he need for aesthetic tooth-colored restorative materialshas resulted in the introduc-tion of a wide variety of com-

posites.1 The ideal material would bebiologically acceptable, have the phys-ical and mechanical properties simi-lar to tooth structure, be moderatelypriced, and be as easily manipulatedas amalgam.1

When composites were first intro-duced in the mid-1960s, they werehailed as an amalgam substitute.However, problems with wear resis-tance, postoperative sensitivity, sec-ondary caries, and fracture reducedthe placement of posterior composites.The past 30-year improvements inwear resistance, dentin bonding, andfracture strength, as well as easierdelivery systems, have resulted in anupsurge of composite placement.2However, despite the improvement inphysical properties of the materials,composite placement is relativelycomplex compared with that of amal-gam. Achievement of adequate con-tacts and appropriate proximal con-tour, decreased sensitivity and recur-rent decay, color matching, and ade-quate curing in a relatively short peri-od of time present a challenge.2

The recent introduction of newcomposites, matrix retainers, wedges,and contact-forming instruments has

Expediting Class II Posterior Composite PlacementBy Richard Trushkowsky, DDS, FAGD, FADM, FICD

T

RESTORATIVE

resulted in techniques to expedite andprovide more predictable compositeplacement. This article delineates the

Figure 1. Class II preparation terminating oncementum.

Figure 2. The Trimax contact forming instru-ment with disposable light-conducting inserts.Each side permits four different positions by90° rotations.

Figure 3. A cut-away model demonstrates thealignment of the marginal ridge guide, contactarea 1 mm below guide, and the position of theinsert in the proximal box.

Figure 4. Composite is placed into the proximalbox until it is half filled.

Reprinted from Dentistry Today (2001:20(10):96-101), Copyright © 2001, Dentistry Today, Inc.

Figure 5. The Trimax instrument is insertedinto the composite in the proximal box untilthe marginal ridge guide lines up with the adja-cent tooth. The tip is moved elliptically to pre-clude any possibility of binding, and torquedagainst the matrix band.

Figure 6. Excess composite is removed withan interproximal carver and a light guide isplaced on the recess provided on the top ofthe instrument so that the light is focuseddown the center of the insert.

Figure 7. Occlusal view demonstrating a thinwall of composite with contact at the correctheight and position.

Figure 8. Ivoclar Vivadent Heliomolar P-1instrument is used to create rounded fossa.The marginal ridge has been established andthe matrix band removed.

Figure 9. A Compo-Sculp instrument asdesigned by Dr. Didier Dietschi (Sutter DentalManufacturing) is used to create more detailedanatomy.

Figure 10. An interproximal carver is used toaccentuate grooves and inclines.

use of new materials and techniquesto provide a more predictable class IIcomposite in a relatively short periodof time.

PROCEDUREThe case presented involved a class IIcomposite restoration placed in amaxillary second molar. The tooth wasanesthetized and a rubber damplaced. The decay on the mesial of thetooth was removed. The gingival mar-gin in the proximal box terminated oncementum (Figure 1). It has beensuggested by some clinicians thatplacement of a light-cured glassionomer lining to the cavosurfacemargin (open sandwich) may inhibitmicroleakage of class II composites.3,4

However, the following technique mayreduce or eliminate this need.

The tooth is etched by placingphosphoric acid on the enamel initial-ly, and then 5 seconds later on thedentin for another 10 seconds. Thetooth is then rinsed with a copiousamount of water for 15 seconds. Ex-cess water is blown off and then ahigh-speed evacuation system is usedto remove remaining excess water.The preparation is then blotted with a

cotton pellet so that the dentinremains slightly moist, to prevent thecollapse of collagen. A single dose ofExcite (Ivoclar Vivadent) is activatedby plunging a microbrush through themembrane in the capsule. This pro-vides a fresh mix each time, and helpsprevent evaporation of the solvent.The microbrush is used with a lightscrubbing motion to apply Excite tocover the dentin and enamel margins.The material is lightly air dried so thematerial is not totally removed, andthen light cured for 10 to 20 seconds.A second coat can be applied in a sim-ilar manner to ensure complete cover-age of all surfaces. The dentin surfaceshould be shiny at this point, indicat-ing complete coverage.

