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Clinical Research

Predictable direct composite


restorations in posteriors.
The Simultaneous Modeling
Technique
Salvatore Scolavino, DDS
Private Practice, Nola, Naples, Italy

Gaetano Paolone, DDS


Private practice, Rome, Italy
Lecturer, Master of Endodontics and Restorative Dentistry, University of Siena, Italy
Lecturer, Facult dOdontologie de lUniversit de la Mditerrane Marseille, France

Giovanna Orsini, DDS, PhD


Associate Professor, Restorative Dentistry, School of Dentistry,
Polytechnic University of Marche, Ancona, Italy

Walter Devoto, DDS


Private and Referral Practice, Sestri Levante, Italy
Lecturer, Master of Endodontics and Restorative Dentistry, University of Siena, Italy
Visiting Professor, University of Marseille, France, and International University of Catalonia,
Barcelona, Spain

Angelo Putignano, MD, DDS


Professor, Restorative Dentistry, Head of Department of Endodontics and Operative Dentistry,
School of Dentistry, Polytechnic University of Marche, Ancona, Italy

Correspondence to: Gaetano Paolone, DDS


address???; gaetano.paolone@gmail.com

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Abstract trol shrinkage stress. Several authors


have proposed different material layer-
Direct posterior restorations represent ing techniques for posteriors.1-8 The au-
a widespread procedure in daily prac- thors of this article propose a simplified
tice. Occlusal layering is often con- approach, which primarily aims to help
sidered a complex task, generally not the clinician perform quick, simple, pre-
predictable and often requiring several dictable, and natural-looking occlusal
occlusal adjustments. Moreover, direct modeling, reducing the need for oc-
posterior restorations are time consum- clusal adjustments.
ing, as many small increments must be
applied and cured individually to con- (Int J Esthet Dent 2016;11:XXXXXX)

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Introduction its preparation; b) from the residual


healthy tooth tissue after preparation;
Occlusal anatomy is very variable; it can c) from the adjacent teeth; and d) from
be steep, flat, smooth or very irregular the contralateral.
(Fig
1). All these surface characteris-
tics are unique, and the clinician should The advantages of this technique are:
avoid trying to replicate identical mor- 1. Time saving: simultaneous compos-
phology for every restoration. ite increments reduce the number of
When part of the occlusal anatomy curing cycles.
is missing, due either to caries or an 2. Easier modeling: the centripetal pro-
unsuitable filling, an accurate analysis jection of the peripheral sound tissue
of the anatomical information of the re- means fewer occlusal adjustments.
maining occlusal tissue is very useful. 3. 
Occlusal preview: preview, verify,
Information taken from the residual oc- and modify the position, extent, and
clusal table tissue such as steepness of orientation of the simultaneous ridg-
the ridges, position of primary and sec- es before light curing.
ondary ridges, grooves, etc, allows for 4. Shrinkage management: due to the
the creation of a custom modeling rather non-contact of multiple increments,
than a standardized one. shrinkage stress can be controlled.
The technique proposed in this article 5. Standardized procedure: a standard-
is based on the following points: ized cavity depth as a starting point
Multiple, simultaneous yet segmented for the occlusal layer makes the pro-
(not in contact) composite increments cedures repeatable.
to define occlusal anatomy.
Occlusal modeling always starts from The limits of this technique are that the
a standardized cavity depth. peripheral sound tissue, from which the
Use of the following anatomical in- central projection starts, can be discon-
formation: a) from the tooth before tinued by the loss of one or both marginal

Fig 1 (From left to right): Variability in occlusal surface anatomy morphology.

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ridges, or one or more cusps. Clinicians


can face two different situations with two
different outcomes:
1. 
Marginal ridges: these can be re-
stored in a predictable way using
proven techniques.9
2. Cusps: freehand modeling of a cusp
(height, thickness, and tip position) is
difficult, arbitrary, and unpredictable,
mainly due to the lack of references.
Due to rubber dam isolation, it is im-
possible to verify the interocclusal
Fig 2The modeling of the occlusal layer starts
relationship. Indirect restorations can from a standardized cavity depth.
provide a more practical and predict-
able solution for the clinician in these
situations.

