CLINICAL - RESTORATIONS
Direct posterior bonded
restorations - an outline of
a clinical technique
By Sergio Rubinstein DDS, Alan J Nidetz DDS & Manal Ibrahim DDS
In this study, the authors explore current
concepts in direct posterior bonded
restorations
Modern dentistry has experienced a major shift on patients’
demands from health and function to cosmetics. Materials
and techniques are constantly evolving to adapt to these
ever-changing needs. One major purpose of modern den-
tistry is not only to deliver this type of care with excellence
but the preservation of healthy tooth structure is just as
essential. This article describes current concepts to help
consistently obtain an excellent, predictable and long lasting
restoration with the direct posterior bonded restoration.
Research has show that the direct posterior composite
fits all of these criteria while also strengthening a tooth that
has lost its integrity (Joynt et al, 1987; Eakle, 1986; Segura &
Riggins, 1999; Reel & Mitchell, 1989; Sheth, Fuller & Jensen,
1988; Simonsen, Barouch & Gelb, 1983; Landy & Simonsen,
1984).
When either decay or removal of a previous restoration
weakens a tooth, the direct posterior composite is the most
conservative technique that can restore the original con-
tours and colour.
While any restorative technique requires meticulous
steps to achieve success, the intermediate steps during
bonding are sensitive and critical. Furthermore, we recog-
nise that if we do not control the shrinkage of the compos-
Figure 1a: Initial picture with amalgam in place
RESTORATIVE & AESTHETIC PRACTICE VOLUME 4 NO. 7 SEPTEMBER 2002
CPD
This article is equivalent
to one hour of
verifiable CPD. See
page 92 for details
ite during its polymerisation it can create stress, microleak-
age, marginal breakdown, fractures and secondary caries. All
of these could lead to the failure of the restoration and
might necessitate endodontic therapy (Davidson, 1997;
Jensen & Chan, 1985; Bausch et al, 1982; Eick & Welch, 1986;
Kemp-Shoulte & Davidson, 1988;Torstenson & Oden, 1989;
Asmussen, 1975).
It is the Class I direct occlusal composite restoration
that carries the highest stress due to the lack of free surface
areas within the cavity (Kanka, 2001). Therefore, the ratio
between the bonded and free restoration surfaces (C-fac-
tor) (Roulet, 1997) is high, creating shrinkage stresses that
are higher than the bond strength (Jackson & Morgan,
2000).
TECHNIQUE
Once clinical or radiographic examination
Sergio Rubinstein is clinical
determines that the old restoration or
assistant professor at the
decay must be removed, it should be
Department of Restorative
done carefully to preserve tooth struc-
Dentistry, UIC College of
ture (Rubinstein & Nidetz, 1995) (Figures Dentistry, Chicago, USA.
1a & 1b). A decision then must be taken Alan Nidetz DDS and Manal
if unsupported tooth structure is to be Ibrahim DDS are his
kept or removed if the composite associates at the Oral
restoration is to be used as a build-up for Rehabilitation Center,
a future onlay or crown. A more conser- Skokie Illinois
vative approach is acceptable if the direct
Figure 1b:Tooth showing the amalgam removed with recurrent
decay
71
 CLINICAL - RESTORATIONS
Figure 2: Intracoronal brush with pumice and cavity cleanser
composite is the final restoration and small undercuts are
present. When an indirect restoration is the treatment of
choice, it will require the removal of healthy but unsupport-
ed tooth structure to establish a path of insertion of the
restoration, hence weakening the tooth.The placement of a
small bevel on all margins is one step that extends bondable
enamel surface area and helps prevent a white micro frac-
ture line around its enamel margin (Kanka, 2001).
DECONTAMINATION
The rubber dam is placed for proper isolation (Rubinstein &
Nidetz, 1995; Leinfelder, 1991) and the deepest decay is
removed with a slow speed round bur. The tooth is disin-
fected (Gwinnett, 1992) using an Intracoronal Brush (Figure
2) with a mixture of pumice and 2% Cavity Cleanser con-
taining chlorhexidine digluconate (Rubinstein & Nidetz,
1995). This step insures the removal of the saliva pellicle.
Grease contamination from the hand piece can hamper
proper bonding without being obvious to the dentist; there-
fore, the tooth is cleaned with a small cotton pellet soaked
in 70% isopropyl alcohol (Kanka, 2001) (Figure 3).
ETCHING,WETTING
If needed, a foam pellet with Cavity Cleanser is used again
Figure 4: Enamel etching
72
Figure 3: Cotton pellet with 70% isopropyl alcohol
to manually eliminate any debris left on the tooth that may
prevent proper etching. After thorough rinsing and drying,
the enamel (Figure 4) and dentin (Figure 5) of the tooth are
now ready for etching (Rubinstein & Nidetz, 1995; Kanka,
1991; Suh, 1991; Fusayama et al, 1979; Kanka, 1990; Kanka,
1990; Bertolotti, 1991; Bertolotti, 1990; Gwinnett, 1971;
Bowen, Cobb & Rapson, 1982; Bowen et al, 1984) with Uni-
Etch 32% phosphoric acid and benzalkonium chloride. It is
first placed on the enamel, then on the dentin for a maxi-
mum of 20 seconds. The tooth is thoroughly rinsed for at
least 5-10 seconds and gently dried to remove any excess
water while the dentin is left moist. Regardless of how deep
the preparation is, the same technique is always applied as
biocompatibility of resins to the pulp has been demonstrat-
ed (Cox et al, 1987; Kurosaki et al, 1990; Fusayama, 1981;
Cox, 1987). Aqua Prep F or Tubulicid Red is placed on the
tooth with a foam pellet for 10 to 60 seconds (depending
on the size of the cavity) (Figure 6) followed by a very light
stream of air, again leaving the dentin slightly moist (Johnson,
Algart & Brannstrom, 1973; Brannstrom, Linden & Astrom,
1967; Brannstrom, Linden & Johnson, 1968) to avoid irre-
versible pulpitis (Brannstrom, 1963).These steps have creat-
ed the best clinical environment to seal the tooth (Suh,
1991; Fusayama, 1987; Pashley, Michelich & Kiehl, 1981) and
Figure 5: Dentine and enamel etching
RESTORATIVE & AESTHETIC PRACTICE VOLUME 4 NO. 7 SEPTEMBER 2002
 Figure 6: Disinfectant application with foam pellet
prevent sensitivity due to possible bacterial microleakage
(Suh, 1991; Nakabayashi, Kojima & Masuhara, 1982;
Nakabayashi, Nakamura & Yasuda, 1991).
