CLINICAL

Simplified layering technique for

superior-quality posterior restorations
Gianfranco Politano1 and Marleen Peumans2

Today, there is a strong trend towards streamlining den-tal materials and procedures.
We would like to show that simplification and good quality are not a contradiction
in terms when posterior teeth are restored with proven direct materials. Furthermore,
we have developed a method to heighten our efficiency which involves a simplified
layering protocol and a composite material that is easy to adapt to the remaining tooth
structure.
In this article, we present a simplified layering protocol for the placement of direct
composite restorations in posterior teeth. In the two cases described, we used Tetric
EvoFlow Bulk Fill as the dentin replacement and a medium-translucency nanohybrid
composite A2/A3 (IPS Empress® Direct and Tetric® EvoCeram) as the enamel
replacement. Clinical experience has shown that the combination of these two material
used with a bilaminar histo-anatomical layering method results in restorations that blend
in seamlessly with the surrounding tooth structure. In the two cases, a simplified layering
protocol was used to place superior-quality restorations in posterior teeth in only 30
minutes.
One of the benefits of streamlined products and procedures is that clinical protocols
are easier to standardize, thereby reducing the risk of error. If we look at the different
steps of the clinical procedure, we see quite clearly that cavity prepa-ration cannot
be simplified. To ensure the longevity of the restoration, the cavity must be properly
prepared according to the biomechanical analysis.
However, with regard to the adhesive protocol, it can defi-nitely be streamlined by
making use of a contemporary uni-versal adhesive (e.g. Adhese® Universal). It can
be applied in several modes: etch-and-rinse, self-etch or self-etch with prior selective
etching of the enamel with phosphoric acid. The restoration is then efficiently placed by
following a simplified layering protocol, taking three important aspects into account:

1
Dr Gianfranco Politano 1. Application of the histo-anatomical bilaminar layering technique
Studio di odontoiatria
Dr Daniele Puzzilli
The objective is to copy the natural tooth. Therefore, the histo-anatomical build-up of
Via dell’Umanesimo, 199 the natural tooth has to be reproduced: The natural occlusal dentin is concave, while
00144 Rome/Italy the enamel is convex. This biological fact (Bazos et al., 2011) has to be taken into
[email protected] consideration during the composite layering process. As a result, the dentin com-posite
2
Assoc. Prof. Marleen Peumans will be layered in a concave way and the enamel composite in a convex way (Fig.
KUL Faculty of Medicine Universiteit 1). Layering according to this “bilaminar” technique is simple. In the prepared occlusal
Leuven cavity, the enamel and dentin can be clearly distinguished so that the dentin and
Department of Oral Health Sciences
Kapucijnenvoer 7
enamel composite can be efficiently applied in the correct spatial order. An additional
B-3000 Leuven/Belgium advantage of the bilaminar histo-anatomical technique is that there is minimal risk of
[email protected] making visual mistakes when grinding in the occlusion.

50 INTERNATIONAL DENTISTRY – AFRICAN EDITION VOL.11, NO. 5 OCTOBER/NOVEMBER 2021

 CLINICAL

Figure 1: The natural occlusal dentin layer has a concave shape, while the enamel layer is convex.

Figure 2: Treatment of two molars with Class II cavities: flowable composite (1) and conventional
composite (2). The flowable composite shows better adaptation.

