Eliminating guesswork

22 September 2021
3 min read

Hussein Hassanali presents a case in which he treated a patient with an occlusal filling.

Treating patients during the Covid-19 pandemic has presented the clinician with many additional considerations. One such challenge is the effort to ensure the patient’s visit to the practice and time spent in the dental chair is used efficiently. Mastery of reliable materials and techniques is critical, in particular those helping to take away uncertainty and minimise the risk of repeat visits.

A 26-year-old female retail assistant attended an emergency as she was experiencing pain from her lower left third molar. A full examination was carried out, which indicated the patient had a very well-maintained and minimally restored dentition.

The examination revealed the patient had a sealant restoration in the lower left first molar. The sealant showed visible clinical signs of leakage resulting in an occlusal cavity with an International Caries Detection Assessment System (ICDAS) score of 4. Ten-year follow up of traditional sealants by Christensen, Ploeger and Palmer show a failure rate of up to 92 per cent. Treatment options were discussed, following which the patient opted for a direct composite restoration for aesthetic reasons.

An aerosol-generating procedure (AGP) treatment appointment was arranged in line with the practice’s current standard operating protocols (SOPs). All images were taken using a Carestream 1500 wireless intraoral camera, as an easily cleansable method to record the treatment stages during the AGP appointment.

The caries was accessed with round-ended diamond burs, and removal was completed with a round rose head bur. Undercuts were removed to create a rounded cavity base to encourage fracture resistance through reduction of configuration factor (C-factor). A wide-radius enamel bevel was created with a flame-shaped diamond bur, forming an infinity edge margin to aid composite bonding and shade integration. 

A 37 per cent phosphoric acid etch gel was selectively applied for 30 seconds to prepare the enamel surface for bonding, followed by copious irrigation with water. A seventh-generation resin bonding agent was massaged into the dentine for 20 seconds. This was then air-thinned and light-cured for 20 seconds. 

Non-stick, non-slumping filling material
The composite chosen to restore the tooth was Kulzer Venus Pearl One which was placed using the Bioclear technique. When selected for appropriate posterior occlusal cavities, Venus Pearl One is ideal for creation of durable, monolithic restorations. It does not stick to instruments or pull away from the cavity, making it easy to shape and form into the surrounding tooth structure and create the required occlusal anatomy.

The material was gently heated in a Bioclear Heat Sync heater. A small amount of bonding adhesive was placed in the cavity to act as a wetting agent, and air-thinned without light-curing. A small quantity of heated A2 shade Kulzer Venus Diamond Flow was placed in the cavity base, again without being light cured. This was immediately followed by injection of the heated Venus Pearl One composite, producing the final monolithic restoration with a high proportion of filler particles, by driving out the uncured flowable composite.

I find that heating can improve the bulk fill of the composite material, enhance marginal integrity and reduce microleakage. Studies also reveal heating can increase the degree of monomer conversion during polymerisation. Some research has indicated that this improves compressive strength and helps to reduce the risk of voids with increased surface hardness.

Seamless colour adaptation
Initial shaping of fissure patterns in the uncured composite was carried out using a Bioclear sculpting point and curved sculpting paddle. The restoration was light-cured for 20 seconds, then a further 20 seconds through K-Y Jelly to set the oxygen inhibition layer.  Occlusal adjustments were made and treatment was concluded with a final polish using a superfine Shofu Greenie polisher. 

The Venus Pearl One occlusal filling, with its adaptive light-matching properties, will draw in colour from the surrounding dentition by absorbing the lightwaves that are reflected by the natural tooth shade value. The composite blends seamlessly into the surrounding dentition and adapts to any tooth shade from A1 to D4. 

Natural-looking restoration
Patient aims and objectives are paramount when considering the selection of materials and techniques for the agreed treatment course. The choice of Venus Pearl One saved time in this case, as there was no need for careful shade matching. Guesswork was eliminated and chairside time reduced, resulting in a more relaxed experience for the patient. 

The treatment has provided a natural-looking restoration (fig 9) which will continue to blend with the surrounding dentition as it changes colour over time. The high flexural strength of the material will further help to reduce the risk of iatrogenic occurrence leading to remedial work.   

The patient was extremely pleased with the outcome. During a follow-up appointment two months after the treatment, the patient reported that she could not point out which tooth had been filled, commenting that the restoration was “brilliant”.

References available on request.