The present case report describes the multidisciplinary treatment of a 25-year old male patient. A complex conservative rehabilitation of all the posterior regions was performed by means of adhesive composite restorations. All teeth were treated with direct restorations with the exception of one tooth that required the fabrication of an indirect restoration cemented with an adhesive luting agent.
It is worth pointing out that specific stratification techniques (horizontal, 4-increment, oblique) were employed according to the different cavity configurations (little, medium, wide, complex). Sometimes those techniques were combined with periodontal surgery in a one-step approach, using an original surgical technique proposed by the author (EJED 2010).
Moreover, the presented case report allows to discuss clinical procedures described in the literature, just like the preservation of cervical enamel not sufficiently supported and the coronal placement of restorative margins without enamel.
INTRODUCTION
In the last 15 years, the evolution of adhesive aesthetic materials dramatically modified the restorative approach in the posterior regions, leading to a more and more limited use of the traditional metal restorative materials. Nowadays, if correctly used, the available composite materials and enamel-dentin adhesive systems allow to guarantee very good long-term aesthetic and functional results, making aesthetic restorations almost invisible in both anterior and posterior regions.
The best advantages offered by resin based materials in comparison to traditional metal alloys regard the aesthetic appearance, the preservation of sound tooth structures and the possibility of reinforcing residual tooth structures. Nonetheless, problems regarding polymerization shrinkage and dentinal adhesion are still controversial.
Nowadays, the increased reliability of adhesive restorations in the posterior regions is mainly due to hybrid resin composites with mini-particles as well as to the last generation adhesive systems. Such materials are characterized by excellent physical-mechanical properties: in fact, they are densely filled, resistant and radiopaque, their elastic modulus is very similar to that of dentin, they are provided with very good surface characteristics and a wear resistance comparable to those of sound enamel and silver amalgam (10-15 micron/year). Consequently, these materials are indicated for all kinds of restorative cavities.
When a proper quantity of sound enamel is present on all cavity margins, direct adhesive restorations represent the first choice therapy in little and medium I and II class cavities. Different clinical procedures were proposed to compensate for shrinkage stress; the most reliable technique is the segmental stratification using pluri-stratified approaches. The incremental techniques vary according to the cavity type; the most validated are the horizontal, the oblique and the 4-increment technique. Conversely, the traditional three-sites procedure described by Lutz (1986) using transparent matrixes and reflective wedges is no longer used.
In the last decade, several studies showed very satisfactory results using direct adhesive techniques in wide cavities requiring cusp coverage as well.
Nonetheless, in the presence of wide and different cavities without two or more walls, with multiple cusp coverage and with absent or reduced cervical enamel, indirect adhesive restorations (inlays, onlays, overlays) cemented with luting agents should be considered as a viable treatment. Such restorations are stratified on a master model and complete polymerization is achieved in the dental laboratory before intraoral cementation. Consequently, indirect restorations allow to better control polymerization shrinkage, bypass the objective procedural difficulties aimed at restoring a correct morphology of the restoration due to the different steps of direct techniques and are provided with better physical-mechanical properties (better dimensional stability, increased toughness and wear resistance) thanks to post-polymerization procedures.
CASE REPORT
A 27-year old male patient with moderate caries propensity was treated. The patient presented with multiple primary and secondary decays on previous incongruous restorations; such decays were evident at both the clinical and radiographic examination by means of bite-wings.
![Fig0003Rosti Q1 Fig0003Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0003Rosti-20Q1_thumb.jpg)
![Fig0004Rosti Q1 Fig0004Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0004Rosti-20Q1_thumb.jpg)
![Fig0005Rosti Q1 Fig0005Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0005Rosti-20Q1_thumb.jpg)
![Fig0007Rosti Q1 Fig0007Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0007Rosti-20Q1_thumb.jpg)
![Fig0006Rosti Q1 Fig0006Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0006Rosti-20Q1_thumb.jpg)
![Fig0001Rosti Q1 Fig0001Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0001Rosti-20Q1_thumb.jpg)
![Fig0002Rosti Q1 Fig0002Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0002Rosti-20Q1_thumb.jpg)
Some of these decays involved the subgingival part of the teeth.