2. Selection of the composite materials for dentin the standard fillers. The dental enamel is replaced using a
and enamel replacement medium-trans-lucency material (A2/A3) that imitates the
A highly filled flowable composite resin should be selected optical properties of natural dental enamel. The esthetic
as the dentin replacement. This type of ma-terial readily IPS Empress Direct materials and the clin-ically proven
adapts to the cavity margins, the cavity floor and the Tetric EvoCeram composite are suitable for this purpose. As
overlaying conventional composite layer (Fig. 2). In addition, described, the enamel material must be applied in a convex
flowable composites show low shrinkage stress because of way, according to the successive cusp build-up technique:
the elastic bonding effect. A flowable composite is easy that is, the cusps are built up in individual steps. An enhanced
to apply as a dentin re-placement, since it automatically esthetic effect can be attained by characterizing the occlusal
assumes the concave shape of the dentin. Very deep cavities fissures with a brown stain (IPS Empress Direct Color Brown).
are quickly filled with a product such as Tetric EvoFlow This results in the optical separation of the cusps. In addition,
Bulk Fill, for example. This flowable composite resin has a the stain seals the fissures, thereby decreasing the possibility
high filler content of 52 vol %. The patented light initiator of plaque accumulation and simplifying the polishing of the
Ivocerin in combination with the Aessencio Technology occlusal surface.
enables you to apply this flowable composite in 4-mm thick
layers, which nevertheless can be reliably cured. During the 3. Layering protocol for Class II restorations
polymerization process the translucency of the flowable When the proximal box of a Class II cavity is filled, the
composite drops from 28 % to a low < 10 %which is very layering pro-cess starts with the placement of a highly filled
similar to that of natural dentin. Further-more, the material has flowable composite in the cervical part of the cavity. This
convenient self-levelling properties, and it optimally adapts layer should be at least 2 mm in thickness (Fig. 3). The aim
to cavity walls. Finally, Tetric EvoFlow Bulk Fill shows low is to improve the marginal adaptation in the cervical area
shrinkage stress, as the material contains an elastic resinous of the preparation. The proximal enamel wall is built up
filler known as a shrinkage stress reliever, in addition to with conventional nanohybrid enamel composite in order

INTERNATIONAL DENTISTRY – AFRICAN EDITION VOL.11, NO. 5 OCTOBER/NOVEMBER 2021 51

P O L I TA N O / P E U M A N S

Figure 3: Layering scheme for a Class II restoration. The flowable Tetric EvoFlow Bulk Fill can be applied in one step
(layer 1 and 3) with a maximum increment thickness of 4 mm.

to obtain the best possible physico-mechanical properties by the diamond bur when the occlusion was ground in.
within the marginal ridge area. Once the Class II cavity has Subsequently, the green and then the pink polishers are used
been transformed into a Class I cavity further layering can to polish the res-toration to a high gloss shine.
take place as described above. The layering proce-dure is
further simplified and accelerated by using Tetric EvoFlow Case 1
Bulk Fill as the dentin replacement, since this material A 35-year-old patient requested us to replace the amalgam
is applied in one step (in the box and the occlusal part). restorations in her first and second lower molars. She
Nevertheless, the maximum thickness of this layer must not complained of pain in the last molar when she chewed. The
exceed 4 mm. clinical pictures showed unacceptable restorations in both of
In the last step of this clinical procedure the functional the teeth (Fig. 4). After having applied the universal adhesive
requirements are checked and the restoration is finished system Adhese Universal, we replaced the dentin with Tetric
and polished. These steps can be simplified by ensuring the EvoFlow Bulk Fill (Fig. 5). This flowable composite resin
following points: has very good self-levelling properties and automatically
• A precise evaluation of the occlusion and articulation of assumes a concave shape. In the second molar, the
the initial situation will prevent any over-contouring of the flowable bulk-fill material was applied in one increment in
occlusal surface. the occlusal part and in the proximal area of the preparation
• In the treatment of Class II cavities, the correct selection and subsequently polymerized with the Bluephase light
and positioning of the matrix band will avoid the use of curing device (light output 1200 mW/cm2) for 20 seconds.
exces-sive amounts of composite material. The manufacturer recommends light curing of 10 seconds. The
• When the cusps are modelled according to the successive layer did not exceed 4 mm in thickness. Due to the Aessencio
cusp build-up tech-nique, attention must be paid to giving Technology, the opacity of the flowable material increased
the cusps the correct inclination and to leaving enough significantly during the light curing process (Fig. 5). Next, we
space for the antagonist cusp. This will significantly reduce replaced the enamel with the medium-translucency Tetric
the time needed for adjusting the occlusion as well as EvoCeram A3 material using the successive cusp build-up
finishing and polishing. technique. We stained the fissures with IPS Empress Direct
The restorations are easy to finish and polish to a high Color Brown (Fig. 6). Once we had removed the rubber dam,
surface gloss with the three silicone polishers of the Astropol we checked the occlusion. As the cusps had been built up in
set. The polishers must be used in the correct order: that is, the correct way, only minimal adjustments were required. We
in decreasing grit size. The grey polishers are suitable for finished and polished the composite restorations using the three
finishing the occlusal surfaces and the margins. They are polishers from the Astropol composite polishing kit. The surfaces of
operated at a speed of 10,000 rpm with water-cooling. the completed restorations were attractive in their simplicity and
These polish-ers remove the scratches that were created blended in seamlessly with the surrounding tooth structure (Fig. 7).