ADHESIVE APPLICATION
Two coats of One-Step Plus are applied on the tooth with
a brush (Figure 7) and the resin is air-dried with the air
syringe to evaporate the acetone solvent. One-Step Plus is
reapplied, thoroughly air dried again and thinned down until
there is no visible excess of resin. It is then light cured for 20
seconds at 600 mW/cm2, thus creating the hybrid layer
(Kanaka, 1991; Nakabayashi, Kojima & Masuhara, 1982;
Nakabayashi, Nakamura & Yasuda, 1991; Kanka, 1992a;
Kanka, 1992b).
PACKING AND POLYMERISATION
While different philosophies exist in regards to how a direct
composite must be polymerised, it has been demonstrated
that a low-intensity curing regimen reduces shrinkage stress
without compromising the mechanical stability of the
restoration (Feilzer et al, 1995; Uno & Asmussen, 1991).
Such a stress can be significantly reduced during polymeri-
sation by a reduced initial conversion rate of the resin mate-
rial (monomer molecules turned into a polymer network)
Figure 8: Low shrinkage composite segmented to its
corresponding cusps
RESTORATIVE & AESTHETIC PRACTICE VOLUME 4 NO. 7 SEPTEMBER 2002
Figure 7: Adhesive application with microbrush
and improving the adaptation of the resin material to its
previously cured walls.
The tooth is rebuilt in incremental layers using Aelite LS.
For the first layer, the packing of the composite must be
done carefully in order not to incorporate any air bubbles
while creating proper adaptation of the material to the pul-
pal floor and axial walls.The first layer of polymerised com-
posite to dentin is the ‘dentin gel cure stage’ which is initial-
ly light cured for six seconds at 600 mW/cm2 and after three
minutes fully cured for 20 seconds. For the next layer the
material is segmented to allow for it to cure only to its cor-
responding walls and respective cusp (Wieczkowski et al,
1988) (Figure 8).These steps reduce the possible sensitivity
and cracks caused by contraction polymerisation of the
composite (Qullet, 1995) approximating buccal and lingual
cusps (Baratieri & Ritter, 2001; Davidson, de Gee & Feilzer,
1984).
The last layer is with Pyramid Neutral, which is adapted
and burnished against the tooth. Glycerine is applied over
the tooth/composite interface to prevent oxygen inhibition
(Figure 9) and is pulse delay light cured for three seconds at
200 mW/cm2. This step initiates the chain reaction on the
photoinitiators to start polymerising the final layer of the
composite with the least possible stress (Suh et al, 1999).
Figure 9: Glycerine application
73
 CLINICAL - RESTORATIONS
Figure 10: Coarse polishing point
After three to five minutes, the composite is polished with
rubber points (Figures 10 & 11), followed by a composite
Polishing Brush. The tooth is rinsed, dried, re-etched and
finally sealed with Fortify Plus and light cured for 20 seconds
for each rebuilt surface.The use of such a surface sealant has
been shown to reduce the wear rate of posterior compos-
ite restorations (Dickinson & Leinfelder, 1993). The rubber
dam is removed to verify that the occlusion does not need
any further adjustments in centric occlusion as well as on
lateral movements (Figures 12 & 13). If any adjustments
were made, those areas should be readjusted.
CONCLUSION
Predictability and longevity of direct posterior bonded
restorations can be obtained by meticulous application of
current composite placement techniques. Controlling
shrinkage stress using a low shrinkage composite significant-
ly reduces the strain placed on the enamel margins, thereby
enhancing the integrity of the restoration. The addition of
the ‘dentine gel cure stage’ is intended to reduce internal
stresses on the tooth during its rebuilding steps. Following a
consistent regimen from preparation to polymerisation
allows for the delivery of excellence in restorative treat-
ment. ■ Bowen RL, Eick JD, Henderson DA, Anderson DW (1984).
Figure 12: Occlusal view of final restoration
74
Figure 11: Fine polishing point
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MATERIALS
Intracoronal Brush, Polishing Brush. Ultradent
Products, Inc. South Jordan, Utah 84095.Tel:
(001)800-552-5512
Aelite LS,Aqua Prep F, Cavity Cleanser, Fortify Plus,
One-Step Plus, Pyramid Neutral. Bisco Dental
Products, Schaumburg, Illinois 60193.Tel: (001)800-
247-3368
Tubulicid Red. Global Dental Products, North
Bellmore, New York 11710.Tel: (001)516-221-8844
CPD
For CPD questions relating to this article,
please see page 92
RESTORATIVE & AESTHETIC PRACTICE VOLUME 4 NO. 7 SEPTEMBER 2002