Dr. Ross W. Nash

	In our esthetically focused society, tooth-colored posterior restorations are the choice for many patients. Ceramic inlays and onlays can provide excellent alternatives to amalgam and gold. However, the cost of indirect restorations is sometimes a limiting factor in today’s economy.

	Direct posterior composites can be affordable alternatives for the patient, but have been challenging for the practitioner due to many factors. Conventional direct composites are light cured and often require layering in increments due to the restriction of curing depth with an LED curing light. Proximal contacts are difficult to achieve with traditional matrix systems. Polymerization shrinkage has sometimes resulted in tooth sensitivity and marginal leakage. And the time required to place these restorations often has resulted in low financial productivity.

	Numerous bulk fill materials have been introduced to help solve some of these issues. One of the newest materials is Fill-Up! from Coltene.

	It involves use of a dual-curing composite resin that sets on its own in three minutes. Since it has a self-curing mode, shrinkage is directed into the center rather than toward the curing light, resulting in less shrinkage stress and an excellent marginal seal when combined with its dual-curing bonding agent (ParaBond). No layering is needed, so the cavity preparation can be filled in one increment. The resulting shade is approximately an A2 Vita shade, which blends well with most posterior tooth structures. Room can be provided for an occlusal layer of composite if a different shade is desired.

	Proximal contacts can be achieved predictably with a ring system, such as the Composi-Tight 3D system by Garrison Dental. By using a curved sectional matrix combined with a wedge and ring system, proper proximal contours are easily obtained.

	The mesial of the first molar and distal of the second premolar (Fig. 1) exhibited proximal decay requiring repair. The patient (male, aged 18 years) chose direct composite restorations for their affordable cost and one-appointment procedure.

	I administered anesthetic, and my assistant placed a rubber dam. I prepared the proximal surfaces using a crosscut carbide bur (Fig. 2), being careful to be minimally invasive and leaving the transverse ridges intact. The finished preparations can be seen in Figure 3.

	A sectional matrix was placed at the distal of the second premolar and secured with a small wedge (Fig. 4). A Composi-Tight ring was placed over the wedge and against the matrix using the forceps designed for the system. Figure 5 shows the system in place.

	Phosphoric acid etching gel was applied to the enamel margins (Fig. 6) and then onto the prepared dentin and immediately rinsed thoroughly with water from the air/water syringe (Fig. 7). The prepared tooth was lightly air-dried using oil-free air from the air/water syringe.

	One drop from each bottle of the bonding agent (ParaBond) was placed in a mixing well, mixed, applied to the prepared areas of the tooth and massaged in for 30 seconds using the applicator tip (Fig. 8). The bonding agent was air dried with oil-free air from the air/water syringe (Fig. 9).

	Fill-Up! composite was injected into the cavity preparation using the auto-mixing tip (Fig. 10). Care was taken to apply the material from the bottom up, leaving the syringe tip in the material so that no voids would be created. In Figure 11, the filled preparation can be seen. The composite was allowed to self-cure for two minutes and a LED curing light was used to cure the surface for five seconds (Fig. 12). The Composi-Tight ring was removed with the forceps and the wedge and sectional matrix were then removed (Fig. 13).

	Another sectional matrix was placed for the mesial of the first molar (Fig. 14). After the wedge and Composi-Tight ring were placed, a spoon was used to burnish the matrix at the contact position (Fig. 15). The tooth was then etched, rinsed and dried and the bonding agent was applied as before. The Fill-Up! composite was applied (Fig. 16) and allowed to cure as before. The cured composite can be seen from the occlusal surface in Figure 17.
	The surface of the composite was contoured using a carbide finishing bur (Fig. 18). Figure 19 shows both posterior composites in place before rubber dam removal.

	After the rubber dam was removed and the occlusion was adjusted, polishing of the composite resin was accomplished with Alpen SwissFlex polishers (Figs. 20-22). Floss was used to confirm a tight contact (Fig. 23). The final result can be seen in Figure 24 at a two-week follow-up appointment.

	In this article, I described a predictable, time-efficient process for applying a direct posterior composite restoration using a new bulk-fill dual-cure composite resin by Coltene and sectional matrix and ring system by Garrison.

Articles

How to apply direct posterior composite restoration with bulk-fill dual-cure composite resin and sectional matrix/ring system.

How to efficiently place posterior direct composites

	Restoration of Class V lesions can be difficult and frustrating. A number of materials choices and techniques are available, but I have found a material that has made my work much easier and I actually enjoy placing Class V restorations today.

While glass ionomers, resin ionomers and composite resins have been successfully used, I prefer a microfil composite resin. One that I particularly like is EPIC

-TMPT by Parkell. In this article, I will illustrate a technique that I have found to be predictable, quick and esthetic.