The treatment plan aimed at establishing proper oral hygiene and periodontal conditions by means of scaling, root planing, polishing and hygienic motivation. Then, a complete aesthetic rehabilitation of all intraoral sites was planned using conservative direct and indirect adhesive restorations. Furthermore, a simultaneous periodontal surgical approach was planned to lengthen the clinical crowns of the teeth interested by subgingival lesions. The maxillary third molars were extracted due to their incongruous position, leading to a difficult achievement of a correct home hygienic maintenance; the extraction of such molars did not impair oral functions. Finally, the impacted right mandibular molar was extracted as well.
The orthodontic examination also evidenced a malocclusion but the patient did not accept to treat it.
QUADRANT 1
At level of the right maxillary premolars (teeth 14 and 15), II class adhesive cavity preparations were performed: a rounded occlusal-distal box was designed, the occlusal margins were regularized, the axial walls were slightly rounded while the margin of the cervical box was cut sharp.
![Fig0008Rosti Q1 Fig0008Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0008Rosti-20Q1_thumb.jpg)
![Fig0009Rosti Q1 Fig0009Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0009Rosti-20Q1_thumb.jpg)
![Fig0010Rosti Q1 Fig0010Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0010Rosti-20Q1_thumb.jpg)
In medium II class cavities, the stratification approach of choice is the 4-increment technique, a modification of the “centripetal build-up” proposed by Bichacho in 1994.
![Fig0011Rosti Q1 Fig0011Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0011Rosti-20Q1_thumb-5B1-5D.jpg)
The rubber dam is of paramount importance for the success of the restoration. The sectional matrixes are placed together with the divaricating rings. Such matrixes were specifically developed for adhesive dentistry and allow to achieve effective contact areas.
After applying a three-step etch-and-rinse adhesive system, the marginal crest is built-up with an increment of enamel mass (increment 1); then, the dentin is completely covered with 0.5 mm of a flowable composite resin (increment 2).
![Fig0012Rosti Q1 Fig0012Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0012Rosti-20Q1_thumb.jpg)
The dentin mass is stratified with a unique increment with a maximum thickness of 2 mm (increment 3).
![Fig0013Rosti Q1 Fig0013Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0013Rosti-20Q1_thumb.jpg)
Then, the build-up is completed with the stratification of a unique increment of occlusal enamel (increment 4), modelling the occlusal surface and applying supercolors in the occlusal grooves and pits, if necessary. Finally, finishing and polishing of the restorations are performed.
![Fig0014Rosti Q1 Fig0014Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0014Rosti-20Q1_thumb.jpg)
Particularly interesting is the operative sequence proposed for the aesthetic and periodontal restoration of the first maxillary molar (tooth 16), in order to recover both the morphological and functional features.
A previous incongruous composite restoration was present with evident microleakage and residual caries that led to a violation of the biological width as well as to inflammation of the soft tissues.
![Fig0016Rosti Q1 Fig0016Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0016Rosti-20Q1_thumb-5B1-5D.jpg)
![Fig0015Rosti Q1 Fig0015Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0015Rosti-20Q1_thumb.jpg)
The treatment was planned with a one-step surgical and restorative approach. Once the rubber dam was placed, the restorative material was removed and the carious lesion evidenced.
![Fig0017Rosti Q1 Fig0017Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0017Rosti-20Q1_thumb.jpg)
![Fig0018Rosti Q1 Fig0018Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0018Rosti-20Q1_thumb.jpg)
![Fig0019Rosti Q1 Fig0019Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0019Rosti-20Q1_thumb-5B1-5D.jpg)
The careful removal of such infiltrated tissues did not allow the rubber dam to properly isolate the operative area, as noticed under the stereomicroscope; moreover, the radiographic control pointed out the invasion of the biologic width.
![Fig0020Rosti Q1 Fig0020Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0020Rosti-20Q1_thumb.jpg)
![Fig0021Rosti Q1 Fig0021Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0021Rosti-20Q1_thumb.jpg)
Consequently, the rubber dam was removed and a lengthening of the clinical crown was performed, in order to restore a correct distance between the sound cervical margin and the bone crest. A resective periodontal surgery procedure was made by means of osteotomy and osteoplasty.
![Fig0022Rosti Q1 Fig0022Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0022Rosti-20Q1_thumb.jpg)
![Fig0023Rosti Q1 Fig0023Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0023Rosti-20Q1_thumb.jpg)
![Fig0024Rosti Q1 Fig0024Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0024Rosti-20Q1_thumb.jpg)
![Fig0025Rosti Q1 Fig0025Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0025Rosti-20Q1_thumb.jpg)
In the meanwhile, the third molar was extracted, as previously planed. The flaps were placed in crest with vertical mattress sutures, using 6-0 vicryl sutures.
