Fig.1
Initial picture.

Fig.2
Initial picture lateral view. We should change the infiltrated old composite restoration in mesial and distal 45.

Fig.3
Close-up view.

Fig.4
Field isolation is mandatory when performing composites: we isolate from molar to incisor with a molar clamp and a good quality opaque dental dam and we invaginate precisely the dental dam.

Fig.5
When opening inter-proximal spaces we always place a wedge for different reasons: one of them is to separate teeth. First we localize the perfect clean enamel along the whole perimeter of the cavity, then we start cleaning the dentin. We disinfect deep cavities with chlorhexidine 2% for 2 min and then we do selective etching; only enamel with 37% phosphoric acid and use a self-etch adhesive in enamel and dentin.

Fig.6
We used composite Ecosite Bulk Fill Universal color

Fig.7
First we transform the mesial cavity, the class II into a class I. We created the wall with a sectional matrix (MyCustom Rings kit, Polydentia) and then we fill with this Bulk composite (Ecosite, DMG) with very low shrinkage that allow us to create a perfect cavity base. In distal cavity we cannot place a sectional matrix and an automatrix creates a wrong profile so we usually prefer to fill the cavity free-hand.

Fig.8

In only three layers we can finish this kind of cavities: step 1 proximal wall, step 2 cavity base, step 3 finish the restoration.  The layers can be up to 5mm thickness with this composite so in a lot of situations step 2 (increment 2) and step 3 (increment 3) can be done in only 1 increment. 
Why must we do the proximal wall independently? Because we don’t want gaps in the gingival floor, buccal or lingual/palatal wall of the cavity to avoid future micro-leakage so when we build a thin proximal wall we focus all our energy on adapting very well the composite on the critical point union tooth-restoration. Once the proximal wall is built it is easier to pack the composite especially the ones that have good thixotropic properties.

Don´t try to bulk with conventional hybrid composites . TIP: We can not use a conventional hybrid composite in Bulk way. What happens if we do it? ADHESION FAILS. The filling technique and composite type may have a great impact on the adhesion of the composite, in particular in high C-factor cavities. The bulk-fill base composite provides satisfactory bond strengths regardless of filling technique and cavity depth, adhesion fails when conventional composites are used in bulk (Van Ende et al).

Fig.9
The universal mass from this composite (Bulk from DMG) has a good opacity, we have to wait for rehydration because after the procedure tooth looks whiter which is completely normal.

Fig.10
Control appointment 1 week after. We only took the control picture and polished the restoration. We are satisfied with the new composite behavior, good opacity, good aesthetics for posterior restorations. We used the universal mass that can be used in most of daily cases. With it, it is possible to obtain shiny composites in a convenient short time.

Fig.11
Pictures after finishing the restoration with Diamond paste (Diamond paste, Premium).

Fig.12
Before and after composite restoration, mesial and distal tooth 35. It is a really simple daily restoration, but I wanted to set the timing.

Conclusions

Much effort has been concentrated on developing materials that are simpler to use by virtue of requiring fewer application steps, such as bulk-fill and self-adhesive composites. Because these techniques are simpler, requiring less clinical time, less effort among other advantages like less post-op sensitivity when using self-etching adhesive, the “new techniques” are becoming more and more popular.

Recent clinical studies indicate that flowable and regular-consistency bulk-fill materials present similar clinical performance compared with conventional materials (van Dijken et al. 2016). Thanks to the fast improvements of this kind of materials in a few years bulk materials have changed dramatically.

Bulk composites  in daily restorative dentistry are convenient because they are quick and easy to use thanks to the innovative filler technology which gives the composite extremely low shrinkage stress values.

Ecosite from DMG is the fourth composite Bulk that I use in my clinical practice. It surprised me in many ways: good mechanical properties (clinical sensation), optimum gloss with a high shine finish and aesthetics with a really good color/opacity in a wide range of daily posterior restorations, especially the universal color which is matching perfectly most of my daily cases.

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