Dr. Ed Lowe

This case illustrates the different reliable methods for posterior restoration placement. 

A healthy 45-year-old male patient presented with occlusal amalgam fillings that were placed more than 20 years previously.

As the materials and processes for posterior restorations have progressed, they have become increasingly more efficient, esthetically pleasing and predictably placed. In this case, the clinician used Tetric EvoFlow and Tetric EvoCeram A3 to place the restoration on tooth No. 31, and the procedure took seven minutes.

 IVA on tooth Nos. 30 and 32, and these restorations were placed in a little more than four minutes each.

 allows for the successful completion of a Class II restoration in half the time.

Click here to read the full technique case study. 

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This case illustrates the different reliable methods for posterior restoration placement.  A healthy 45-year-old male patient presented with occlusal amalgam fillings that were placed more than 20 years previously.

How Tetric EvoCeram Bulk Fill helps complete a Class II restoration in half the time [VIDEO]

Placing composite restorations in the posterior region can be a time consuming and technique sensitive procedure.

Historically, clinicians have used traditional direct composites to complete these restorations, carefully layering, sculpting and curing 2 mm increments. This process, while still used, presents several difficulties to the clinician, primarily in the form of polymerization shrinkage and shrinkage stress.1

These difficulties can cause stress fractures at the margins, marginal leakage, or an increased likelihood of secondary caries and post-procedural sensitivity,2 ultimately leading to clinical failure of the restoration.

The continued search for a more efficient and less technique sensitive procedure led to the invention of bulk fill composites. These materials allowed clinicians to fill and cure preparations up to 4 mm deep in one increment. Unfortunately, these materials were highly translucent and were available only in limited shades that appeared grey next to natural dentition.

Some of these materials also had a high reactivity to ambient operatory light; this severely limited the amount of time the clinician had to perform the restorative procedure, and the esthetics were compromised.

The next logical progression was to create a bulk fill composite that still exhibited high strength characteristics but had greater esthetics and manipulability.

This was achieved by altering the size of the filler particles. Modern bulk fills are typically nano-hybrids, meaning the size of the filler particles are much smaller.

This allows for a bulk fill material with a greater depth and uniformity of cure, a smooth consistency, life-like optical properties, and easier sculpting of anatomic form without requiring an additional “capping layer.”3

 is billed as a true advancement in bulk fill technology. One of the innovations featured in this product is the inclusion of the 

This new germanium-based light initiator allows a complete, homogenous cure in 10 seconds using any basic curing lights. One of the components of Ivocerin is an ambient light immunizer that ensures ample working time for the clinician to create artistic anatomical form.

 also contains a shrinkage stress reliever, eliminating the worries of shrinkage stress, because forces are evenly distributed across cavity walls and surfaces. Volumetric shrinkage of the material is very low, which provides a more predictably placed restoration.

The layered silicates that form the bulk of this material provide a smooth consistency, which facilitates optimal adaptation to cavity walls and easy contouring with conventional dental instruments. The following presentation demonstrates two effective bulk fill methods for posterior composite restorations compared with traditional layering and the time required to complete each procedure.

A healthy 45-year-old male patient presented with occlusal amalgam fillings that were placed more than 20 years previously. A treatment plan was agreed upon involving the restoration of tooth Nos. 30 and 32 using a

, and tooth No. 31 using both a flowable and universal composite (

One of the three universal shades most closely matching the patient’s dentition was selected (

). This patient was well matched to shade IVA (for slightly reddish teeth).

After inspecting the old amalgam restorations (

). Next, using Sybron Dental’s Axis course diamond bur, KS3, the amalgam restorations and all damaged tooth structure were removed (

All remaining sharp edges of the preparation were then beveled with Sybron Dental’s Axis fine finishing diamond #846-016, completing the preparations (

Ivoclar Vivadent’s AdheSE® One F self-etch dental adhesive

A stream of oil-free, moisture-free air expelled from a warm air tooth dryer from A-dec was then directed over the adhesives to evaporate the solvent (

). The adhesive was light cured with Ivoclar Vivadent’s LED curing light, 

A single increment of Tetric EvoCeram Bulk Fill in shade IVA was then placed in the preparation of tooth No. 30 (

), then with an OptraSculpt pyramid attachment (

). The final anatomy was contoured using a P1 plugger (

). As a final step before finishing, the restoration was light cured with the LED curing light (

 was applied to the enamel and allowed to penetrate for 15 seconds, after which the etchant was applied to the dentin and allowed to penetrate for 10 seconds to ensure proper etching of both surfaces (

). The etchant was then rinsed off with water, and all excess moisture was removed.