![Fig0026Rosti Q1 Fig0026Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0026Rosti-20Q1_thumb.jpg)
Thanks to the low rate bleeding due to the vasoconstrictor agent as well as to the rapid and correct surgical procedures, it was possible to place the rubber dam immediately. In order to isolate correctly the post-surgical area, a specific cellulose foam was injected before placing the rubber dam.
![Fig0027Rosti Q1 Fig0027Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0027Rosti-20Q1_thumb.jpg)
![Fig0028Rosti Q1 Fig0028Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0028Rosti-20Q1_thumb.jpg)
Then, the sectional matrix was placed using a Compositigth 3D ring together with a Silver ring. A three-step etch-adn-rinse adhesive system was used. After etching, 2% digluconate chlorexidine was applied for 30 sec in order to inhibit the metalloproteinases and stabilize the adhesive bond over time.
![Fig0029Rosti Q1 Fig0029Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0029Rosti-20Q1_thumb.jpg)
![Fig0030Rosti Q1 Fig0030Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0030Rosti-20Q1_thumb.jpg)
![Fig0031Rosti Q1 Fig0031Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0031Rosti-20Q1_thumb.jpg)
![Fig0032Rosti Q1 Fig0032Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0032Rosti-20Q1_thumb.jpg)
Afterwards, a complex cusp covering restoration was performed with oblique stratification and multiple increments. The first increment was made with a flowable composite resin, in order to fully covering the dentin and to seal the cervical margin in absence of enamel.
![Fig0033Rosti Q1 Fig0033Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0033Rosti-20Q1_thumb.jpg)
The marginal crest and the axial mesial-buccal wall were built-up with a double vertical increment of enamel mass;
![Fig0034Rosti Q1 Fig0034Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0034Rosti-20Q1_thumb.jpg)
![Fig0035Rosti Q1 Fig0035Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0035Rosti-20Q1_thumb.jpg)
then the oblique stratification of the dentin masses with multiple increments was made;
![Fig0036Rosti Q1 Fig0036Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0036Rosti-20Q1_thumb.jpg)
![Fig0037Rosti Q1 Fig0037Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0037Rosti-20Q1_thumb.jpg)
finally, the occlusal surface was modelled with enamel masses and post-polymerization supercolors in the grooves and pits.
![Fig0038Rosti Q1 Fig0038Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0038Rosti-20Q1_thumb.jpg)
![Fig0039Rosti Q1 Fig0039Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0039Rosti-20Q1_thumb.jpg)
The final polymerization was made using a glycerin gel so as to inhibit the superficial oxygen. The restoration was finished and polished as previously described.
![Fig0040Rosti Q1 Fig0040Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0040Rosti-20Q1_thumb.jpg)
![Fig0041Rosti Q1 Fig0041Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0041Rosti-20Q1_thumb.jpg)
The quadrant 1 after the operative procedures and at the 3-month follow-up.
![Fig0042Rosti Q1 Fig0042Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0042Rosti-20Q1_thumb.jpg)
![Fig0043Rosti Q1 Fig0043Rosti Q1](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0043Rosti-20Q1_thumb.jpg)
It is worth noticing that the one-step surgical and restorative approach allows to complete the treatment in a single appointment with the following advantages: optimization of the procedural times, elimination of the problems related to the temporary restorations, sealing of the cavity by means of a finished and polished final restoration with correct emergence profiles, rapid and easy healing of the soft tissues.
QUADRANT 2
At level of teeth 24, 25 and 26 II class restorations were made (OD cavities on the premolars and a complex cavity on the first molar). Such restorations were similar to those made on the first quadrant.
![Fig0044Rosti Q2 Fig0044Rosti Q2](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0044Rosti-20Q2_thumb.jpg)
![Fig0045Rosti Q2 Fig0045Rosti Q2](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0045Rosti-20Q2_thumb.jpg)
It is worth noticing the cavity design on tooth 26, where the non supported cusp was cut by means of an internal bevel, in order to preserve the maximum amount of sound tissue and hold properly the divaricating ring at cervical level. All the three restorations were built up contemporaneously, so as to optimize the operative time. The matrixes were placed forcing adequately the wedges and using the most divaricating rings.
