The Posterior Aesthetics Health And Social Care Essay

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Total no. of words

(excluding references)


To answer this question you will first need to review the accompanying Clinical Case Scenario. ‘This is a pdf document titled ‘Unit 5 Clinical Case Scenario for Structured Essay Question’ which can be found in the resources section of your learning plan under ‘Unit 5: Assessments’.


Describe all of the equipment, materials and techniques you would select to optimise the operative management of the lesion in the lower left premolar with regard to:

a. Cavity preparation 25 marks

b. Prevention of iatrogenic damage to the adjacent proximal tooth surface

10 marks

c. Moisture control 20 marks

d. Matrix system 20 marks

e. Restoration using direct composite 25 marks

Total: 100 marks

For each section describe your chosen equipment, materials and techniques in the order that they are employed providing reason(s) for each choice and details of how they are used. This should include each and every item utilised during the procedure.

Maximum word count 2500 words

• 10 % deduction for exceeding word limit


According the clinical photographs and radiograph this is a typical class II cavity. The

concept of minimal intervention is based upon very early detection of a lesion with

surgical treatment undertaken only if surface cavitation is occurred. In view of

potential remineralisation and the presence of adhesive restorative materials, as

much as possible natural tooth should be retained, leading further to minimal

damage of the tooth. This is an extremely sensitive technique and the operative

management should have specific form on the location and the size of the lesion.

Dentist is responsible to establish an absolute isolation of the site and all aspects of

preparation should be accessible to the curing light. The preparation should be free

of foreign debris to allow an optimal bonding. Needs a careful operative

management – we have to preserve the maximum amount of tooth tissue The

principles that needs to be followed in order to design and prepare the cavity ( for a

conventional type of restoration) are: To obtain an outline , resistance, retention

and convenience form, then to remove any carious dentin, to finish the enamel wall

and finally to clean the cavity.

However in minimal invasive dentistry for small cariogenic lesions, a saucer-shaped

cavity preparation suggested by Nordbo (Nordbo, 1998), for posterior approximal

resin composite restorations. No bevel used and the tooth substance saved by

parallel walls and rounded internal angles. The study is valid and relevant to clinical

practice, as it offers a preparation design for optimal restorations. The authors used

10 years follow up which is acceptable and represents a viable treatment modality

for small cavities. Prior to isolation of the area and outline the form of the cavity, it

is necessary to mark the centric stop with articulator paper after registering the bite

in centric occlusion. Begin the occlusal segment of the tooth preparation by entering

the deepest carious pit orienting the bur 90 degrees to the occlusal plane,

handpiece parallel to the long axis of the tooth and tilted slightly laterally for ease of

penetration. As the bur enters the pit, establish the initial outline form by extending

the external walls to sound tooth structure. With intermittent pressure and

continuous movement from one point to another following the DEJ. Before

dropping the box, the marginal ridge is thinned out as much as possible. This

thinned enamel provides protection for the adjacent tooth and is also a guide for

dropping the box later. Remove loose enamel and examine buccal and lingual

proximal walls to ensure complete removal of caries

The soft , wet ,demineralised dentin should be removed. Stop drilling when

reasonable hard dentine, scratchy to probe, firm, leathery, moderate resistance to

gentle scraping Avoid heat, pressure, maintain the maximum amount of residual

dentin thickness

Gradually preparation until marginal ridge to avoid iatrogenic trauma to adjacent

tooth. We remove peripheral caries using slow handpiece burs and a tactile feel to

the adjacent tooth which is protected by marginal ridge

Use of enamel hatchets for cervical margins and trimmers to finish the margins of

the cavity

There are not burs that if we want to prepare that margin without damaging the

surface of the adjacent tooth. Hand instrument or specialised ultrasound

instruments to approach cavity

After preparation of the occlusal segment a thin layer of enamel at the

proximal area is remaining to prevent accidental damage of the adjacent tooth. We

thin marginal ridge with a carbide bur and then hand instrument only to brake the

marginal ridge. Following the complete removal of the caries lesion remove loose

enamel (buccal and lingual proximal margin) using hatchets or chisels.

