Fig.1
A 19-year-old patient came to the clinic suffering from multiple caries, especially in the molar area. At the first sight, a failed composite filling needed to be replaced on first left upper molar and a I class on the second left upper molar were evident. I decided to both treat them on the same appointment.

Fig.2
First of all, the operative field was isolated with the rubber dam.

Fig.3
The old restoration was removed, and both cavities were properly cleaned and finished.

Fig.4
Selective etching of the enamel with ortophosphoric acid was performed for 30 seconds for both the cavities.

Fig.5
After rinsing the cavities for 30 seconds, a Universal bonding, in a selective etching mode (Ecosite Bond, DMG) was preferred to simplify the adhesive protocol. After brushing it for 20 seconds, the adhesive was gently air-blown to achieve an even thickness and remove excess, before curing it for 20 seconds.

Fig.6
After curing the adhesive and covering the deepest dentin with a thin layer of flowable composite, the cavities were filled altogether, up to the top by using a packable bulk fill (Ecosite Bulk Fill, DMG).

Fig.7
Taking all the residual anatomical information, I performed a subtractive technique. I pushed the composite towards the cusps using the thicker tip of the LM Solo Posterior (LM Arte, powered by Styleitaliano) first, and the thinner one after, in order to remove all the excess; by means of the pointed tip, I fixed the fossa – the centre of the modeling (the green circle in the picture) – and I outlined primary sulci (in pink). Then, playing with composite pushing it to make it higher on primary ridges and lower in the grooves, and brushing the composite towards the margins and in correspondence of the drawn anatomy, I gave the restoration a more natural aspect.

Fig.8
I followed the same steps for the upper first molar being the cavity 4 millimeters deep.

Fig.9
Once the anatomy was satisfactory, I cured the composite and the restorations were considered complete.

Fig.10
Still using LM Solo Posterior, I added some brown stain (Brown, DMG) to mimic the adjacent teeth. Remember, the less, the better. A microbrush was used to absorb the excess stain, leaving it only at the bottom of the fossae and the sulci.

Fig.11
The composite has its own luster, but a polishing procedure can improve the longevity of the restoration. In this case a brown Shofu rubber first, and a yellow rubber polisher then were enough to obtain a natural-looking polish.

Fig.12
Final result after rubber dam removal. The more chromatic aspect is correct. We just need to wait for rehydration.

Fig.13
Occlusal check with Troll Foil premounted articulation paper 8 µ (Directa, SW).

Fig.14
Restorations at 6-month check-up show good integration despite the use of only one bulk mass and a non-optimal hygienic maintenance by the patient.

Conclusions

Always remember:
1) to probe the cavity depth. Choose a bulk fill if the clean cavity is up to 5 mm. If we can “go bulky” to make our appointment shorter, let’s do it!
2) to prefer universal adhesive paired with a selective etching strategy to prevent the post operative hypersensitivity;
3) don’t forget to follow the residual anatomy and color the pits to easily perform a lifelike restoration.

Bibliography

1) van Dijken JWV, Pallesen U. Bulkfilled 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 NovDec;31(6):719-27.
3) Ilie N. Sufficiency of curing in highviscosity 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