![Fig0046Rosti Q2 Fig0046Rosti Q2](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0046Rosti-20Q2_thumb.jpg)
Obviously, the most challenging target was to obtain effective interproximal contact areas together with a correct anatomy on the molar. The segmentation of the stratification was made using the 4-increment technique on the premolars and the oblique stratification technique with multiple increments on the molar with cuspal coverage.
![Fig0047Rosti Q2 Fig0047Rosti Q2](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0047Rosti-20Q2_thumb.jpg)
Then, the finishing and polishing procedures were performed, achieving satisfactory morphological and functional results as well as optimal aesthetics. Moreover, a good integration of the mesial-buccal cusp of tooth 46 restored with a direct technique was obtained.
![Fig0048Rosti Q2 Fig0048Rosti Q2](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0048Rosti-20Q2_thumb.jpg)
At level of tooth 27, an extremely wide occlusal cavity was evident and a microcrack going through the occlusal surface was noticed.
![Fig0050Rosti Q2 Fig0050Rosti Q2](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0050Rosti-20Q2_thumb.jpg)
![Fig0051Rosti Q2 Fig0051Rosti Q2](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0051Rosti-20Q2_thumb.jpg)
![Fig0052Rosti Q2 Fig0052Rosti Q2](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0052Rosti-20Q2_thumb.jpg)
Consequently, two operative choices were available:
- complete cuspal coverage by means of an adhesively luted overlay;
- direct restoration preserving the cusps, although interested by the microcrack.
Accordingly to the patient, the latter more conservative option was chosen, even if it was less predictable. The small mesial-occlusal II class was filled with the 3-increment horizontal stratification technique. On the contrary, the wide occlusal cavity affected by the microcrack was restored using the oblique stratification technique with multiple increments (flow, 4 increments of dentin, 2 increments of enamel), in order to compensate for the polymerization shrinkage as much as possible.
![Fig0053Rosti Q2 Fig0053Rosti Q2](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0053Rosti-20Q2_thumb.jpg)
![Fig0054Rosti Q2 Fig0054Rosti Q2](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0054Rosti-20Q2_thumb.jpg)
![Fig0055Rosti Q2 Fig0055Rosti Q2](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0055Rosti-20Q2_thumb.jpg)
![Fig0056Rosti Q2 Fig0056Rosti Q2](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0056Rosti-20Q2_thumb.jpg)
![Fig0057Rosti Q2 Fig0057Rosti Q2](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0057Rosti-20Q2_thumb.jpg)
![Fig0058Rosti Q2 Fig0058Rosti Q2](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0058Rosti-20Q2_thumb.jpg)
![Fig0059Rosti Q2 Fig0059Rosti Q2](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0059Rosti-20Q2_thumb.jpg)
The final restoration after finishing and polishing and the completed quadrant at the 3-month follow-up, showing proper morphological and functional results as well as good aesthetics.
![Fig0060Rosti Q2 Fig0060Rosti Q2](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0060Rosti-20Q2_thumb.jpg)
![Fig0061Rosti Q2 Fig0061Rosti Q2](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0061Rosti-20Q2_thumb.jpg)
QUADRANT 4
Tooth 47 showed significative loss of tissues on the distal cusps and the decay interested the subgingival area, interfering with the biological width. An incongruous temporary filling was evidenced.
![Fig0062Rosti Q4 Fig0062Rosti Q4](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0062Rosti-20Q4_thumb-5B11-5D.jpg)
The following treatment plan was chosen: clinical crown lengthening, adhesively luted restoration, extraction of the impacted third molar.
In this case, the author performed a two-appointment combined surgical-restorative procedure, according to the protocol published on the EJED (nr. 1, 2010). A full thickness lingual flap and a double mixed buccal flap were elevated, a limited osteotomy was made and the impacted third molar was extracted.
![Fig0063Rosti Q4 Fig0063Rosti Q4](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0063Rosti-20Q4_thumb.jpg)
![Fig0064Rosti Q4 Fig0064Rosti Q4](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0064Rosti-20Q4_thumb.jpg)
Then, osteotomy and osteoplasty were performed on tooth 47, lengthening the clinical crown and recovering a proper biological width on the distal surface. The rubber dam was carefully placed, in order to obtain a perfectly isolated area to perform the adhesive procedures.