	Continue to the next page to learn how EPIC-TMPT can make the process easier.

 shows a patient with non-carious Class V grooving in the canine, first premolar and second premolar teeth. The molar has already been restored with a full crown. Restoration was desired by the patient for esthetic reasons. 

	I used a small fine round diamond bur to slightly roughen the areas to be restored in order to remove the sclerotic layer on the dentin surface. Phosphoric acid etching gel was injected along the enamel margins (

Continue to the next page for the next step.

	The etching gel was thoroughly rinsed with water from an air/water syringe (

) and lightly air dried. I then applied a universal bonding agent (Brush and Bond, Parkell). The bonding agent was messaged in for ten seconds using an applicator tip (

	It was then air dried (Fig. 6) and light cured for ten seconds with a LED light curing unit (

Continue to the next page for the next steps...

This is where the process gets to be fun! I took a small amount of EPIC-TMPT, rolled it into a ball and place it on the end of an instrument. I gently laid the material into the preparation (

) and it almost “fell” into the shape of the preparation on its own.

	I used the instrument to lightly touch the material where I wanted it to flow more (

). Even though the thixotropic nature of the material encourages it to flow, its viscosity allows it to stay in place. I applied the material in the same way to the other two teeth. Final placement of all three restorations is shown in 

A LED light was used to cure the restorations for twenty seconds each (

Finishing of the contours and margins was carried out with a small carbide finishing bur (

	Smoothing of the composite surface was performed using an E2hance cup by Dentsply (

) and polishing was accomplished with a diamond impregnated brush (

One dentist outlines how using EPIC®-TMPT Composite by Parkell can simplify Class V restorations.

How to restore Class V restorations with EPIC-TMPT

	Since their introduction in the late 1960s composite resins have continually evolved in terms of convenience, durability and esthetics. The evolution in esthetics has been particularly important to increasingly demanding patients and is largely because of enhanced optical properties and improvements in the ability to achieve a high surface luster. Esthet-X® HD High Definition Micro Matrix Restorative is the next generation of Esthet-X® Micro Matrix Restorative, a universal composite and a pioneer in nano technology with a clinical track record of more than 10 years.

	Esthet-X HD restorative shares the same chemistry with the original Esthet-X
	and provides the same physical properties, clinical performance, handling characteristics and life-like esthetics. The difference is Esthet-X HD’s enhanced filler technology that results in a material that takes polish to a new level. This was accomplished by removing the proportion of larger filler particles and shifting the particle size distribution to smaller size particles including nano particles.

	The patient was a young female pedodontist who wished to enhance the appearance of her smile by having her maxillary central incisors restored with composite resin. Previous composite resin restorations had been placed a number of years earlier after trauma resulted in a Class IV fracture of her right central incisor and incisal fracture of her left central (Fig. 1)

	No pulpal damage had occurred and the teeth were caries free and periodontally sound. Esthet-X HD was chosen as the restorative material because of its high strength, excellent polish, easy handling and shade selections.

	01. Use a football-shaped diamond bur to prepare the lingual surface of the left central incisor. Next, a small chamfer diamond is use

	02. Fig. 2 shows the final preparations for direct composite facial veneers and Class IV repair.

	03. Etching gel is applied to the right central incisor and then Dentsply International’s Prime & Bond NT is applied to the etched surface (Fig. 3). 

	04. Esthet-X HD body shade is applied to the Class IV area of the right central incisor (Fig. 4). Fig. 5 shows the incisal build-up with body shade. 

	05. The enamel shade is applied to the entire facial surface of the right central incisor, and the incisal shade is applied to the facial surface of the right central incisor. 

	06. Use a football-shaped carbide finishing bur to refine the contour of the lingual area. A small carbide bur is used to finish the marginal areas.  

	07. A plastic instrument is used to “torque” the teeth and separate the composite from the adjacent tooth (Fig. 6). A Dentsply Int’l PoGo Polisher is used to achieve a high gloss (Fig. 7).

	08. After the restoration was completed, Fig. 8 shows the right central incisor completed and Fig. 9 shows the tissue healing at two weeks’ post-op.


	The procedure was accomplished in a single appointment and a post-operative evaluation was performed two weeks later (Fig.10). The patient was extremely pleased with the end result and commented that her friends and family immediately noticed the improvement in her smile and could not differentiate between her natural teeth and the composite resin restorations. Fig. 11 shows the completed case with the patient’s new smile with Esthet-X HD direct composite restorations. 

 Since their introduction in the late 1960s composite resins have continually evolved in terms of convenience, durability and esthetics. The evolution in esthetics has been particularly important to increasingly demanding patients and is largely because of enhanced optical properties and improvements in the ability to achieve a high surface luster.