The patient presented with old Class II composite restorations on teeth 4 and 5. Tooth 3 was previously restored with an Empress Indirect Pressed Ceramic Onlay. After radiographic examination, proximal caries was found on the mesial surface of tooth 4. Both existing composites show signs of staining around the cavosurface margins. Although there was no radiographic evidence of recurrent decay around the restoration in tooth 5, the patient was told that the distal proximal surface would be clinically evaluated after preparation of tooth 4 to determine if replacement was necessary at this time.
1. An occlusal preoperative view of existing Class II composite restorations in tooth numbers 4 and 5.
2. Fender Wedges are placed to protect the adjacent proximal surfaces during the rotary removal of the existing composite. The Fender Wedges also compress the periodontal ligaments, slightly separating the teeth, simplifying matrix placement. It was determined after preparation that the restoration that existed in tooth 5 was clinically acceptable and would not be replaced at this time.
3. A “Tofflemire-type” matrix Slick Bands is placed with the retainer positioned on the facial surface of tooth 4 and wedged in place. A curved hemostat is used to crimp the band on the palatal aspect to tighten the band against the cavosurface margins of the preparation creating a more “anatomized” matrix that will limit the probability of creating overhangs of composite in the palatal embrasure.
4. After tooth preparation is complete and the matrix is in place, the tooth is etched with 37% phosphoric acid for 15 seconds. Isolation in this case was performed with an Isolite. After etching, the preparation is thoroughly rinsed for 15 seconds, then air dried.
5. The dentin is rewetted with AcQuaSeal desensitizer; the excess moisture is removed by placing the high volume suction approximately 2 mm from the preparation for 2 seconds. This will leave the dentin moist and ideal for the application of adhesive resin.
6. Excite VivaPen 5th generation bonding resin is applied to the preparation and agitated into the etched surface for about 20 seconds.
7. After a thin layer (< .5mm) Tetric EvoFlow flowable resin is applied to line the cavity and cured, an increment of Empress Direct is placed into the disto-proximal box of the preparation. Without curing, the OptraContact contact forming instrument is pushed into the composite while leaning the side of the instrument against the proximal surface of the adjacent tooth. The composite is cured, then the instrument is removed and the process is repeated in the other proximal box.
8. An occlusal view of tooth 4 shows the “bridges” of cured composite that extend from the axial walls of the preparation to matrix band in both the mesial and distal proximal box.
9. After the remaining portions of the preparation are filled with Empress Direct, sculpted, then cured, minor contouring and finishing is accomplished as necessary using composite finishing burs and rubber polishing abrasives (Astropol P and HP).
10. A final luster is accomplished using an Astrobrush polishing brush.
11. The completed Empress Direct MOD composite resin is shown from the occlusal aspect. Note the aesthetic comparison to the Empress Pressed Ceramic Onlay on tooth 3. It is difficult to distinguish between the ceramic and the composite in a side-by-side viewing of these materials.