The patient was anesthetized and the operative site isolated with a rubber dam (Figure 2). Teeth #18 and #19 (Figure 3) were prepared, removing the existing amalgam and underlying caries, and angles of the preparation refined to maintain the integrity of the tooth structure and retain as much enamel as possible for a durable restoration. The preparations were air-abraded (Prep-Start Danville Engineering) using 27-micron aluminum oxide at 40 psi to help increase the bond strength of the composite to the tooth enamel (Figure 4). The preparations were then rinsed and cleaned and disinfected with a 2.0% chlorhexidine gluconate antibacterial slurry (Consepsis Scrub, Ultradent).
After the preparations were thoroughly cleaned and disinfected, a single component 37% phosphoric acid etch material (Etch-37 wBAC, Bisco) was applied to the enamel of both teeth (Figure 5) and air-dried to ensure a strong marginal seal of the composite to the enamel. A universal adhesive (Adhese Universal, Ivoclar) was then scrubbed onto the cavity walls of each tooth (Figure 6), air-dried and cured (BluePhase PowerCure, Ivoclar) for 3 seconds (Figure 7). Next, a single layer of flowable composite (Tetric PowerFlow, Ivoclar) was applied to line the internal aspects of the cavity and light cured for 3 seconds (Figure 8). The flowable composite ensures a complete seal of the dentin against microleakage and recurrent caries and helps eliminate the stress of polymerization shrinkage. In addition, during the curing process, the high translucency of the flowable material gradually changes to a more opaque shade that is closer to that of natural dentin in value and will conceal the stained underlying tooth structure to optimize the esthetics of the final restoration.
The internal depth of each tooth was then measured with a periodontal probe (Figure 9) to verify that the depth of each cavity was not more than 4mm in depth, which is essential when using a single cure bulk restorative material. A single 4mm layer of a bulk fill composite (Tetric PowerFill IVB, Ivoclar) was placed in each tooth (Figure 10), compressed and flattened (OptraSculpt, Ivoclar) to remove any air bubbles (Figure 11) and final anatomy sculpted (Figure 12) using a contouring instrument (P1 Plugger, Ivoclar). The composite fillings were light-cured for the manufacturer recommended 3 seconds (Figure 13). Once curing and occlusal adjustments were made, the restorations were finished and polished using silicone polishers (OptraGloss, Ivoclar) (Figure 14).
For busy clinicians adopting an efficient esthetics approach for posterior restorations maximizes dental practice productivity and profitability. Using a single coordinated system of restorative and bonding materials in conjunction with efficient, and streamlined protocols for Class I restorations helps save chair time without compromising the integrity, predictability and long-term durability of the final restoration. Most importantly, it optimizes the patient experience. By minimizing chair time for patients while meeting their esthetic demands helps build trust and confidence in the dentist/patient relationship. In this case the patient was so pleased with the esthetic outcome, he scheduled an appointment to restore the two amalgam restored molars on the opposite side of his lower arch.
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