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Dental Tribune Nordic Edition | 3/201508 TRENDS&APPLICATIONS Direct composites in posterior teeth are a part of the standard therapy spectrum in modern dentistry. The excellent performance of this form of restoration in the masticatory load-bearing posterior region has been demonstrated in numerous clinical studies. The procedure is usually carried out in an elaborate layering technique. Aside from the possibilities that highly aesthetic composites offer in the application of polychromatic multiple-layer techniques, there is great demand forthemostsimpleandquicktouse, and thereforemoreeconomical,com- posite-basedmaterialsforposterior teeth.This demand can be met with ever more popular composites with increased depths of cure (bulk-fill composites). Introduction The range of products available inthefieldofdirectcompositeshas expandedgreatlyinrecentyears.1–3 In addition to the classic universal composites, the enormous rise in patients’ aesthetic expectations hasresultedinthelaunchofalarge number of so-called “aesthetic composites” on the market, which are characterised by composite materials in a sufficient number of different shades and different grades of translucency and opa- city.4 Opaque dentine shades, translucent enamel pastes and, if required, body shades make it possibletoachievehighlyaesthetic directrestorationsusingthemulti- coloured layering technique. They are practically indistinguishable from the dental hard tissue, and they rival the aesthetics of all-ce- ramic restorations. Some of these compositesystemsconsistofmore than 30 different composite mate- rials of various shades and degrees of translucency. It is, however, es- sential to have appropriate experi- ence in the handling of these ma- terials, which are primarily used in the anterior region with a layering technique employing two or three different opacities and translucen- cies.4, 5 Owing to their polymerisation properties and limited depth of cure, light-curing composites are generally used in a layering tech- nique with individual increments ofnomorethan2mminthickness. Each increment is polymerised separately, with exposure times ranging from 10 to 40 seconds, de- pendingonthepowerofthecuring light and colour or translucency of thecompositepaste.6 Withthema- terials available up until recently, thicker composite layers resulted in insufficient polymerisation of the composite resin and thus in poorer mechanical and biological properties.7–9 Applying the com- posite in 2 mm increments can be a very time-consuming procedure, especially in large posterior cavi- ties. Consequently, there is con- siderable demand in the market forcomposite-basedmaterialsthat are simple and quick to use, and therefore more economical, for this range of indications.10 In order to satisfy this demand, bulk-fill composites have been developed overrecentyearsthat,givenasuffi- ciently powerful curing light, can be placed more quickly in the cav- ity, using a simplified application technique,inlayers4to5mmthick and with short increment curing times of 10 to 20 seconds.11, 12, 6, 13, 14 Taken literally, “bulk fill” means thatthey canbe usedto fillthe cav- ityinasinglesteplegeartiswithout the need for a layering technique.15 With plastic restorative materials, this is currently only possible with cements and chemically activated or dual-curing core build-up com- posites. However, the former do not possess adequate mechanical properties for restorations that are clinically stable in the long term in the masticatory load-bearing posterior region of the permanent dentition and are consequently only suitable for use as interim restorations or long-term tempo- raries.16–18 The latter are neither ap- proved as restoratives nor suitable for such indications from a han- dling perspective (e.g. shaping of occlusal surfaces). The bulk-fill composites currently available for the simplified filling technique in the posterior region are not actu- allybulkmaterialsinthetruesense when examined more precisely, as the approximal extensions of clin- ical cavities, in particular, are gen- erally deeper than the maximum depth of cure (4–5 mm) specified for these materials.19, 20 That said, it is possible to fill cavities with depths of up to 8 mm in two in- crements if a suitable material is selected—andthiscoversthemajor- ity of defect dimensions encoun- tered in routine clinical practice. Most composites contain orga- nic monomer matrices based on conventional methacrylate chem- istry.21 Silorane technology22–27 and ORMOCERchemistry28–35 presental- ternative approaches. ORMOCERs (organically modified ceramics) are organically modified, non- metallic inorganic composites.36 Ormocers can be classified be- tween inorganic and organic poly- mers and possess both an inor- ganicandanorganicnetwork.37,38,34 This group of materials was devel- oped by the Fraunhofer Institute forSilicateResearchinWürzburgin Germanyandmarketedforthefirst time as a dental restorative mate- rial in 1998 in collaboration with partners in the dental industry.33, 34 Since then, there has been con- Nano-hybrid ORMOCER for the bulk-fill technique in the posterior region A clinical case report By Prof.Jürgen Manhart,Germany 1 Fig. 4: Demarcation of the cavity with a sectional matrix.—Fig. 5: Selective enamel etching with 35% phosphoric acid.—Fig. 6: Situation after rinsing off the acid and carefully drying the cavity.—Fig. 7: Application of the bonding agent Futurabond M+ to the enamel and dentine with a micro-brush.—Fig. 8: Careful drying of the solvent from the adhesive system with an airstream.—Fig. 9: Light curing of the bonding agent for 10 seconds.—Fig. 10: Once the adhesive had been applied, the entire sealed cavity had a shiny surface.—Fig. 11: The first increment of Admira Fusion x-tra filled the mesial area of the cavity and shaped the approximal wall up to the level of the marginal ridge. Fig.1: Situation before treatment:amalgam filling in tooth #46.—Fig.2: Situation after removal of the amalgam filling.—Fig.3: After excavation,the cavity was finished and isolated with a rubber dam. 4 5 6 7 8 9 10 11 2 3 DTNE0315_08-09_Manhart 02.11.15 11:03 Seite 1 4567 891011 23 DTNE0315_08-09_Manhart 02.11.1511:03 Seite 1