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Restoration of Posterior Teeth Using Traditional Layering Technique or the Bulk-fill Technique

Info: 2158 words (9 pages) Nursing Essay
Published: 3rd Dec 2020

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Title: Restoration of posterior teeth using traditional layering technique or the bulk-fill technique

Tooth treated: LR6

Procedure: Packing and curing of occlusal composite restoration

Photograph 1

Photograph 1

The mesial restoration in the LR6 reached the fissure pattern and extended downwards by 2mm.

Photograph 2

A diagram to show a single increment of bulk-fill composite in a cavity

The LR6 had a leaking composite restoration that extended from the mesial surface onto the occlusal surface. The shade selection took place before the rubber dam was placed so that the selected shade was appropriate. The old composite first was drilled out using the fast handpiece and then a matrix band was placed onto the tooth needing the restoration. The matrix band was then burnished to get a good contact point and a wedge was placed underneath this. Both the enamel and dentine aspects of the cavity were etched with 37% phosphoric acid, the enamel was etched for 30 seconds and the dentine was only etched for 10 seconds. The acid etch was then washed off using the 2-in-1 and was aspirated well ensuring that no acid etch reached the soft tissues. The enamel and dentine were dried. Bond was then applied to the chalky enamel and dentine, ensuring that there was no pooling of the bond in the cavity. This was light cured for 20 seconds.

Filtek Supreme XTE resin composite was chosen as the restorative material. Firstly, a small dot of composite was placed into the base of the cavity and light cured to reduce the polymerisation shrinkage stress. After this, 2mm increments were placed with the composite gun and packed with a flat plastic, aiming to only touch two surfaces of the tooth to reduce the C factor. This was carried out until the cusp was reformed. Each increment of composite was light cured for 20 seconds using an LED curing light. The matrix band was then removed so that the restoration could be checked. Using the rugby ball diamond bur, the fissure pattern was highlighted. Following this, the restoration was polished using Soflex discs from the most course to the least course. This had to be repeated a few times as the fissures had not been highlighted enough. Once the restoration was finished, a straight probe was dragged around the tooth to check for “catches” so that this restoration would not secondary caries.

Had this procedure been carried out in a patient, the occlusion would have needed to be checked and the patient would have needed a local anaesthetic for the rubber dam.

This procedure is similar to that of the bulk-fill technique. The only dissimilarity is that with the bulk fill technique, increments of composite would not have been added, the material would have been placed all in one increment and then light cured. This could then be followed by a single increment above the bulk fill to ensure an aesthetic restoration was produced.

A systematic review conducted in 2018 (Veloso, et al., 2018) summarised that the main reasons for the failure of direct resin composite restorations in posterior teeth are due to secondary caries and fractures of the restoration. Shrinkage stress can lead to marginal gaps between the tooth and restoration upon which plaque and bacteria can accumulate, leading to secondary caries. The longevity of the restoration is also dependent on the limitations of the material’s mechanical properties, the area of the tooth structure remaining and the patient’s occlusion. Thus, the technique that would be better suited for these restorations would be one that encounters these issues less often.

The aim of incrementally placed composites is to reduce the C factor; the more bonded surfaces there are, the greater the polymerisation shrinkage on the tooth and therefore, the more stress on the tooth.  Posterior composite resins can shrink up to 3% on curing, this can lead to micro-fractures, marginal gaps and a risk of post-operative sensitivity because the walls of the tooth are pulled inwards. Incremental layering aims to minimise the stresses as the restoration is placed in increments to ensure that only one surface of the tooth is bonded at a time and to allow for a limited cure depth. 

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Bulk-filled composites have been shown, by a randomised control trial (D. Hickey et al., 2016), to cause marginally higher post-operative sensitivity after 2 days of the restoration being placed, but, the same randomised control trial showed that the difference becomes statistically insignificant as time passes because with time, the degree of conversion of the setting composites increases and the post-operative sensitivity is no longer present after 7 days. There are currently very few randomised control trials regarding this and very few on a longer-term basis.

Bulk-fill resin composites simplify the restorative process, making it faster and are less technique sensitive than incrementally filled composites. They can be used in single increments in cavities sized up to 4-5mm and then light cured. This can be achieved as there are more reactive photo-initiators in the bulk-fill material. There are different types of bulk-fill composites, some of which are flowable; these flow into the cavity and then are set, resulting in no gaps and a well filled cavity. This could be advantageous in itself as it creates more predictable restorations in which there are no voids or risks of moisture contamination between the layers like there may be in incremental filling as oxygen in the air causes interference in the polymerisation of composite.  Bulk-fill composites are explained to have gained their improved properties from modified monomers including aromatic dimethacrylate (AUDMA), additional fragmentation molecules (AFM), urethane dimethacrylate (UDMA), and 1,12-dodecane dimethacrylate (DDMA) in its resin matrix. These monomers allow the plyometric network to relax and reorganise, particularly in areas of high stress. This, should enable adaptation during polymerisation and reduce polymerisation shrinkage stress.