The operative management regarding the isolation of the site could be

undertaken with optidam. Initially we select a posterior OptiDam because is suited

perfectly to restorations of sectors from the first pre-molar to the second molar.

Then install the rubber dam with an autoclavable plastic frame and with a pair of

scissors, cut the nipples off the teeth to be restored. . It is necessary to produce

minimum three holes. The first is for the clamp distal of the site (to LL6).Apply the

autoclavable plastic SoftClamp at the level of the most distal perforation of the

rubber dam. The dam is stretched in place above the lateral wings of the clamp.

With the use of any generic forceps, the combination dam and clamp /frame is

placed directly on the most distal tooth- lower left first molar. The 3-diamensiotnal

shape of optidam, in addition to anatomical design of the support frame, follows the

contour of patient’s face and allows placing the rubber dam without the help of the

assistant. Also the design frame facilitates increased patients comfort and allows for

them to breath with no pressure around the nose. At the clamp level, the dam is

positioned under the wings to ensure complete water-tightness of the operating

field. The second hole is for the second premolar and the third for the first

premolar. For the placement of rubber dam could be used more holes but there is

always greater risk of moisture contamination of the site. We do not want to place

the rubber dam in the tooth the we are working otherwise will get on the way of the

matrix. The interdental area is encapsulated and sealed by the rubber dam (the

importance of thickness). . The third hole is necessary not only for placing the

wedges (preferable flexible wedges) or dam stabilizing cord but because we need to

see the adjacent tooth in order to visualise and produce higher and greater contact

point/surface. Some operators prefer to add floss around the tooth that restoration

is planned but there is always a risk that the rubber dam could flick into the sulcus

and cause additional problems to soft tissues. The flexibility of Optidam allows

immediate set up of the operating filed before the use of any rotary instruments

and also the neutral taste is appreciated by the patients. In conclusion the

combination of Optidam- SoftClamp facilitates, improves and secures the placement

of the operating field, providing a stress free and time efficient working

environment. The effect of the use of rubber dam on the marginal adaptation of

composite resin fillings to acid-etched enamel (van Dijken,1987) is remarkable.

However it is difficult to prove that only the rubber dam and not the entire protocol

ensure it.

There are a lot of different matrix systems in the market today. The execution

of such a class II restoration would benefit from a sectional matrix system. A clinical

study by Loomans confirmed that sectional matrix systems, combined with

separation rings, resulted in tighter contacts, while other systems resulted in looser

interproximal contacts.(Loomans,2007).The study is valid and relevant to clinical

practice as it provides vital information for restoring posterior teeth, but could be

criticized for the small amount of sample. The sectional matrix fits around the

proximal box and the curve is towards the occlusal surface. Garrison matrix with an

ultra-thin metal matrix would be the ideal choice. The sequence that should be

followed for this particular matrix system is matrix- wedge- separation ring. As

already mentioned metal matrix needs to be thin in order to be able to adjust if

necessary. The separation ring, separate the teeth and provide a sort of lateral seal.

Flexi wedges have the advantage that they can contour. However they concave on

the gingival side and fit over the papilla, not like wooden wedges, that positioned in

between teeth and may deform matrix and furthermore affect the emergence

profile of the restoration. At the completion of the restoration first remove wedge

and then the matrix with special matrix removal forceps. Garrison system gives the

cervical seal, teeth separation ( Inside dentistry, 2009). In addition improves the

contact tightness and minimizes the finish of the restoration.. It is stable system

matrix, has optimal retention on the tooth and finally it is easy to use (easy insertion

and removal).

In order to execute a predictable and optimal composite restoration each of

the following steps should be followed:

- Selective etch to enamel only with 35% phosphoric acid for 15s

Then we wash and dry the cavity. It is important not to over dry the cavity because

we will not have good bonding results (we will not have proper penetration and

hybridisation of the dentine)

Cavity should be visibly moist but with no obvious pooling. After the adhesive

application, if the entire cavity should appear glossy and shiny then is ready for

restoration with composite. It is proven than high bond strength to dentin can be

obtained under dry condition when adhesive system is vigorously rubbed on dentine

surfaces. On wet surfaces, light rubbing may suffice. Self-adhesive systems do not

yet produce bond strengths as high as etch&rinse systems.