Description of the ations, the analysis of these teeth allows


the clinician to define the position of the
technique
grooves and pits, as well as the orienta-
Knowledge of dental anatomy is cru- tion and steepness of the crestal slopes.
cial. Although this technique presents a
workflow that allows for simplified mod- Analysis of the adjacent teeth
eling in posteriors, the main aspects The depth of the grooves, the inclina-
of occlusal anatomy and their possible tion of the crestal slopes, and the height
variability should be known for every of the marginal ridges (in the case of
tooth, including the average position of class II) can be quickly detected from
grooves, pits, ridges, triangular ridges, the neighboring teeth.
oblique ridges, and marginal ridges, as
well as the size ratio of ridges. Cavity requirements

Observation Cavity floor


The technique described here is referred
The preliminary stage of gathering in- to as modeling the anatomy of the oc-
formation should be performed prior to clusal layer. This technique starts from a
rubber dam isolation. simplified cavity floor, with no anatomic
pre-modeling and approximately 1 to
Analysis of the teeth to be treated 2mm deeper than the marginal ridge
Observation plays a very important role (Fig2). The cavity floor is then flat or
in the initial stage. If the teeth to be treat- slightly rounded.
ed are not already destroyed or do not A cavity depth of 1.5 to 2mm allows
contain incongruous extensive restor- for an average depth of 3 to 3.5
mm

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Fig 3 Grooves and pits are generally 3 to 3.5mm from the top of the cusps.

Fig 4 A standardized cavity floor depth of about 1 to 2mm (measured at the marginal ridge) allows for
reproducibility of the correct position and depth of pits and grooves.

Fig 5 Simultaneous increments are applied to each corresponding cusp.

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1 2 3 4 5

Diagrams 1 to 5 1 and 2: Simultaneous increments. 3: Centripetal projection of composite increments


to define ridges. 4 and 5: Excess removal following the residual anatomy.

Fig 6 Increments are pushed centripetally in order to define ridges.

from the top of the buccal cusp tip of the ner than 2 to 2.5mm have been report-
grooves (Figs3 and 4), as suggested by ed.11,12 Cusps thinner than this value
Kano.10 should be lowered and, as previously
The above-mentioned cavity floor mentioned, an indirect restoration could
can be obtained with different materials be a more predictable solution.
(flowables, bulk-fill materials, regular
composites), depending on the clinical Cuspal ridges
situation and the clinicians choice.
The first composite increments are per-
Cuspal thickness formed simultaneously, in correspond-
Cuspal thickness is 2mm. Structural ence with two or more cusps (Fig5; Dia-
issues related to cuspal thickness thin- grams1 and 2) in order to better preview

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Fig 7 Excesses are removed by dragging a sharpened instrument along the sound residual tissue.

Fig 8 All ridge characteristics (width, length, height, etc) can be modified simultaneously before light
curing.

Fig 9 Composite is spread on the margin with brushes for margin adaptation.

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5 6 7 8 9

Diagrams 5 to 9 5 to 7: Once excess is removed, composite is spread on the margin with a brush.
8 and 9: All the increments are light cured at once.

Fig 10 Definition of marginal ridges. (From left to right): simultaneous application, centripetal spreading,
excess removal. A different color has been used for teaching purposes.

cuspal relationships. Composite is then 1. Main ridge orientation, location, and


squeezed and pushed toward the cent- volume.
er of the occlusal table (Fig6) to extend 2. Approximate path of the primary
the ridge bodies (Diagram3). To con- and secondary grooves.
trol shrinkage stress, ridge extensions 3. Approximate position of the main pits.
should not be in contact with each other.
The occlusal table will be closed in the In this step, the clinician can check
final step, allowing further anatomy ad- and correct length, orientation, and
justments. Any excess composite can ridge volumes before light curing (Dia-
be removed by dragging along a sharp- grams8 and 9). The first increments can
ened instrument parallel7 to the sound be slightly undersized, both to manage
residual tissue (Fig7; Diagrams4 and shrinkage stress and to allow appropri-
5). Final ridge adjustments are done be- ate corrections with further increments.
fore light curing (Fig8). Margin adapta-
tion is achieved by spreading compos- Marginal ridges
ite on the margin with a brush (Fig9;
Diagrams5 to 7). The mesial and distal ridges are mod-
In this step, we define the anatomic eled in the same way as the cuspal
sketch that outlines: ridges (Fig10). Composite is added as

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small drops, and spread with a sharp-


ened instrument. Excesses are removed
by pushing a sharpened probe into the
sound tissue. Sometimes, they are split
into two or more ridges, and this can be
detected on the residual marginal crest.
Triangular ridge extension merges into
the distal or mesial triangular pit. Mar-
ginal ridge composite adaptation is
obtained through the use of brushes
(Fig11).