![Fig0065Rosti Q4 Fig0065Rosti Q4](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0065Rosti-20Q4_thumb.jpg)
The adhesive build-up and the cavity preparation were made. The rubber dam was removed and the post-operative impression was immediately taken; although the surgical procedures had been just done, the surgically exposed margins were easily recordable with a correct impression.
After one week (the time necessary to the dental laboratory to build-up the indirect composite restoration), during the second appointment, the sutures were removed and the inlay was intraorally tried-in.
![Fig0066Rosti Q4 Fig0066Rosti Q4](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0066Rosti-20Q4_thumb.jpg)
![Fig0067Rosti Q4 Fig0067Rosti Q4](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0067Rosti-20Q4_thumb.jpg)
![Fig0068Rosti Q4 Fig0068Rosti Q4](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0068Rosti-20Q4_thumb.jpg)
Then, the rubber dam was set in place and both the cavity and the inner surface of the inlay were conditioned, in order to perform the adhesive cementation correctly.
The restoration after cementation, finishing and polishing and a follow-up after 22 days from the surgery.
![Fig0069Rosti Q4 Fig0069Rosti Q4](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0069Rosti-20Q4_thumb.jpg)
![Fig0070Rosti Q4 Fig0070Rosti Q4](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0070Rosti-20Q4_thumb.jpg)
The restoration showed optimal marginal adaptation, proper morphological and functional results and good aesthetics. Moreover, the healing of the soft tissues was very satisfactory. This is one of the most important advantages of the proposed technique: the two-appointment combined surgical-restorative approach allows to finalize the case in short time, avoiding possible problems derivating from temporary restorations and sealing the cavity with a final restoration properly finished and polished, so as to facilitate the healing of soft tissues.
Finally, at level of tooth 46, a small interproximal lesion was evident. The limited dimensions require maximum care in designing the cavity and in the stratification, due to the difficult access to the cavity.
![Fig0072Rosti Q4 Fig0072Rosti Q4](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0072Rosti-20Q4_thumb-5B1-5D.jpg)
![Fig0073Rosti Q4 Fig0073Rosti Q4](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0073Rosti-20Q4_thumb-5B4-5D.jpg)
![Fig0071Rosti Q4 Fig0071Rosti Q4](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0071Rosti-20Q4_thumb.jpg)
In cases like this, once the cavity is prepared, the horizontal stratification technique is recommended, using 3-4 increments (0.5 mm of flow over the dentin,
![Fig0074Rosti Q4 Fig0074Rosti Q4](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0074Rosti-20Q4_thumb-5B2-5D.jpg)
1-2 increments of dentin,
![Fig0075Rosti Q4 Fig0075Rosti Q4](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0075Rosti-20Q4_thumb-5B1-5D.jpg)
![Fig0076Rosti Q4 Fig0076Rosti Q4](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0076Rosti-20Q4_thumb-5B1-5D.jpg)
1 increment of enamel).
![Fig0077Rosti Q4 Fig0077Rosti Q4](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0077Rosti-20Q4_thumb-5B1-5D.jpg)
The apical-coronal stratification has to be performed and supercolors may be used if necessary.
![Fig0078Rosti Q4 Fig0078Rosti Q4](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0078Rosti-20Q4_thumb-5B1-5D.jpg)
The matrix has to be kept in place till the end of the stratification.
![Fig0079Rosti Q4 Fig0079Rosti Q4](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0079Rosti-20Q4_thumb-5B2-5D.jpg)
The final restoration after finishing and polishing and the completed quadrant at the 3-month follow-up.
![Fig0080Rosti Q4 Fig0080Rosti Q4](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0080Rosti-20Q4_thumb.jpg)
![Fig0081Rosti Q4 Fig0081Rosti Q4](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0081Rosti-20Q4_thumb.jpg)
QUADRANT 3
Teeth 36 and 37 needed treatment in quadrant 3. Clinically, no decays were evident but the radiographic control showed severe carious lesions.
![Fig0082Rosti Q3 Fig0082Rosti Q3](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0082Rosti-20Q3_thumb.jpg)
In this quadrant, tooth 46 was particularly interesting: a medium-wide adhesive cavity was prepared and the distal-buccal cusp was covered using a beveled cut. Particular care was taken to the gingival box, where a technique to preserve the cervical enamel not supported by the dentin was adopted.