Placement of a thin layer of flow-able composite is optional at thispoint. Studies have indicated mixedresults regarding the need for flow-ables to reduce microleakage.5,6 Athin layer of Heliomolar Flow (IvoclarVivadent) was placed in this case, cov-ering the axial walls and extendingout to the gingival margin. This layerwas then light cured. A recently intro-duced instrument, the Trimax (Figure2) (AdDent Corporation) can be used

to light cure this layer, and even theprevious layer of bonding agent(Figure 3). This allows a close proxim-ity of light into the proximal box.Some clinicians place a flowable com-posite but do not light cure immedi-ately, using the heavy body materialsthat follow to help seal the margins,7and then light cure. HeliomolarHB–C2 (Ivoclar Vivadent) was placedin the proximal box so that it wasfilled halfway (Figure 4). A smoothplugger was used to carefully adaptthe composite to the walls of thepreparation. Since the material is notsticky, there is no pullback, whichmay result in open margins.

The Trimax instrument with itsremovable and disposable insert wasplaced into the composite, pushed intoplace until the marginal ridge guidealigned with the adjacent tooth,moved slightly elliptically (to preventany possible binding), and thentorqued toward the matrix band(Figure 5). The insert is 4 mm fromthe marginal ridge guide to the tip,and can be shortened by cutting theend. The largest insert (of three avail-able sizes) that will fit into the proxi-mal box should be selected. This will

reduce the bulk of resin composite,and wedge the composite against thewalls of the preparation and towardthe bonded surface. If the insert is toowide, it can be tapered.

Excess composite at the marginalridge can now be contoured with aninterproximal carver. The compositeis cured through the Trimax instru-ment, allowing the light to penetratethe depth of the preparation (Figure6). This is done for 10 to 40 secondsdepending on the light or compositeused. Because the insert is dispos-able, repeated sterilization does notdegrade optical output. The Trimaxinstrument is then removed. Becausethe greatest curvature of the convexside is 1 mm below the marginal ridgeguide, this is where the contact areais achieved (Figure 7). By anglingthe Trimax instrument buccally orlingually (if necessary), the contactcan be positioned even more precisely.Heliomolar HB can be used as anenamel replacement to finalize themarginal ridge contour and occlusalembrasure, and the matrix bandremoved.8,9

The dentin layer is now built upwith Heliomolar. A variety of instru-

ments are used to create cusps andfossae, including Heliomolar P-1(Ivoclar Vivadent) (Figure 8), Compo-Sculp (Sutter Dental Manufacturing)(Figure 9), and an interproximalcarver (Figure 10). This is light cured40 seconds. Tetric Color can be placedin the grooves with an endodontic fileif desired (Figure 11). The final e-namel layer using Heliomolar HB isthen placed and contoured followingthe previously incorporated cusps andfossae, and then light-cured for 10 to40 seconds. Finishing burs and dia-monds can be used to remove excesscomposite and refine anatomy if need-ed (Figure 12) (posterior compositesculpting kit, Brassler). The Astropol(Ivoclar Vivadent) series of points(Figure 13), cups (Figure 14), anddiscs (Figure 15) can be utilized toachieve a polished smooth surface forthe final restoration. The final res-toration demonstrates a pleasing nat-ural contour that can be achieved in arelatively short period of time (Figure16).

DISCUSSIONComposites are often used as an alter-native to amalgams in class I and

class II restorations. Packable com-posites should be considered amalgamalternatives, not substitutes. Amal-gams can be condensed to hold thecontact. Composites are pushed backalmost to the original position by thematrix band. Composites exhibit vis-coelastic behavior, and deformation ofthe composite by pushing duringpacking is not retained.2 The mater-ial undergoes viscoelastic recovery,thereby reversing some of the previ-ous deformation. Resistance to flow orBinghan body behavior would beideal, but this doesn’t occur. To over-come this deficiency and achieve amore predictable, properly contouredcontact, a combination of matrix re-tainer and bands, modification in thecomposite, and instrumentation todisplace the band and move the adja-cent tooth slightly is necessary.

The Trimax allows the achieve-ment of a tight anatomical contactarea. It also conducts light into thecomposite, possibly reducing micro-leakage and improving the degree ofconversion and physical properties.Heliomolar HB (High-Viscosity Re-inforced Microfilled restorative) isbased on the chemistry of Heliomolar.

Figure 11. Stain can be placed in the grooveswith an endodontic file.

Figure 12. Finishing burs are used just toremove excess at the margins.

Figure 13. Astropol points are used to polishfossa.

Figure 14. Astropol cups are used on inclinesand buccal and lingual margins.

Figure 15. Astropol discs can also be used oninclines and interproximal margins.

Figure 16. The final restoration demonstratesa natural occlusal anatomy, tight anatomicalcontact area, and a smooth surface.

It can be light cured in 20 secondswhen placed in 2-mm increments.The availability of nine aestheticshades allows the creation of a natur-al-appearing restoration.

