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Dental Tribune Middle East & Africa Edition | 6/2016 4 restorative Solving the problem of postoperative complications of Class I restorations ByDr.ValentinaKondratieva,Russia Introduction In the recent years there has been a rapid improvement in the physical properties of the composite materi- als and adhesive systems that cer- tainly helped dentists to improve the quality of their work. Shrink- age of composite materials today is lower than before, their strength and wear resistance have increased, and aesthetic rates are comparable totheaestheticsofnaturalteeth.But, unfortunately, the problem of the polymerization stress has remained to the present time. Shrinkage of the composite material during polymer- ization causes stress in the compos- ite, the adhesive layer and the tooth tissues. The intensity of the stress depends on such factors as cavity configuration (C-factor), the physical properties and composition of the composite material. The result of the polymerization stress is a number of complications - micro leakage, post- operative sensitivity, cracks in the tooth, subsequent secondary caries and others. To prevent such prob- lems during performing restorations withclassiccompositematerialsit’sis recommended to use flowable com- posites as an adaptive layer (creat- ing the ‘elastic cavity wall’), as well as performplacementofthecomposite in small portions during filling the cavity (‘incremental" technique’). [1] Such approach is familiar to the den- tists but require a lot of time for res- toration of each tooth as during the work the clinician has to insert into the cavity and adapt multiple num- ber of layers of the composite mate- rial.Thatiswhybulkfillmaterialsare increasinglypopular.Theyhelpsolve theproblemofpolymerizationstress andreducetheamountoftimespent on the restoration of the tooth. One of such materials, Filtek™ Bulk Fill Posterior Restorative, is used a lot in dentalpracticesworld-wideanddaily helpsustodoabetterjob. Clinicalcase The patient came to the dental of- fice with complaints about increased sensitivity of the posterior teeth of the lower jaw on the right while eat- ing sweets. During the examination the poor quality restorations of teeth 4.6, 4.7 with micro leakage, numer- ous cracks and color change along the border between the restoration and the tooth were found (Fig. 1). To minimize polymerization stress, savetimeduringthetreatmentwith- out compromising the strength and thewearresistanceoftherestoration it was decided to make a direct resto- ration of the teeth with Filtek™ Bulk FillPosteriorcompositematerial. Isolationoftheworkingfield When working with composite ma- terials the use of the isolation will helptomaketheadhesiveprocedure more predictable and will provide a dry working field and retraction of the soft tissues surrounding the tooth. But in this case the applica- tion of a clamp for fixing the rubber dam material has certain difficulties – a tooth 4.7 has a low clinical crown and there is no possibility to rigidly fix the clamp on it. There is a simple solution to this problem: 36% phos- phoric acid is applied on the area near the gingiva on the buccal wall of the tooth in two places and after 5 seconds washed out with the plenty of water, then a piece of the compos- ite material is placed on the surface (composite shoulder), which after the polymerization will perform the functionofholdingtheclamponthe tooth.Aftertheplacementoftherub- ber dam all possible leaks are sealed withgingivalprotector(Fig.2). Preparationstep Old restorations were removed with the diamond burs (diamond particle size is 120-140 microns), the univer- sal carbide bur (SS-White SSW FG- 1702SL) was used for preparation of carious dentin, enamel walls of the cavities were treated with fine-grain diamond burs (diamond particle size is 25 microns) and polished with Fig. 1. Initial clinical situation. Teeth 4.6, 4.7 have unsatisfactory restorations with microleakages, color changes along the restoration-toothborder. Fig. 6. 10-second polymerization of Single BondUniversaladhesive Fig.15.Curingofthecompositefor20sec- ondswithElipar™S10CuringLight Fig. 10. Shaping the distal buccal cusp of the tooth4.6withLM-Applica tool Fig. 2. Isolation of the working field with thelatexcurtain Fig.7.ApplicationofFiltek™BulkFillFlow- able composite as an adaptive layer on thebottomof thecavities Fig.11.Shaping themesiallingualcuspof the tooth4.6withLM-Applica tool Fig. 16. Restorations of the teeth 4.6, 4.7 beforefinishing Fig. 17. Restorations of the teeth 4.6, 4.7 beforefinishing Fig.18.X-Rayofthefinalrestorations.The material shows an excellent radiopacity andadaptation to thecavitywalls Fig. 19. Final restorations after the oc- clusaladaptation,finishingandpolishing Fig.20.Restorationsafter10months Fig. 12. Shaping the fissures of the tooth 4.6withLM-Fissura tool Fig. 13. Position of the LM-Fissura