Fig 11 Composite is spread on the margin.

10 11 12 13

Diagrams 10 to 13 First increments should be applied and cured simultaneously. When grooves and
pits need to be defined, increments should be cured one by one.

14 15 16 17

Diagrams 14 to 17 A natural-looking groove is obtained by pushing a drop of composite towards a


cured one.

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Closing the occlusal table brush (Diagram18). A sharpened instru-


ment can be used to redefine pits and
The central gap, derived from the in- grooves (Diagram19), and final light cur-
complete modeling of the vertexes of the ing is performed (Diagrams20 and 21).
ridges, is closed by adding small drops Closing the occlusal table can be
of composite and squeezing them to es- achieved in the following ways:
tablish the correct final relationship that 1. Extending the vertex of a ridge with
defines grooves and pits (Diagrams10 a small drop of composite (Fig12).
to 13). 2. Extending the marginal ridges
In this step, composite increments are (Fig13).
pushed towards an already cured incre- 3. Adding the oblique ridge in the
ment. To obtain a natural-looking groove, maxillary molars (Fig14). In this
composite should be pushed downwards step, every little increment is added,
with instruments or brushes to meet the then modeled and cured.
opposite cured cusp (Diagrams
14 to 4. Adding or extending secondary
17). Increments are then smoothed with a ridges (Fig15).

18 19 20 21

Diagrams 18 to 21 18: Composite is spread following the anatomic profile. 19: A sharpened instrument
can be used to redefine pits and grooves if they disappear during modeling. 20 to 21: Final light curing of
the increment.

Fig 12 The vertex of a ridge can be lengthened with a little increment.

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Fig 13 A centripetal extension of the marginal ridge is another way to close the occlusal table.

Fig 14 The oblique ridge can be modeled in one increment, and its central groove is generally not deep.

Fig 15 Secondary ridges, detected on the peripheral ridge, are added with a small drop of composite
and modeled with a sharpened instrument.

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Fig 16 Small cavities: one ridge is modeled and cured at a time.

Fig 17 A natural-looking groove can be obtained by pushing a small drop of composite towards a well-
defined cured one.

Small cavities Materials and shades

The technique presented here is applica- While this article describes a modeling
ble not only to large cavities, where many technique for occlusal anatomy, it is
ridges have to be restored, but also to not dependent on the type and shade
small cavities. When the clinician has to of composite used. The authors do not
deal with small cavities, the steps shown ascribe much importance to color in
in Diagrams1 to 9 can be skipped, and posterior direct restorations, but believe
those shown in Diagrams9 to 21 should that a correct anatomical modeling rep-
be followed, relative to closing the oc- resents the best mimesis, independently
clusal table. To give pits and grooves of the shades used.
a natural aspect, increments should be
cured one by one (Figs16 and 17).

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Shrinkage in the occlusal layer The simultaneous split incremental pro-


cedure proposed here is based on re-
Although none of the layering tech- specting all the above-mentioned issues
niques can avoid the effects of poly- aimed to reduce polymerization shrink-
merization shrinkage,13 many studies age stress. In particular, among all the
have shown that an incremental layer- composite ridges, the final connection
ing technique results in better perfor- (closing the occlusal table) is achieved
mance than does bulk placement.14-17 with only a little increment that fills the
Shrinkage stress seems to relate more small residual occlusal gap in the least
to the volume of the restoration than to stressful way.
its C factor.18,19
In a multi-layered restoration, if the fi-
nal occlusal increment is cured all at Clinical cases
the same time, it produces the highest
cuspal deflection.20 The following clinical cases have been
The shrinkage direction of compos- restored using the technique described
ite increments is affected by both the in this article.
bonded surfaces and the free ones.21

Case 1

Fig 18 Initial situation: class I on 3.6. Fig 19Isolation. Fig 20Cavity preparation.

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Fig 21After adhesion and flowable composite on the bottom of the cavity, simultaneous increments
are placed to restore DL and MB ridges. Fig 22 Ridges are driven centripetally. Residual anatomy on
sound tissue is important to understand a ridges orientation and steepness. Margin adaptation is achieved
through the use of brushes. Fig 23Simultaneous increments on ML and DB.

Fig 24 Closing the occlusal table: a drop of composite is placed on the apex of DB to extend it. Fig25The
ridge tip of DB is extended centripetally. Fig 26 DB ridge extended. To achieve a natural-looking anatomical
modeling in mandibular molars, the vertices of ridges do not generally merge in the same pit.