In order to ensure and improve marginal adaptation flowable composite could be

applied. It is usually applied a thin layer maximum of 0.5mm flowable resin just to

seal the cavity. A study revealed that it is feasible if certain clinical protocol would

be followed then better marginal adaptation could be achieved(Cunningham,1990).

However this needs further investigation and the most contemporary resin

materials have different physical properties.

- Composite shrinkage may lead to stress on the restoration. Incremental

placement could reduce the stress on the composite. The composite of choice for

this case is Filtek Silorane. This low shrink posterior restorative is designed to

minimize shrinkage and polymerization stress.(Burke,2011) Filtek in combination

with the excellent bond strength, leads to excellent marginal integrity of the

restoration .A high compressive and a flexural strength of the restoration material

protects from fractures and stabilizes the tooth at the same time, especially when

used in posterior restorations.the study is valid and relevant to clinical practice but

could be criticized from the size of the sample used and definitely require further


The application of Silorane Adhesive system is simple. The application of the etch-

primer with a microbrush, followed by gentle air dispersion and 10 seconds of light

curing. In addition, the application of Silorane System Adhesive Bond with

microbrush, followed by gentle air,dispersion and 10 seconds of light curing as well.

Finally the incremental placement (2.5mm) and shaping of Filtek Silorane Low Shrink

Posterior Restorative is undertaken under full operatory light conditions and

follower by 20 seconds light curing.

-. The most important in the posterior composites are the tight contact point and

the nice contour. Open contacts leads to immediate failure as the food debris can be

trapped. In high risk patients the contour should be clear, easy to clean and

accessible during cleaning, otherwise the surface will demineralise and cause

secondary caries. A good approach restoring the cavity with hybrid composite is the

incremental technique.

The increment placement could be performed with horizontal or oblique layers but

to touch one wall at time.The final increment could be applied with Garrison

instrument. For the marginal fissures, the pointed tip-acron tip- need to stick to the

marginal fossa and then we can produce the marginal ridge.

TriMax contact forming instrument can be used for the filling of the proximal box.

We put a block of composite into the proximal box, hold tight against the adjacent

tooth and then light cure it. This instrument sets the composite tight and forces the

matrix the adjacent tooth. TriMax can guarantee nice and tight contact

-. Coltene instruments could be used in order to fill the rest of the occlusal cavity

and seal the fissures.

-. Then we remove the separation ring with special forceps

-. Reflect the matrix in order to give more space for the light cure from the sides.

Initially light cure from occlusal surface and then lateral surfaces.

The main objective of polymerisation is to achieve adequate curing of the

material . The steps that would help to ensure better light curing are:

Wear orange safety glasses

Re-position the patient so that you can see the restoration and access it with the light

Dentist should be positioned so that can stabilise the light directly over the preparation

Stabilise the light so that the beam is perpendicular to the surface of the resin

Begin curing no closer than 1mm from the resin, then move as close as possible after 1s

Adjust the light guide so that you can operate the light comfortable

Ensure that the tip is free of damage and debris

Don’t look directly to curing light as there is a risk of retina burn

Remove the flexi wedge and finally the matrix (with Pi tweezers,Triodent)

The finishing of the definitive composite restoration could be with various

instruments (Morgan,2004 ) such as:

Minimal invasive finishing discs to finish marginal ridge

The occlusal and lateral surfaces could be finished with Mikron , Compo shape even with Sofu carbide burs. Kerr composite finishing system is found to be useful as well

Diamond polishing pastes

The finishing of the embrasures could be performed with disks or composite strips

Excess of composite could be removed easily with a hand instrument – scalper blade or ultrasound scaler- if area is not etched. On the other hand if the surface is over etched, the composite material sticks outside of the cavity. So after occlusal adjustments should re-light cure (it hardens the surfaces) and add a shiny layer on it. Various material on the market offer such a sealing of microscopic defects ( BisCover,G-coat) and gives shiny surfaces