Heliomolar chemistry featuresPIP (particle in particle) technology.This allows the volume of filler to beincreased beyond that of traditionalmicrofilled composites. Filler parti-cles in microfills are very small (0.4µm), and have a combined surfacearea that is 1,000X greater than thesurface area of macrofillers. This in-creased surface area of particlesmeans the resin (organic) portionbecomes too viscous and unworkable.

Heliomolar HB is made by com-pressing individual particles intolarge agglomerations or clumps ofparticles. By doing this, filler loadingcould be nearly twice what wasachievable before with microfills, andstill provide good handling properties.Prepolymerized particles are alsomade by creating an agglomeratedmixture, curing it, and then millingthis prepolymerized composite intosmall “fillers.” The prepolymerizedparticles are then added into a freshmixture of free resin and agglomerat-ed particles to allow increased fillerloading. Heliomolar HB may allowthe surface benefits of a microfill (pol-ish and wear).8

The use of sectional matrices andretainers such as Composi-Tight(Garrison Dental Solutions), PalodentMatrix System (Dentsply Caulk), orContact Matrix Danville Engineeringaid in the formation of contacts byproviding separation, and some of thebands are precontoured, providing amore natural shape. An ultra-thinband is provided by Microband(Innovative Technology, Dental In-novations). A wedge such as the FlexiWedge (Common Sense DentalProducts Inc) allows close adaptationof the matrix to minimize excess. TheV-shaped wedge collapses whenplaced, then expands to adapt theband into any concavity. The wedge ismainly used for this purpose, not forseparation.

Minimizing finishing and polish-ing saves time and also minimizescrack formation in the composites.The Astropol System provides finish-er, polisher, and high polisher in avariety of sizes and shapes. The firsttwo contain silicon dioxide, and thehigh polisher contains silicon dioxideand diamond particles to achieve asmooth gloss surface.

CONCLUSIONThe proper selection of materials andinstruments to restore missing toothstructure is a mandatory initial step.

Dr. Trushkowsky is director of operative dentistry and continuing education atStaten Island University Hospital. He maintains a private practice in Staten Islandemphasizing aesthetic and restorative dentistry. He is a fellow in the Academy ofGeneral Dentistry, the Pierre Fauchard Academy, Academy of Dental Materials,and the American and International College of Dentists. He is a member of theAmerican Prosthodontic Society, Academy of Osseointegration, and AmericanAcademy of Cosmetic Dentistry. Dr. Trushkowsky has authored over 60 articleson aesthetics and dental materials. He has spoken nationally and internationallyat many major dental meetings, and is online with Dental Quest. He is on the edi-torial board of Contemporary Esthetics and Restorative Practice, and authored abook chapter on direct composites. He is an evaluator for many leading manu-facturers and CRA, and is a senior consultant to the Dental Advisor. Disclosure:Dr. Trushkowsky holds a patent on the Trimax instrument. The instrument isowned by AdDent Corp, but Dr. Trushkowsky retains a small royalty interest.

If composite is selected, the cliniciannow has an armamentarium availablethat permits the insertion of a highlyaesthetic and durable restoration in amoderate amount of time.�

References1.Willems G, Lambrechts P, Braem M, et al. A classifica-

tion of dental composites according to their morphologi-cal and mechanical characteristics. Dent Mater.1992;8:310-319.

2. Leinfelder KF, Bayne SC, Swift EJ Jr. Packable compos-ites: overview and technical considerations. J EsthetDent. 1999;11:234-249.

3. Aboushala A, Kugel G, Hurley E. Class II compositeresin restorations using glass-ionomer liners: microleak-age studies. J Clin Pediatr Dent. 1996;21:67-71.

4.Trushkowsky, R.D. In:Aschheim K, Dale B, eds. EstheticDentistry: A Clinical Approach to Techniques andMaterials. 2nd ed. St. Louis, Mo. Mosby Inc; 2001:69-96.

5. Beznos C. Microleakage at the cervical margin of com-posite class II cavities with different restorative tech-niques. Oper Dent. 2001;26:60-69.

6. Bell S, Inokoshi S, Ozer F, et al. The effect of additionalenamel etching and a flowable composite to the interfa-cial integrity of class II adhesive composite restorative.Oper Dent. 2001;26:70-75.

7. Belvedere PC. Contemporary posterior direct compos-ites using state-of-the-art techniques. Dent Clin NorthAm. 2001;45-69.

8. Heliomolar HB. Scientific Profile. Feb 2001; Ivoclar.9. Bichacho N. The Centripetal build-up for composite

resin posterior restorations. Pract Periodont AesthetDent. 1994;4:17-23.