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Special Issues
July/August 2017
Volume 38, Issue 2
Peer-Reviewed

A Conservative Technique to Put Life Back Into Indirect Restorations

Mark I. Malterud, DDS

The more trauma a tooth endures, the greater the possibility of creating tooth damage and pulpal changes. Often, doing as little as possible to restore a tooth is the kindest procedure. This case presentation represents a conservative, minimally invasive approach to restoring a previously restored segment of a dental quadrant. The patient presented with two restorations that had been placed as extraorally fabricated bonded composite restorations about 20 years previously and had now outlived their serviceable protective life. Tooth No. 19 had occlusal wear with dentin exposure on the mesial-buccal cusp. Tooth No. 20, with the old resin washed out, was undercontoured such that the tooth was functionally compromised and food was being entrapped both occlusally and laterally at the gingival level. Featuring the use of Mosaic® universal nanohybrid composite (Ultradent Products, Inc., ultradent.com), the conservative treatment rendered with direct composite restoration replacement and repair was accomplished with little additional lifetime trauma to the teeth, and it stabilized the patient’s dentition for the future with the potential to match the initial life of the original restorations.

Key Takeaways

• With advances in material sciences and restorative techniques occurring virtually daily, clinicians need to consider new paradigms.

• A conservative approach to restoration can minimize trauma and help teeth last longer before any further restoration is needed.

• With the right combination of new and existing materials, establishment of proper form, function, and esthetics can be accomplished for re-restorations, limiting added stress to the dentition.

About the Author

Mark I. Malterud, DDS
Past President
Minnesota Academy of General Dentistry;
Private Practice
St. Paul, Minnesota

Fig 1. Preoperative photograph showed the washed-out filling on tooth No. 20 and the wear of the margin of tooth No. 19 on the mesial-buccal and the buccal cusps.

Figure 1

Fig 2. Tooth No. 20 was prepared with a high-speed rotary diamond bur (Microcopy Single-Use Bur #330, Microcopy Dental, microcopydental.com) to dissect out all of the existing inlay composite. Then the area was prepared with micro-air abrasion (PrepStart™ H20, Danville, danvillematerials.com), and the cusp tips of tooth No. 19 were prepared with air abrasion.

Figure 2

Fig 3. The final preparations preserved as much tooth structure as possible for future use should the tooth eventually need to be restored again. The patient was experiencing some lateral impaction of food between teeth Nos. 19 and 20, so tooth No. 20 needed to be matrixed to obtain a fuller contour to fill in the embrasures. Tooth No. 19 was already fully contoured, so only the exposed dentin needed repair.

Figure 3

Fig 4. The area was matrixed using a 3-dimensionally shaped Blue Cure-Thru® matrix band (Premier Dental, premusa.com) that was trimmed to allow proper tissue emergence profiles as well as filling in the buccal and lingual embrasures. Because of the thickness of the bands (0.075 mm thick), some separation of the teeth was necessary, so the Triodent® V4 (Ultradent Products) clear cure-through matrix ring and Triodent® wedges were used to seal the gingival margins of the Cure-Thru band strip to the tooth.

Figure 4

Fig 5. The area was etched using Ultra-Etch® (Ultradent Products) and then thoroughly rinsed and dried.

Figure 5

Fig 6. The bond resin, PQ1® (Ultradent Products), was delivered through an Inspiral® brush tip (Ultradent Products), and the area was flooded with bond resin and left for 30 seconds to penetrate the dentin to create a solid hybrid layer. The excess PQ1 resin was removed through a high-volume evacuator, the alcohol carrier was volatilized, and the area was polymerized for 10 seconds from the occlusal direction with a VALO® curing light (Ultradent Products).

Figure 6

Fig 7. The filling material used for this case, Mosaic® universal nanohybrid composite (Ultradent Products), was placed using a bulk-fill technique and cured with a transdental polymerization process that the author has used for more than 30 years. After placement, the composite was cured through the tooth from both the buccal and lingual directions with the V4 ring in place. Light energy was activated for 20 seconds from the curing light from each buccal and lingual direction.

Figure 7

Fig 8. After the V4 ring was removed, the area was polymerized again from the buccal and lingual aspects for another 10 seconds from each direction per tooth restored to ensure that the light energy could reach the deepest recesses of the filling.

Figure 8

Fig 9. The final cure was done from the occlusal to prevent any polymerization shrinkage stresses at the pulpal floor of the preparations. The purpose of this last cure was to ensure that everything was fully polymerized because the light to that point had only been delivered from the buccal and lingual directions down by the gingival surface of the teeth.

Figure 9

Fig 10. After the area was shaped with a Dura-Green® stone (Shofu Dental Corp., shofu.com) and a 7902 flame finish bur (Microcopy Dental) to remove excess flash, it was polished using Jiffy® composite polishing brushes (Ultradent Products).

Figure 10

Fig 11. The Jiffy pointed brush was then used on the internal anatomy and to reach interproximally to the bur-finished margins. The surfaces that were polymerized against the Cure-Thru matrix did not require polishing because they were as smooth as restorations can be polished without manipulation.

Figure 11

Fig 12. The final sheen was placed using a Jiffy goat hair brush along with Ultradent® Diamond Polish Mint (Ultradent Products).

Figure 12

Fig 13. The final restorations satisfied the need for re-restoring tooth No. 20 and repairing tooth No. 19. The establishment of proper form, function, and esthetics was accomplished with minimal added trauma or stress to the patient’s dentition, allowing resolution of symptoms (occlusal and gingival food impaction) while still creating the proper contours to protect the tooth from occlusal forces. It is anticipated that the composite filling material used will enable the tooth to function well into the future.

Figure 13

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