Fig.1
First of all we should apply a rubber dam. For this particular case we use (Non Latex Flexi Dam, Coltene/Whaledent) As preparation is done, it is time to think about how to restore the proximal wall at the same height of the adjacent tooth.

Fig.2
In the past, for measuring the height of the adjacent proximal wall a periodontal probe was used and then a mark of the marginal ridge was made. It used to be a very complicated work, but now with this new instrument it is not anymore.

Fig.3
To simplify our daily practice we now have the new posterior version of the popular LM Misura instrument with 2 tips on its ends.

Fig.4
The fork shaped tip of the instrument allows measuring and modeling of the composite wall with the presence of a matrix.

Fig.5
The other end was designed for the horizontal and vertical measuring of thickness of the last composite layer on posterior restorations. To block the color of the bottom layer we always need minimum 1,5 mm of Body shade composite

Fig.6
We placed black matrix (LumiContrast Sectional Matrices, Molar 0.025mm / 6.4mm) wedge and MyRing Classico with delta tubes (Polydentia)

Fig.7
Now we can start adhesive procedures. The first step is to etch enamel for 30 second with a selective etching technique – in this case we use 35 % phosphoric acid Etchant Gel S (Coltene)

Fig.8
After rinsing the etching gel from enamel, it is time to place self etching One Coat Universal Adhesive (Coltene). We start by applying the new generation of adhesive (multilayer) by brushing actively, more on the the dentin and less on the enamel. We must wait minimum 20 seconds for the exposition of the adhesive followed by 5-10 second air drying to remove the solvent.

Fig.9
Light curing for adhesive layer will be minimum 20 seconds. We have to finish adhesive layer with a small drop Bulk fill flowable composite for creating a hydrophobic protection layer. For Light curing we used S.P.E.C.® 3 lamp (Coltene) In this lamp we have 3 curing modes (Standard Mode), (3K Mode), (Ortho Mode) • Standard Mode: Ideal for most composite curing scenarios.
• 3K Mode: For rapid curing when time is an issue, like pedo or patients with gag reflex.
• Ortho Mode: Cures an entire full-arch of brackets with 2 three second intervals per bracket.

Fig.10
For great sealing of the margins we need to apply a little drop of Bulk-flow composite between the matrix and tooth. Then immediately place regular composite above flowable composite without curing.

Fig.11
Placing Bulk-flow between matrix and tooth. spreading with LM Arte Fissura powered by Styleitaliano

Fig.12
Placing regular body shade composite Brilliant Ever glow (Coltene)

Fig.13
Applying to the vestibular and palatal walls with LM Arte Condensa instrument powered by Styleitaliano. You can notice that the height of the new crest is more than the one of the adjacent tooth.

Fig.14
Now it is time for the main step.
TIP: If you want to have the same marginal crest height of the adjacent tooth, use the LM Posterior Misura instrument

Fig.15
We can easily eliminate excess material with half of the fork shaped end while the second half is controlling the height

Fig.16
And then we apply material and smoothen the surface with CompoBrush (Smile Line)

Fig.17
The wall is ready and now we can check the height with the same instrument. You can notice that both approximal walls are at the same level.

Fig.18
After having transformed the class II cavity into a class I, it’s time to fill it. To this end we can use incremental layering technique but using this technique will take to much time. Today we have a lot of bulk fill composites in the market. In this case, we use Fill-up! (Coltene) because we can place this dual curing bulk composite in deep cavities in only one layer. No matter what layer thickness is applied, there is no need to worry about thorough curing, as Fill-Up! consists of both light and chemical curing properties. Light-curing for just 5 sec.

Fig.19
As the dentin layer is finished, it is time to switch to enamel layer. As we mentioned we need just 1,5 mm thickness of the last layer If we want to avoid to have high spots after restoration, the other end of this instrument gives us a chance to leave this exact space for the final layer.

Fig.20
Final occlusal anatomy is always a problem for the dentist. But we think that it is important to follow the nature. The occlusal map is always guiding us. You can see on the picture occlusion map. This shows us the place where the sulcus will be between the cusps

Fig.21
For this case we use easily polishable Brilliant Ever glow composite material (Coltene).

Fig.22
Occlusal view after applying composite to the walls with LM Arte Condensa instrument and with a CompoBrush (Smile Line)

Fig.23
Now it is time to follow to the natural GPS. You can see that with this essential lines we can easily recreate the anatomy. Today we have a new FMT with Essential lines technique by Styleitaliano which give us a chance to model the last layer in just 2 minutes.

Fig.24
Modeling was done in 1-2 minutes tops: FMT with Essential Lines technique will be described very soon

Fig.25
Stain application with LM Arte Fissura instrument.

Fig.26
This stage is the final polymerization under glycerine. We need minimum 1 minute of polymerization for blocking of oxygen inhibited layer.

Fig.27
Finishing and polishing starting with abrasive rubber cups for cusps, then the rubber points for deep fissures and finished with silicone abrasive wheels without any polishing paste at low speed. (Diatech Polishers by Coltene)

Fig.28
Final view of the proximal walls after restoration.

Fig.29
Final view of occlusion surface after restoration.

Conclusions

Measuring thicknesses is always a benefit in everyday dentistry, makes it fast, reliable and more predictable.
The two measures LM Arte Posterior Misura gives changed and sped up my practice.

Bibliography

Radhika M, Sajjan GS, Kumaraswamy BN, Mittal N. Effect of different placement techniques on marginal microleakage of deep class-II cavities restored with two composite resin formulations. J Conserv Dent. 2010;13:9–15.
Caixeta RV, Guiraldo RD, Kaneshima EN, Barbosa AS, Picolotto CP, Lima AE, Gonini Júnior A, Berger SB. Push-Out Bond Strength of Restorations with Bulk-Fill, Flow, and Conventional Resin Composites. ScientificWorldJournal. 2015;2015:452976. doi: 10.1155/2015/452976
Monterubbianesi R, Orsini G, Tosi G, Conti C, Librando V, Procaccini M, Putignano A. Spectroscopic and Mechanical Properties of a New Generation of Bulk Fill Composites. Front Physiol. 2016 Dec 27;7:652.Manauta J. Back to Basics – Bulk and body. www.styleitaliano.org
JORDI MANAUTA- BACK TO BASICS: BULK AND BODY
GIUSEPPE MARCHETTI – SINGLE SHADE MAKEOVER
MANAUTA J., SALAT A. LAYERS, An atlas of composite resin stratification. Quintessence 2012.