Restoring a posterior cavity with composite
Featured Products Promotional FeaturesPosted by: Dental Design 26th March 2024
Author Bio: Dr Sandeep Sadana (Dr Sunny) began his dental journey at Bart’s and the Royal London School of Medicine and Dentistry, simultaneously serving in the Army Reserves with the University of London Officers Training Corps. Dr Sunny now runs his own restorative referral service and provides educational courses (www.drecomposite.com).
Here he presents an awkward restorative case which uses a minimally invasive technique to treat caries and provide a high-quality direct composite restoration.
Patient background
A patient presented to the practice complaining of a ‘broken’ tooth on the upper right side. They reported no pain, however food was getting stuck in the space, and they were seeking treatment to prevent the situation worsening.
Assessment and diagnosis
On examination, the UR6 had a disto-palatal cavity with gingival overgrowth (Figure 1). Based on this, it was deduced that caries had been present for some time, and that the undermined enamel had given way.
Treatment planning
Together we discussed the patient’s situation, and I explained that the tooth had caries, which is why the tooth had ‘broken’. As the patient was interested in restorative treatment to prevent further damage, composite to reconstruct the tooth. A minimally invasive approach was recommended to treat the caries and provide a functional restoration.
Treatment provision
Local anaesthetic was provided as a single buccal infiltration using Articaine 4% 1:100000. The tooth was accessed using a high-speed handpiece and coarse pear-shaped diamond bur, removing the undermined enamel and giving better visual access (Figure 2).
Caries indicator dye was used in tandem with tactile feedback from hand instruments for caries detection. Caries dye stains the affected dentine a light colour and the infected dentine a dark colour (Figure 3 and 4).
It allows for the clearer detection of caries under the cusps along the enamel dentine junction, which can often be overlooked. An additional benefit is that, if the cavity is deep and there is risk of pulpal exposure, caries can simply be removed around the periphery, and be left as is on the pulp. Approximately 1.5mm of peripheral good clean enamel and dentine is ideal to achieve a seal preventing bacteria from receiving any substrate. The intention of an approach such as this is to arrest caries over the pulp, and preserve tooth vitality.
The contact between the UR6 and UR7 was cleared (Figure 5) in order to move the margin buccally, making it easier for the patient to maintain oral hygiene. This also provides more enamel rods to bond to, and allows for easier seating of the matrix. In this case some interproximal enamel was removed as it was fractured.
The matrix system used in this case was the Greater Curve System and the matrix band was the Greater Curve Stainless Steel Standard Band (Figure 6 and 7). Using this improves predictability of subgingival restorations, allowing us to achieve standalone isolation or enhanced rubber dam isolation. The Matrix tightens at the base of the tooth, preventing the ingress of blood, saliva, gingival crevicular fluid, and other contaminants. It also flares coronally towards the adjacent tooth surface, preventing open contacts, especially when wider than usual spaces exist.
A modified wooden wedge (Figure 8) was also used in this case to supplement the seal due to concavity at the base. The wedge was modified using a rugby ball shaped bur. This helped to supplement subgingival sealing, whereas an unmodified may introduce an undesirable kink/distortion to the matrix, and thus the composite.
The excess gingiva was removed after the matrix was seated as it trapped the unwanted soft tissue. An ultrasonic scaler without water was used to remove the tissue cleanly, which I coined the USG (Ultrasonic Scaler Gingivectomy) Technique.
The restoration was completed using the snowplough method. BRILLIANT EverGlow and BRILLIANT EverGlow Flow composites from COLTENE were used, both in the shade A2/B2, along with the One Coat 7 Universal Bond from COLTENE. The snowplough method involves using a small amount of uncured flowable composite before each increment of packable composite. This method aims to prevent the formation of any unwanted voids – simply and predictably.
Outcome
The restorative treatment was a success, because the infected tissue was managed accurately around the pulp, a clean periphery was prepared, a verifiable seal was present, a reliable composite system was employed, and the restoration was delivered in record time. Both my patient and I were happy with the comfortable result (Figure 9 and 10).
Case appraisal
The combined use of the reliable matrix system with high-quality composite bonding systems allows me to produce predictable composite restoration results reliably.
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