Landuyt, A. Poitevin, M. Peumans, B. Van Meerbeek. Bulk-filling of high C-factor posterior cavities: effect on adhesion to cavity bottom dentin. Dental Materials 29 (2013) 269-277
  • Van Dijken JW, Pallesen U. 2016. Posterior bulk-filled resin composite restorations: a 5-year randomized controlled clinical study. J Dent. 51:29–35