ExciTE® F total-etch dental adhesive was then applied to the preparation and agitated for 10 seconds (

). A stream of warm air was expressed onto the adhesive to evaporate the solvent (

), and the adhesive was light cured using the Bluephase Style for 10 seconds.

Tetric EvoFlow shade A3 was flowed 0.5 mm thick onto the floor of the preparation of tooth No. 31 and light cured for 10 seconds (

). Then, a layer of Tetric EvoCeram shade A3 was placed within 0.5-1 mm of the cavosurface margin.

This second layer was shaped to replicate the dentin layer, then light cured for 10 seconds (

Tetric EvoCeram Transparent was then used to create each of the four triangular ridges of the natural tooth, and each ridge was subsequently light cured for 10 seconds (

Lastly, preparations began on tooth No. 32 by applying the Total Etch phosphoric acid to the enamel and allowing 15 seconds for penetration, then applying the etchant to the dentin and allowing 10 seconds for penetration. Then, the etchant was completely rinsed off, leaving the area moist. ExciTE F dental adhesive was then applied, and a warm stream of air was directed over the preparation to evaporate the solvent.

The ExciTE F adhesive was then light cured for 10 seconds. One increment of Tetric EvoCeram Bulk Fill shade IVA (for slightly reddish teeth) was then delivered to tooth No. 32 (

An OptraSculpt sphere was then implemented to sculpt the composite to the floor and walls of the preparation (

), after which an OptraSculpt pyramid was used to further form the tooth shape (

The restoration, now fully formed, was light cured with the Bluephase Style for 10 seconds. Note that the shape of the light’s tip allowed easy access to the tight space. A fine, tree-shaped diamond, similar in shape to the P1 plugger, was then used to establish occlusal anatomy (

 was used to polish the completed restorations of all three teeth to a high-gloss (

After polishing, the rubber dam was removed, and articulating paper was used to check the patient’s occlusion (

The occlusion was determined to be satisfactory and the restorations complete (

. The patient returned the following week for a visit and reported no post-op sensitivity. After re-hydration, the excellent color-matching to the patient’s natural dentition was visible, and all three restorations appeared esthetically similar.

This case illustrates the different reliable methods for posterior restoration placement.

The clinician used Tetric EvoCeram Bulk Fill IVA on tooth Nos. 30 and 32, and these restorations were placed in a little more than four minutes each. Tetric EvoCeram Bulk Fill allows for the successful completion of a Class II restoration in half the time.


	1. Giachetti L, Scaminaci-Russo D, Bambi C,
	Grandini R. A review of polymerization shrinkage
	stress: current techniques for posterior
	direct restorations. J Contemp Dent Pract.
	2006;7(4):79-88.
	2. Cheung GS. Reducing marginal leakage
	of posterior composite resin restorations: a
	review of clinical techniques. J Prosthet Dent.
	1990;63(3):286-288.
	3. Ferrcane JL. Resin composite-state of the
	art. Dent Mater. 2011;27(1):29-38. Epub Nov
	18, 2010. ?

Technique: How to cut procedure time in half with Tetric EvoCeram Bulk Fill

 region, it is reassuring to know that those fabricated from IPS e.max lithium disilicate provide dentists and their patients with strength, esthetics and the security of monolithic structures. These uniformly constructed restorations perform at maximum strength and potential durability. The minimal draw and adequate height of the preparation ensure good resistance and retention.

Further enhancing restorative predictability and simplicity is SpeedCEM®, a self-curing, self-adhesive resin cement with a light-curing option for quickly and easily cementing high-strength indirect restorations fabricated from metal, metal-ceramic, high-strength all-ceramic, and fiber-reinforced composite materials. With excellent shear bond values to dentin and enamel, SpeedCEM offers a simple conventional placement technique to achieve predictable bonding characteristics.

When using this resin cement, the need for dentists to condition the tooth preparation or apply dentin/enamel 

 is eliminated. Thus, SpeedCEM facilitates a more rapid and efficient technique for definitively seating high-strength restorative materials. Furthermore, because the resin cement is applied directly through a double push syringe, additional mixing devices and applicators are not required. SpeedCEM is available in three shades, (transparent, yellow and white opaque) offering various degrees of translucency.

A 57-year-old female presented with a failing porcelain-fused-to-metal (PFM) crown on tooth No. 29 due to caries under the margin 

. Throughout the years, the patient received regular dentistry and was in good health. Like many patients who grew up in the 1950s and 1960s, her existing direct and indirect restorations were created with a potpourri of restorative materials. The resulting mosaic was not the most esthetic smile ever seen, but both form and function were sound.