![Fig0083Rosti Q3 Fig0083Rosti Q3](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0083Rosti-20Q3_thumb.jpg)
![Fig0084Rosti Q3 Fig0084Rosti Q3](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0084Rosti-20Q3_thumb.jpg)
![Fig0085Rosti Q3 Fig0085Rosti Q3](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0085Rosti-20Q3_thumb-5B1-5D.jpg)
The level of the dentinal cavity is often more apical than the level of the enamel cavity, since the progression of the decay develops along the path of the dentinal tubules (typically from coronal to apical in this area).
In the cases in which the amount of enamel is sufficient and thick, although not ideally supported, it is possible to choose a minimally invasive approach, preserving such enamel in order not to perform a crown lengthening. Conversely, this is mandatory in those cases in which the cervical enamel has to be removed, affecting the biological width.
The minimally invasive approach requires particular care during the cavity preparation, using small spherical diamond burs mounted on a low speed device (red ring) to clean the cavity at the enamel border, avoiding the use of multiple blade burs on a blue ring rotary device, since they would undermine the enamel. Furthermore, before placing the wedges and the matrixes, it is necessary to “support” the cervical enamel by means of an increment of a flowable composite adhesively placed behind the enamel itself.
![Fig0086Rosti Q3 Fig0086Rosti Q3](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0086Rosti-20Q3_thumb.jpg)
Two different medium shaped mesial-occlusal and occlusal-distal cavities were prepared on tooth 37.
Both the restorations on teeth 46 and 47 were made using a direct technique, building-up contemporaneously the marginal ridges by means of two sectional matrixes. A wedge was forced between the teeth and a strong divaricating ring (Golg Compositight) was placed upon the wedge to create a proper contact area.
![Fig0087Rosti Q3 Fig0087Rosti Q3](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0087Rosti-20Q3_thumb.jpg)
The wide occlusal-distal box on tooth 46 required a stratification with two vertical increments of enamel to build-up the marginal ridge, in order to have a favourable C-factor.
![Fig0088Rosti Q3 Fig0088Rosti Q3](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0088Rosti-20Q3_thumb.jpg)
Then, multiple oblique increments of dentin were stratified and the occlusal surface was completed with an enamel mass and supercolors.
![Fig0089Rosti Q3 Fig0089Rosti Q3](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0089Rosti-20Q3_thumb.jpg)
![Fig0090Rosti Q3 Fig0090Rosti Q3](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0090Rosti-20Q3_thumb.jpg)
![Fig0091Rosti Q3 Fig0091Rosti Q3](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0091Rosti-20Q3_thumb.jpg)
The final restorations after finishing and polishing under rubber dam and the 3-month follow-up.
![Fig0092Rosti Q3 Fig0092Rosti Q3](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0092Rosti-20Q3_thumb.jpg)
![Fig0093Rosti Q3 Fig0093Rosti Q3](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0093Rosti-20Q3_thumb.jpg)
The final images of both the dental arches show the optimal morphological and functional results as well as the good aesthetics achieved using adhesive techniques together with the proper management of the supporting periodontal tissues, where needed.
![Fig0094Rosti fin Fig0094Rosti fin](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0094Rosti-20fin_thumb.jpg)
![Fig0095Rosti fin Fig0095Rosti fin](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0095Rosti-20fin_thumb.jpg)
The good dimensional and chromatic stability of the restorations as well as the sound state of both the soft and bone tissues are evident in the follow-up pictures and in the Bite-Wing radiographic control after 1.5 years.
![Fig0099Rosti fin Fig0099Rosti fin](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0099Rosti-20fin_thumb.jpg)
![Fig0100Rosti fin Fig0100Rosti fin](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0100Rosti-20fin_thumb.jpg)
![Fig0096Rosti recall1.5aa Fig0096Rosti recall1.5aa](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0096Rosti-20recall1.5aa_thumb.jpg)
![Fig0097Rosti finrecall1.5aa Fig0097Rosti finrecall1.5aa](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0097Rosti-20finrecall1.5aa_thumb.jpg)
![Fig0098Rosti recall1.5aa Fig0098Rosti recall1.5aa](https://www.zerodonto.com/en/wp-content/uploads/2011/03/Fig0098Rosti-20recall1.5aa_thumb.jpg)
The case should be completed with an aesthetic treatment of the maxillary lateral incisors, to restore their correct morphology, and with an orthodontic therapy, to correct the malocclusion and increase the alignment of the teeth. Nonetheless, the patient has not accepted such treatment plan yet.
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