Simone Deliperi

With the recent founding of the International Academy for Adhesive Dentistry (IAAD), scientific research, commercially available products, and clinically proven protocols will be brought together with the dental profession.

SUMMARY: Amalgam has been used in the restoration of structurally compromised posterior teeth for many years. When placing large amalgam restorations, replacement of weak cusps with restorative material is recommended to prevent tooth fracture. This recommendation can be modified with new guidelines using modern adhesive techniques. Semidirect and indirect inlay/onlay composite restorations have progressively replaced amalgam restorations over the past 20 years. Lately, single visit direct resin-bonded composite (RBC) restorations have also been used as a viable alternative to conventional indirect restorations. This paper is intended to introduce a step-by-step protocol for the direct restoration of structurally compromised posterior teeth using RBCs with stress-reducing protocols.

SUMMARY: Objective: To evaluate the clinical performance of class II large-size direct composite restorations. Materials and Methods: Fifty (50) patients 18 years or older were included in this clinical trial restoring 75 vital molar teeth with large-size cavities. Inclusion Criteria: Occlusal extension greater than two-thirds the intercuspal distance and proximal extension greater than half the distance between line angles. Teeth with residual cavity walls less than 1 mm and with one or more cusps involved were excluded. Teeth were randomly divided in three groups. Group 1: Opti-Bond FL; group 2: Scotchbond 1 XT; group 3: PQ1. Total-etching was performed using 35% phosphoric acid followed by the application of 2% chlorhexidine gluconate in the three groups. All teeth were restored using Vit-l-escence microhybrid composite resin. The proximal surface was built up first, followed by dentin and enamel occlusal surface stratification; wedge-shaped increments of composite resin were placed and cured using the UltraLume V curing light through a combination of pulse and progressive curing techniques. Results: Restorations were evaluated at six-month intervals during the two-year period using a modified US Public Health Service criteria by two independent evaluators precalibrated at 85% reliability. No failures were reported and α scores were recorded for all parameters. Statistical analysis was performed using a χ2 test and the Fisher exact test (χ2=10.6; p=0.001). No teeth exhibited sensitivity in the three groups both at the two-week recall and two-year follow-up.

To evaluate the clinical performance of direct Class II fiber-reinforced composite restorations on nonvital teeth. Thirty patients age 18 or older were included in this clinical trial restoring 35 molars. The inclusion criteria were: two- to four-surface restorations, replacement of composite and amalgam restorations necessary or unrestored teeth with decay reaching the pulp, teeth having homogeneous root canal fillings terminating 0 to 2 mm from the radiographic apex. Teeth with residual cavity walls less than 1 mm or with complete loss of the clinical crown were excluded. Teeth were restored using a combination of Ultra etch 35% phosphoric acid, PQ1 adhesive system, and Vit-l-escence microhybrid composite resin. The enamel peripheral shell of the restoration was built up first; a resin-impregnated piece of polyethylene ribbon fiber (Ribbond Triaxial) was covered with B1 Perma-Flo flowable composite, placed into a prepared canal, folded, and light cured; then, dentin and enamel occlusal surface stratification was completed. All 35 restorations were evaluated at 6 months and 1 year by two independent evaluators using modified USPHS criteria. No failure was reported and alpha scores were recorded for all parameters. Before starting the treatment, 26 out of 35 teeth (74%) had apical periodontitis as diagnosed radiographically. At the 1-year recall, no signs of periapical lesions were detected and radiographs reported neither periodontal ligament widening nor periapical radiolucency. Direct fiber-reinforced composite resin restorations demonstrated excellent clinical performance at 1 year.

Many factors contribute to the achievement of clinical success with direct posterior composite restorations: (1) analysis of the occlusion and opposing dentition, (2) complete excavation of dental caries, (3) analysis of residual tooth structure, (4) control of polymerization stresses by using appropriate layering and curing techniques, (5) occlusal force equilibration, and (6) patient compliance to maintain good oral health. The goal of this paper was to provide a clinical protocol for the direct restoration of severely damaged posterior teeth, analyzing the benefit and limits of a similar procedure.CLINICAL SIGNIFICANCE: This paper is intended to introduce specific esthetic and functional guidelines for the placement of cusp‐capping restorations using resin‐bonded composite.

Clinical Relevance: The proper utilization of fiber-reinforced resin composite restorations in endodontically-treated molars may preclude the use of more extensive restorative treatment, possibly delaying the need for expensive indirect restorations.

The purpose of this study was to evaluate the efficacy of nonvital bleaching and clinical performance of direct composite restorations when used to reconstruct multisurface restorations on endodontically bleached teeth. Twenty-one patients 18 years or older were included in this clinical trial. Twenty-six endo-bleached maxillary and mandibular teeth were restored using a microhybrid composite resin. A Vita shade guide arranged by value order was used to record the shade for each patient. Temporary or existing restorations were removed along with 1 mm of gutta-percha below the cementoenamel junction and a resin-modified glass ionomer barrier was placed. Bleaching treatment was performed in the office and at home. Two weeks after the completion of bleaching, teeth were restored using a combination of a filled adhesive system and microhybrid composite resin. All but one restoration was evaluated every 12 months during a 5-year period using modified United States Public Health Service criteria by two independent evaluators. No failures were reported and alpha scores were recorded for all parameters except color stability (Alpha: 10; Bravo: 14; Charlie: 1). ANOVA showed a significant shade change between baseline (mean = 14.13) and 2 weeks (mean = 1.6), 2 years (mean = 2.8), and 5 years (mean = 3.4), P < .0001. A post hoc test showed a significant shade change between a 2week and 5-year follow up (P = .001). Shade rebound was reported for 15 out of 25 nonvital teeth, but was limited to a maximum of 6 shades; direct anterior composite restorations demonstrated outstanding clinical performance after 5 years.

Clinical Relevance: The combination of minimally invasive cavity preparations and adhesive restorations allows clinicians a significantly more conservative approach to proximal carious lesions of teeth adjacent to MO/DO preparations.

Nightguard vital bleaching with 10% carbamide peroxide was shown to have some minor effects on certain brands of amalgam mainly related to mercury release. However, in this case report, amalgam staining of the bleaching tray was detected in correspondence of the left and right first upper molars following tooth whitening for a week. These teeth presented mesio occlusal distal amalgam fillings with superficial chipping at the cavosurface margins. The same phenomena did not occur in the mouth with other amalgam intracoronal restorations not showing marginal defects. No decay or discoloration was noted around the amalgam fillings both in the upper and lower teeth. At the 1-week recall visit, patient was recommended to avoid the bleaching gel application in the maxillary first molar teeth. The existing fillings were replaced with composite resin restorations after a 2-week elapse time. The unusual amalgam staining of the bleaching tray suggests that amalgam restorations with defective cavosurface margins should be monitored during the tooth whitening therapy. Alternatively, their replacement should be considered prior to bleaching.