The viscosity of full-body bulk fill resins allows them to be sculpted and the high inorganic filler loading allows for use in areas of high masticatory load. In comparison to incrementally filled composite resins, they have reduced polymerisation shrinkage stress due to polymerisation modulators present in the material which organises the monomers in a way that reduces the polymerisation shrinkage stress. The reduced polymerisation shrinkage of bulk-fill composites is stated by manufacturers of the composites and in studies comparing the material to traditional composites, however there are no studies yet to confirm this. Moreover, studies, such as by Tardem C et al. (2019) and Kruly PdC et al. (2018) have shown that when comparing bulk-fill and incremental composites, there is no significant difference between the post-operative sensitivity, the rate of secondary caries or marginal discolouration. In fact, the only significant difference found through meta-analysis (Kruly PdC et al., 2018) was that after a 12-month follow-up period, the marginal adaptation of conventional composite restorations was better than that of bulk fill composites.

Another meta-analysis of data collected from randomised control trials, (Veloso et al., 2019), demonstrated that there was no significant difference between the failure rates of bulk-fill and conventional incremental filled teeth. The failures were due to the risk factors mentioned. This leads to the potential opinion that the two methods may have similar failure rates and thus, their use may be chosen due to different factors including cost, viscosity and time consumption as well as preference of the restorative method.

Reflection

Overall it seems that both incremental placement of composite and the bulk fill method are credible methods to undertake the procedure.  Composite restorations are very technique sensitive. Overall, I feel that the technique I used was appropriate as it has been used and proven to work for many years. The incremental technique that I used produced an acceptable outcome for the restoration, with no marginal defects or ledges at the enamel-composite interface which, with good oral hygiene, would hopefully result in no secondary caries. As the work was carried out in a phantom head and not in the mouth, I cannot be certain as to whether post-operative sensitive would have been experienced. However, the evidence suggests that if placed in increments as I did, the post-operative sensitivity is low. The restoration was placed according to manufacturer instructions and aiming to reduce the C factor by reducing the bonded surfaces. In the future, if I was to complete a similar restoration and I had the materials available, I would certainly consider using the bulk-fill method. Research has shown the benefits of using the bulk fill method; the bulk fill method is a faster method and this would allow more patients to be seen. Moreover, the flowable bulk-fill composites offer the advantage of directly filling the cavity and thus, avoiding voids and oxygen interference of polymerisation.

However, bulk-fill composites are a recent development and thus are currently relatively expensive. Furthermore, it would be a big transition for current dentists to change the materials that they are currently using and that they know work well. Many of the follow-up periods in studies are relatively short and this does not allow a holistic view of the material to be formed as the long-term effects may not be shown. Although there is research to show that there is minimal difference between the two materials other than a possibility of more post-operative sensitivity with the bulk fill composite after 2 days of placement, altogether there is very little statistical evidence to support changing to bulk-fill resin based composite. Although bulk-fill composites have a lot of potential in the dental industry due to their innovative properties, it is not surprising that with the choice of a material that is known to work well and a material that has less long-term research, dentists often opt for the prior.

Conclusion

All in all, having researched both techniques and ascertaining that there is no significant difference in the common causes of failure in the restorations nor any significant benefits to the bulk-fill method’s end-restoration, I feel pleased with the technique that I used and the results that it produced.

References

  • Veloso, S.R.M., Lemos, C.A.A., de Moraes, S.L.D., do Egito Vasconcelos, B.C., Pellizzer, E.P. and de Melo Monteiro, G.Q., 2019. Clinical performance of bulk-fill and conventional resin composite restorations in posterior teeth: a systematic review and meta-analysis. Clinical oral investigations23(1), pp.221-233.
  • Hickey, D., Sharif, O., Janjua, F. and Brunton, P.A., 2016. Bulk dentine replacement versus incrementally placed resin composite: A randomised controlled clinical trial. Journal of dentistry, 46, pp.18-22.
  • Tardem, C., Albuquerque, E.G., Lopes, L.D.S., Marins, S.S., Calazans, F.S., Poubel, L.A., Barcelos, R. and Barceleiro, M.D.O., 2019. Clinical time and postoperative sensitivity after use of bulk-fill (syringe and capsule) vs. incremental filling composites: a randomized clinical trial. Brazilian oral research, 33.
  • de Castro Kruly, P., Giannini, M., Pascotto, R.C., Tokubo, L.M., Suga, U.S.G., Marques, A.D.C.R. and Terada, R.S.S., 2018. Meta-analysis of the clinical behavior of posterior direct resin restorations: Low polymerization shrinkage resin in comparison to methacrylate composite resin. PloS one13(2), p.e0191942.

 

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