The patient’s goal was to replace tooth No. 29 with a durable restoration that would match tooth No. 28. As a clinician, my goal was to place a restoration that would be both esthetic and fracture resistant. Therefore, based on its ability to satisfy certain esthetic and functional demands, 

 lithium disilicate was selected as the restorative material that would best fulfill the patient’s needs.

The patient was anesthetized, and pre-operative digital photographs and a photograph of the final shade were taken. Using the Chromascop shade guide, Shade 220 was selected for the final restoration 

. Prior to tooth preparation, a clear polyvinyl siloxane (PVS) impression of the existing restoration was made and set aside for use in fabricating the acrylic provisional restoration.

Tooth No. 29 was vital, with a composite buildup under the existing PFM crown. The old PFM crown was removed, and the tooth was prepared for a full-coverage IPS e.max lithium disilicate crown. Final occlusal reduction of 2 mm and axial reduction of 1.5 mm were accomplished using an 856-016 super coarse diamond from Axis Dental’s NTI line and finished using a similar diamond in a fine grit 

. All sharp edges were removed, and the preparation had minimal taper.

A PVS bite registration was taken with Ivoclar Vivadent’s Virtual while the patient was sitting up. A #0 cord was placed in the sulcus, and a #1 cord was placed above it. Then, a triple tray impression of the preparation was taken using an extra light body PVS material around the tooth using a medium body PVS material loaded in the tray. The impression was inspected for accuracy and set aside.

The preparation shade was determined to be ST1. This was recorded on the laboratory prescription, along with the final shade and a shade map of the restoration 

 crown was fabricated using the following technique: the acrylic was placed in the clear matrix and then onto the moistened prepared tooth. After 2 minutes, the matrix was removed and the excess acrylic flash discarded. The provisional crown was allowed to set for another minute prior to removal from the matrix. A medium Soflex XT disk from 3M ESPE was used to trim and shape the provisional.

A brush was used to buff the provisional 

, after which it was cemented using a dual-cure provisional cement (Ivoclar Vivadent’s Systemp.link). The occlusion was verified, and the patient was dismissed.

A week later, the patient returned for delivery and cementation of the definitive 

 lithium disilicate crown restoration. The crown was inspected on the model for fit and color accuracy 

. The patient was anesthetized, and the provisional crown removed with hemostats. The preparation was cleaned with 3% hydrogen peroxide and a 0.12% chlorhexidine rinse.

. The lithium disilicate restoration was then tried-in dry, and the margins were checked using an explorer.

. It was determined that the transparent shade of SpeedCEM should be used for luting. The preparation then was rinsed clean with water and blotted dry.

. The intaglio surface of the restoration was cleaned with a 35% phosphoric acid etch for 15 seconds and rinsed with water. After drying, a silane coupling agent (Ivoclar Vivadent’s Monobond Plus) was painted onto the etched surface and remained in contact for 1 minute prior to being air dried.

. Using an automix syringe, the transparent shade of SpeedCEM was dispensed directly into the restoration 

. The crown was seated and held in place with uniform pressure using a ball burnisher and spot tacked for 2 seconds using a 2 mm tacking tip 

. Excess resin cement was light cured with Ivoclar’s 

 for 1 second per quarter surface (i.e., mesio-lingual, disto-lingual, mesio-buccal, disto-buccal) at a distance of approximately 0-10 mm. The excess material then was easily removed with a scaler 

. The contacts were flossed, and Ivoclar’s Liquid Strip glycerin gel was applied to all margins before curing for 20 seconds from the occlusal, buccal and lingual aspects.

. Using a fine finishing carbide (Axis Dental’s TDF 9), residual cement was removed from around the margins.

. The contacts were checked with floss, and the occlusion was adjusted in MIP and all excursions. Note that the high value of the old zirconium crown on tooth No. 30 adjacent to the esthetic and life-like IPS e.max lithium disilicate crown on tooth No. 29 became more apparent 

 the definitive restoration based on its easy cleanup. It is user-friendly and, in many cases, the patient does not need local anesthetic at the seating appointment. When searching for an easy-to-use conventional cementation technique, the protocol outlined here is as close as you can get.

Edward Lowe, B.Sc., D.M.D., established and heads the Vancouver Centre for Cosmetic and Implant Dentistry in Vancouver, BC, Canada.

Acknowledgement: The IPS e.max lithium disilicate restoration was fabricated by Brian Lee from SmileTec Dental Lab, Vancouver, BC, Canada.

When placing restorations in the posterior region, it is reassuring to know that those fabricated from IPS e.max lithium disilicate provide dentists and their patients with strength, esthetics and the security of monolithic structures. These uniformly constructed restorations perform at maximum strength and potential durability. The minimal draw and adequate height of the preparation ensure good resistance and retention.