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Placing Bulk-Fill Composites
The creation of esthetic posterior restorations using Tetric EvoCeram Bulk Fill
Bulk-fill composite simplifies layering in the direct restoration of teeth and reduces the number of working steps. For some time now, major dental manufacturers have been offering composite resins suitable for the bulk-filling technique. The compositions and working properties of some of these materials vary quite considerably.
One such composite, Tetric EvoCeram® Bulk Fill (Ivoclar Vivadent, www.ivoclarvivadent.com), allows sculpting of the occlusal anatomy, meaning that the placement of a capping layer using a conventional composite is not required. Moreover, it exhibits wear resistance similar to that of conventional Tetric EvoCeram and is excellently suitable for use in occlusal load-bearing areas due to its flexural strength of 120 MPa. Its special filler composition makes Tetric EvoCeram easy to adapt and contour and allows for excellent polishability.
The two case reports presented below are testimony to the wide range of indications covered by Tetric EvoCeram Bulk Fill.
Tooth No. 16 showed a fractured mesial marginal ridge that was undermined by caries. Following the placement of a rubber dam, the tooth was prepared and a medium-sized Class II cavity resulted (Figure 1).
With the exception of composite placement, which is done in 4-mm increments, the rules established for adhesive restorative procedures still apply when bulk-fill composite is used.
To achieve optimum adhesion to enamel, it is essential to prepare the enamel margins in such a way that the enamel prisms are obliquely cut. This entails bevelling of the vertical proximal margins and the gingival shoulder.1-5
After a sectional matrix band had been placed, a dentin/enamel bonding agent was applied. The author’s preferred technique is a combined one,6 consisting of the selective etching of enamel for 30 seconds and the subsequent application of a two-bottle self-etch adhesive (AdheSE®, Ivoclar Vivadent). One increment of shade IVA Tetric EvoCeram Bulk Fill was sufficient to fill the entire cavity (Figure 2). The completed restoration was polished with Sof-Lex™ discs (3M ESPE, www.3mespe.com) and OptraPol® Next Generation (Ivoclar Vivadent).
Preoperatively, tooth No. 19 displayed a fractured lingual wall and cracked buccal cusps. Figure 3 shows the situation after placement of the rubber dam and preparation of the tooth. Only the mesio-buccal cusp remained intact. However, it had to be shortened by 1.5 mm to ensure sufficient stability. Adhesion was again achieved by selectively etching the enamel for 30 seconds and subsequently applying AdheSE Primer and Bond.
Following the placement of sectional matrix bands, the tooth was built up in stages using Tetric EvoCeram Bulk Fill. Only six increments were needed to rebuild the entire crown (Figures 4 to 9). Each individual increment was light-cured for 20 seconds using the Bluephase® Style (Ivoclar Vivadent) curing light. Even though this is more time than is recommended by the manufacturer, the author believes that this length of time is necessary in view of the clinical variables that may influence polymerization (distance to the restoration surface, irradiation angle, undercut areas), particularly when restoring occlusal load-bearing teeth. The failure mode most frequently observed in conjunction with composite resin fillings is filling fracture,7 which is most probably due to the fact that the restorations tend to be less than properly cured and thus do not demonstrate ideal physical stability.
Coarse finishing was performed with Sof-Lex discs and fine diamonds. After the occlusion had been adjusted, the restoration was polished to a high gloss with OptraPol Next Generation. Figure 10 shows the restoration immediately after completion. One year postoperatively, the restoration was found to be unchanged clinically.
Tetric EvoCeram Bulk Fill considerably facilitates the placement of all types of composite fillings, both those that are small and large. Due to the material’s non-slump consistency and excellent sculptability, even large restorations that involve the reconstruction of cusps can be fabricated in an efficient manner. The limited range of shades has proved completely unproblematic in practical use. For the restoration of anterior dentitions and esthetically sensitive cases, the author normally uses IPS Empress® Direct (Ivoclar Vivadent). Thus with Tetric EvoCeram Bulk Fill, Tetric EvoFlow® (Ivoclar Vivadent), and IPS Empress Direct, one can cover the entire spectrum of indications in the direct restoration of teeth with composite.
1. Ikeda T, Uno S, Tanaka T, et al. Relation of enamel prism orientation to microtensile bond strength. Am J Dent. 2002;15(2):109-113.
2. Purk J, Dusevic V, Kruse D, et al. Bonding to Beveled vs Non-Beveled Enamel at the Gingival Margin [abstract 15]. Presented at: AADR Annual Meeting; March 3, 2010; Washington, DC.
3. Schmidlin PR, Wolleb K, Imfeld T, et al. Influence of beveling and ultrasound application on marginal adaptation of box-only Class II (slot) resincomposite restorations. Oper Dent. 2007;32(3):291-297.
4. Shimada Y, Tagami J. Effects of regional enamel and prism orientation on resin bonding. Oper Dent. 2003;28(1):20-27.
5. Swanson TK, Feigal RJ, Tantbirojn D, Hodges JS. Effect of adhesive systems and bevel on enamel margin integrity in primary and permanent teeth. Pediatr Dent. 2008;30(2):134-140.
6. Frankenberger R, Lohbauer U, Roggendorf MJ, et al. Selective enamel etching reconsidered: better than etch-and-rinse and self-etch? J Adhes Dent. 2008;10(5):339-344.
7. Heintze SD, Rousson V. Clinical effectiveness of direct class II restorations - a meta-analysis. J Adhes Dent. 2012;14(5):407-431. doi: 10.3290/j.jad.a28390.
About the Author
Markus Lenhard, DDS
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