52 INTERNATIONAL DENTISTRY – AFRICAN EDITION VOL.11, NO. 5 OCTOBER/NOVEMBER 2021

P O L I TA N O / P E U M A N S

Figure 4: Case 1: Defective restorations in two lower molars

Figure 5a and 5b: Replacement of the dentin layer using Tetric EvoFlow Bulk Fill. Due to the Aessencio Technology, the opacity of the composite
increases during the polymerization process.

Case 2
A thirty-year-old patient presented with defective restora-
tions in two lower molars (Fig. 8). We placed a rubber
dam and removed the old restorations. In the process, we
found numerous carious lesions (Fig. 9). We removed the
infected dentinal tissue with a round tungsten carbide bur
at a low speed. Next, we cleaned the prepared cavities by
air-abrading them with aluminium oxide particles (30 μm).
Figure 6: Replacement of the enamel with a medium-translucency We did not reduce the slightly under-mined buccal cusp of
composite (Tetric EvoCeram A3) using the successive cusp build-up the first molar, as it was not exposed to heavy loading during
technique. The fissures were characterized with IPS Empress Direct Color
Brown. occlusion and articulation (Fig. 10).
After the polymerization step, the composite showed a

Figure 7: Result after finishing and polishing

54 INTERNATIONAL DENTISTRY – AFRICAN EDITION VOL.11, NO. 5 OCTOBER/NOVEMBER 2021

 P O L I TA N O / P E U M A N S

Figure 8: Case 2: The two molars required direct composite restorations. Figure 9: When the old restorations were removed, numerous caries
lesions were revealed.

Figure 10: Prepared cavity after air-abrasion with aluminium Figure 11: Reconstruction of the dentin layer with Tetric EvoFlow Bulk Fill
oxide (after curing)

Figure 12: Result after finishing and polishing. The enamel layer was rebuilt one cusp at a time with IPS Empress Direct Enamel (A2).

significant increase in opacity, and the material effectively in posterior teeth in a normal time frame. The bilaminar
masked the discoloured bottom of the cavities (Fig. 11). We histo-anatomical layer-ing protocol significantly simplifies
used IPS Empress Direct Enamel in shade A2 to replace the the treat-ment process. A highly filled flowable bulk-fill
enamel. Subtle staining of the fissures with IPS Empress Direct composite showing a dentin-like opacity and an enamel
Color Brown created an optical separation of the cusps. The composite resin exhibiting medium translucency are key
finished and polished restorations looked very attractive and elements of this protocol.
could not be distinguished from the natural tooth structure
(Fig. 12). Reprinted with permission by Reflect 01/2020

Conclusion This article was published online in International Dentistry -

Superior-quality composite restorations can be placed African Edition in 2020

56 INTERNATIONAL DENTISTRY – AFRICAN EDITION VOL.11, NO. 5 OCTOBER/NOVEMBER 2021