Fig 27 Distal marginal ridge is added, as well as secondary ridges on the cusps of ML and DL. A small
increment is added on the ridge tip of DL to define the distal groove. Fig 28Staining is placed to outline
anatomy and to give a better three-dimensional aspect. Fig 29Final result.

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Case 2

Fig 31 Cavities prepared.

Fig 30 Initial situation and isolation.

Fig 32 After adhesion, a flowable base is placed Fig 33Simultaneous placement of ridges and
at the bottom of the cavities, and the buccal surface centripetal projection in accordance with residual
of 4.6 is restored. anatomical information.

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Fig 35 6-months recall.

Fig 34 Final result before and after dental dam


removal.

Case 3

Fig 36 Initial situation, isolation, and cavity prep- Fig 37 A base is placed at the bottom of the cav-
aration. ity, after which simultaneous increments are placed
to define MB, DB, and MP ridges. Marginal ridges
and secondary ridges are added to complete the
occlusal table.

Fig 38 Final result. Fig 39 Final result after dental dam removal.

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Case 4

Fig 40 Initial situation: 4.7, 4.6, and 4.5 with un- Fig 41 On 4.5, class II is transformed to class I.9
suitable restorations.

Fig 42A small amount of flowable material is Fig 43Simultaneous increments are placed in-
placed to level the bottom of the cavities. side the opposite cusps of the first molar.

Fig 44 On 4.6, composite is pushed centripetally,


but the extensions of the ridges are not in contact.
After having defined the length and orientation of
the ridges, composite is spread on the margin of
the restoration with a brush for better marginal ad-
aptation and to make it anatomically consistent with
the residual tooth structure. On 4.7, increments are
placed for ML and DB ridges.

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Fig 45 On 4.7, ridges are pushed centripetally Fig 46 4.5: projections of ridges pushed centrip-
and the margin is smoothed with a brush, as de- etally. 4.6: increments for MB and distal ridges 4.7:
scribed for 4.6 (Fig 44). On 4.5, increments are increments for MB and DL ridges.
placed for all the three ridges.

Fig 47 4.6: buccal cavity restored, and final incre- Fig 48 Stains have been placed to enhance the
ments on the tip of the ridges to close the occlusal three-dimensional aspect of the restoration.
table.

Fig 49 Final result after dental dam removal. Fig 50 6-months recall.

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Fig 51 Final radiograph.

Case 5

Fig 52 2.6: initial situation, and after dental dam isolation.

Fig 53 Two sectional matrixes are placed in order Fig 54 The occlusal perimeter restored.
to restore marginal ridges. DP cusp is missing. As it
is quite small, it will be restored directly.

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Fig 55 Increments for DB and MP ridges. Fig 56 Increments for MB and DP ridges.

Fig 57 MB and DP ridges pushed through the Fig 58 Increments for the mesial marginal ridge
center, and margin smoothed with a brush. and the oblique ridge.

Fig 59 Increments for the distal marginal ridges Fig 60 Occlusal anatomy finished.
and for a DB secondary ridge.

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Fig 61 Staining.

Fig 62Final result after dental dam removal. Fig 63 6-months recall.
Sound tissue is dehydrated.

Fig 64 Final radiograph.

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Case 6

Fig 65 Initial situation. 2 class I on 3.6 and 3.7. Fig 66 After isolation, cavities are prepared.

Fig 67 Self-etching adhesive system with enamel Fig 68 A small amount of flowable composite has
pre-etching has been performed. been placed on the floor cavities.

Fig 69 (Left): Contemporary increments of disto- Fig 70Last increments for small cavities and
buccal and mesiolingual cusps. (Right): Mesiolin- definition of grooves.
gual and distobuccal.

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Fig 71 An oblique view before dental dam removal.

Fig 72 Final result after dental dam removal.

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Conclusion clinicians to perform simpler, quicker


restorations that need fewer occlusal
Direct posterior restorations are a com- adjustments.
mon task in daily practice. This article
describes a simplified approach, based
Acknowledgments
on the simultaneous increments for mod-
The authors would like to thank Dr Gurvinder Bhirth
eling the occlusal table according to the and Dr Ronan ODonoghue for their valuable sug-
peripheral residual anatomy. This helps gestions and their help with proofreading this article.

in the aesthetic treatment of


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