tool during the process of creating the tooth shape Fig. 14. Removal of the excess of material from the border tooth-restoration with syntheticfiberbrush Fig. 4. Selective etching of the enamel with36%phosphoricacidfor10seconds Fig. 3. Old restorations are removed from the teeth, preparation of carious dentin is performed, cavities are prepared for fur- therrestorations Fig.8.ApplicationofFiltek™BulkFillPoste- rior(shadeA2)afterthepolymerizationof theadaptivelayer Fig. 5. Application of Single Bond Univer- saladhesive Fig. 9. Adaptation of the top layer of the Filtek™ Bulk Fill Posterior with a ball bur- nisherbur "Kenda" polishing cup for a better fit of the restoration. [2] The result of thepreparationistwoClassIcavities, teeth4.6and4.7.(Fig.3). Adhesiveprotocol To prevent postoperative complica- tionsandprovideproperadhesionof the composite to enamel and dentin an adhesive protocol using selec- tive enamel etching was performed. Phosphoric acid was applied on the enamel edges of the cavity for 10 sec- onds (Fig. 4), fully washed out with water. After drying the teeth, a self- etch adhesive was used in the cavity, agitating the dentine for 20 seconds (Fig 5). The adhesive was dried until formation of a smooth shiny film and then polymerized for 10 seconds (Fig.6). Flowablecompositeuse Many authors describe the use of flowable composite underneath pos- teriorrestorations.Improvedadapta- tion and contribution to lower post- operativesensitivityhavebeengiven as reasons for this. Although Filtek™ Bulk Fill Posterior is very flowable upon extruding, the author also pre- fers to apply a layer of flowable com- posite prior to placing the composite restorative [3M]. [3] In this clinical case,forthispurposeFiltek™BulkFill flowable composite was placed on the dentin in an increment of about 0.5-0.7 mm and polymerized after- wards(Fig.7). Compositerestoration The further restoration was per- formed with Filtek™ Bulk Fill Poste- rior Restorative material (Shade A2). The product has high strength and wear resistance, good polishing, self- adaptation, it allows placement in an increment up to 5 mm and has low modulus of elasticity to prevent de- velopment of postoperative compli- cations. [4] Filtek™ Bulk Fill Posterior was placed into the cavity directly fromthecapsuleinonelargeportion (Fig. 8), and then adaptation of the upper layer was performed with the large ball burnisher bur (Fig. 9) to makeanocclusalsurface. Anatomy of the occlusal surface was performedwiththinLM-Applicaand LM-Fissura tools using the technique of direct carving (Fig. 10-13). The ex- cess of the composite material from a tooth-restoration border was re- moved with a synthetic fiber brush, slightly moistened with the model- ling resin (Fig. 14). Polymerization of thecompositematerialwasmadefor 20 seconds (Fig. 15). With the power of curing light of 1000 mW/cm2 this time is sufficient for the full polym- erizationofFiltek™BulkFillPosterior attheentiredepthofthecavity. Finishingoftherestoration On the Fig. 16 and 17 the restora- tions before finishing and polishing are shown. After the rubber dam removal, the composite shoulder was removed from the buccal wall of the tooth using an ultrasonic tip for removing dental plaque, and the remaining of the composite was polished with the SS-White 12-sided carbide bur during finishing and oc- clusal adaptation of the restoration. Finishing and polishing of the resto- rationtoa"drylight"wereperformed with a two-stage polishing system: Sof-Lex™ Spiral Wheels (beige and white). Finalresult The X-Ray showed that the material has an excellent radiopacity and ad- hesiontothecavitywalls(Fig.18).The amount of time consumed on the restoration of two teeth with Filtek™ Bulk Fill Posterior Restorative was equivalent to the amount of time which is usually taken to treat one posteriortooth,whichisanaddition- al advantage for both dentist and the patient. The final result of the resto- rationafterpolishingisshownonthe Fig.19.Long-termresultin10months after the restoration is shown on the Fig.20. Conclusions With this technique using bulk fill nanocomposite materials such as Filtek™ Bulk Fill Posterior the author has less post-operative sensitivity is- sues than with multi-layer compos- iteplacement[3M].Inaddition,using the material in one layer up to 5 mm allowsdentiststosignificantlyreduce theamountofworkingtimewithout sacrificingthequalityofwork. Full list of references is available from thepublisher. Dr. Valentina Kondra- tieva, leading specialist in esthetic restorations, Hummingbird Dental Practice, the author of EVRICAProject,success- ful practicing dentist with over 13 years of experience. Owner of the patents in the field of dentistry and developer of "one opacity" technique of aestheticanteriorteethrestorationwithFil- tek™ Z550 nanocomposite material. Over the past 5 years conducted more than 150 educationaleventsinRussiaandabroad. e-mail:wax.vs@yandex.ru