CATEGORY AUSTRALASIAN DENTIST85 CLINICAL Patient Information A 25-year-old male, presented with a noncontributory medical history, reporting no known allergies and no systemic conditions of relevance. His chief complaint was sensitivity and esthetic dissatisfaction with his anterior and posterior teeth, attributable to existing restorations that had become old and discoloured. Clinical Examination Intraoral examination revealed discoloured composite restorations on teeth #36 and #37), with clinical evidence of active caries associated with the existing restorations (Fig. 2). The patient reported sensitivity to sweet foods in the region of teeth #36 and #37. These findings were indicative of compromised marginal integrity of the existing restorations. Treatment Plan Following clinical assessment, a treatment plan was formulated to replace the failing restorations on teeth #36 and #37 with direct composite restorations, to address both the concerns of sensitivity and esthetics. Clinical procedure Isolation Isolation was achieved using a rubber dam before beginning the restorative procedure to ensure a contamination-free operative field (Fig. 3). Effective isolation is essential in adhesive dentistry, as moisture contamination can significantly compromise bond strength (Nasser A 2021). Cavity Preparation The existing restorations were carefully removed and carious dentin was excavated using rotary instrumentation with a highspeed handpiece (Fig. 4). Completely removing carious dentin is essential to eliminate all bacteria from underneath the restoration and thus ensure long-term clinical success. Cavity Assessment Cavity depth was confirmed to be approximately 4mm on both teeth (Fig. 5), making the clinical scenario well-suited for bulk-fill composite application. As mentioned earlier, bulk-fill materials are specifically engineered to achieve reliable polymerisation at depths of up to 4mm, reducing the requirement for incremental layering and thereby minimising the risks of void formation and interlayer contamination, and lowering the polymerisation shrinkage stress. Bonding Protocol Selective enamel etching was performed using phosphoric acid (Fig. 6), followed by rinsing and gentle air-drying (Fig. 7). Adhese Universal (Ivoclar, Schaan, Liechtenstein), a multi-mode universal adhesive, was then applied to both enamel and dentin, air-thinned, and light-cured (Fig. 8). In selective enamel etching, phosphoric acid is applied exclusively to the enamel margins for ~15 seconds. This approach encourages better micromechanical retention at the enamel margins which translates to superior bond strength and marginal integrity. (Koup MA, Blatz MB 2024) By not etching dentine, it also reduces the risk of post-operative sensitivity. The Vivapen system ensures precise, Fig. 5: Cavity depth measurement on tooth #37 using a periodontal probe, confirming a depth of 4mm. Fig. 8: Application of Adhese Universal using the Vivapen delivery system to the prepared cavity of tooth #36. Fig. 2: Pre-operative intraoral photograph of teeth #36 and #37, demonstrating aged occlusal composite restorations with evident marginal discolouration, loss of surface lustre, and brown pigmentation along restoration margins and adjacent fissures, most likely indicative of secondary caries. Fig. 6: Application of self-etch phosphoric acid gel to the enamel of teeth #36 and #37. Fig. 9: Light curing of Adhese Universal on tooth #36 using the Bluephase PowerCure unit, delivering a high irradiance of 3,000 mW/cm². Fig. 3: Rubber dam isolation in situ prior to cavity preparation on teeth #36 and #37. Fig. 7: Occlusal view of teeth #36 and #37 following rinsing and drying of the etchant. Fig. 10: Initial placement of Tetric plus Flow, shade A2 plus, into the prepared cavity of tooth #36 to a depth of approximately 2mm. Fig. 4: Occlusal view of teeth #36 and #37 following removal of existing composite restorations and cavity preparation. Both cavities demonstrate well-defined margins with exposure of cariesaffected dentin at the cavity floor.
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