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![\"Fig0003Rosti](\"https:\/\/www.zerodonto.com\/en\/wp-content\/uploads\/2011\/03\/Fig0003Rosti-20Q1_thumb.jpg\" "\\"Fig0003Rosti")
<\/a><\/p>\nAt 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. 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. 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.<\/p>\n 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.<\/p>\n 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.<\/p>\n Teeth 36 and 37 needed treatment in quadrant 3. Clinically, no decays were evident but the radiographic control showed severe carious lesions.<\/a><\/p>\n<\/a><\/p>\n<\/a><\/p>\n<\/a><\/p>\n<\/a><\/p>\n<\/a>
\nSome of these decays involved the subgingival part of the teeth.
\nThe 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.
\nThe orthodontic examination also evidenced a malocclusion but the patient did not accept to treat it.<\/p>\nQUADRANT 1<\/b><\/h3>\n
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\nIn medium II class cavities, the stratification approach of choice is the 4-increment technique, a modification of the \u201ccentripetal build-up\u201d proposed by Bichacho in 1994.
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\nThe 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.
\nAfter 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).
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\nThe dentin mass is stratified with a unique increment with a maximum thickness of 2 mm (increment 3).
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\nThen, 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.
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\nParticularly 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.
\nA 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.
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\nThe 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.
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\nThe 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.
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\nConsequently, 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.
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\nIn 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.
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\nThanks 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.
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\nThen, 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.<\/p>\n<\/a><\/p>\n<\/a><\/p>\n<\/a><\/p>\n<\/a>
\nAfterwards, 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.
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\nThe marginal crest and the axial mesial-buccal wall were built-up with a double vertical increment of enamel mass;
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\nthen the oblique stratification of the dentin masses with multiple increments was made;
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\nfinally, the occlusal surface was modelled with enamel masses and post-polymerization supercolors in the grooves and pits.
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\nThe final polymerization was made using a glycerin gel so as to inhibit the superficial oxygen. The restoration was finished and polished as previously described.
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\nThe quadrant 1 after the operative procedures and at the 3-month follow-up.<\/p>\n<\/a><\/p>\n<\/a>
\nIt 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.<\/p>\nQUADRANT 2<\/b><\/h3>\n
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\nIt 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.<\/p>\n<\/a><\/p>\n<\/a>
\nThen, 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.<\/p>\n<\/a>
\nAt level of tooth 27, an extremely wide occlusal cavity was evident and a microcrack going through the occlusal surface was noticed.<\/p>\n<\/a>
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\nConsequently, two operative choices were available:<\/p>\n\n
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\nThe 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.<\/p>\n<\/a><\/p>\n<\/a><\/p>\nQUADRANT 4<\/b><\/h3>\n
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\nThe following treatment plan was chosen: clinical crown lengthening, adhesively luted restoration, extraction of the impacted third molar.
\nIn 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.
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\nThen, 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.
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\nThe 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.
\nAfter 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.<\/p>\n<\/a><\/p>\n<\/a><\/p>\n<\/a>
\nThen, 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.
\nThe restoration after cementation, finishing and polishing and a follow-up after 22 days from the surgery.
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\nThe 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.
\nFinally, 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.<\/p>\n<\/a><\/p>\n<\/a><\/p>\n<\/a>
\nIn 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,
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\n1-2 increments of dentin,
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\n1 increment of enamel).
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\nThe apical-coronal stratification has to be performed and supercolors may be used if necessary. <\/i>
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\nThe matrix has to be kept in place till the end of the stratification.
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\nThe final restoration after finishing and polishing and the completed quadrant at the 3-month follow-up.<\/p>\n<\/a><\/p>\n<\/a>
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\nQUADRANT 3<\/b><\/h3>\n
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\nIn 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.
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\nThe 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).
\nIn 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.
\nThe 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 \u201csupport\u201d the cervical enamel by means of an increment of a flowable composite adhesively placed behind the enamel itself.<\/p>\n<\/a>
\nTwo different medium shaped mesial-occlusal and occlusal-distal cavities were prepared on tooth 37.
\nBoth 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.<\/p>\n<\/a>
\nThe 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.<\/p>\n<\/a>
\nThen, multiple oblique increments of dentin were stratified and the occlusal surface was completed with an enamel mass and supercolors.<\/p>\n<\/a><\/p>\n<\/a><\/p>\n<\/a>
\nThe final restorations after finishing and polishing under rubber dam and the 3-month follow-up.<\/p>\n<\/a><\/p>\n<\/a>
\nThe 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.<\/p>\n<\/a><\/p>\n<\/a>
\nThe 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.<\/p>\n<\/a><\/p>\n<\/a>
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