The present case report describes the multidisciplinary treatment of a 25-year old male patient. A complex conservative rehabilitation of all the posterior regions was performed by means of adhesive composite restorations. All teeth were treated with direct restorations with the exception of one tooth that required the fabrication of an indirect restoration cemented with an adhesive luting agent.
It is worth pointing out that specific stratification techniques (horizontal, 4-increment, oblique) were employed according to the different cavity configurations (little, medium, wide, complex). Sometimes those techniques were combined with periodontal surgery in a one-step approach, using an original surgical technique proposed by the author (EJED 2010).
Moreover, the presented case report allows to discuss clinical procedures described in the literature, just like the preservation of cervical enamel not sufficiently supported and the coronal placement of restorative margins without enamel.
In the last 15 years, the evolution of adhesive aesthetic materials dramatically modified the restorative approach in the posterior regions, leading to a more and more limited use of the traditional metal restorative materials. Nowadays, if correctly used, the available composite materials and enamel-dentin adhesive systems allow to guarantee very good long-term aesthetic and functional results, making aesthetic restorations almost invisible in both anterior and posterior regions.
The best advantages offered by resin based materials in comparison to traditional metal alloys regard the aesthetic appearance, the preservation of sound tooth structures and the possibility of reinforcing residual tooth structures. Nonetheless, problems regarding polymerization shrinkage and dentinal adhesion are still controversial.
Nowadays, the increased reliability of adhesive restorations in the posterior regions is mainly due to hybrid resin composites with mini-particles as well as to the last generation adhesive systems. Such materials are characterized by excellent physical-mechanical properties: in fact, they are densely filled, resistant and radiopaque, their elastic modulus is very similar to that of dentin, they are provided with very good surface characteristics and a wear resistance comparable to those of sound enamel and silver amalgam (10-15 micron/year). Consequently, these materials are indicated for all kinds of restorative cavities.
When a proper quantity of sound enamel is present on all cavity margins, direct adhesive restorations represent the first choice therapy in little and medium I and II class cavities. Different clinical procedures were proposed to compensate for shrinkage stress; the most reliable technique is the segmental stratification using pluri-stratified approaches. The incremental techniques vary according to the cavity type; the most validated are the horizontal, the oblique and the 4-increment technique. Conversely, the traditional three-sites procedure described by Lutz (1986) using transparent matrixes and reflective wedges is no longer used.
In the last decade, several studies showed very satisfactory results using direct adhesive techniques in wide cavities requiring cusp coverage as well.
Nonetheless, in the presence of wide and different cavities without two or more walls, with multiple cusp coverage and with absent or reduced cervical enamel, indirect adhesive restorations (inlays, onlays, overlays) cemented with luting agents should be considered as a viable treatment. Such restorations are stratified on a master model and complete polymerization is achieved in the dental laboratory before intraoral cementation. Consequently, indirect restorations allow to better control polymerization shrinkage, bypass the objective procedural difficulties aimed at restoring a correct morphology of the restoration due to the different steps of direct techniques and are provided with better physical-mechanical properties (better dimensional stability, increased toughness and wear resistance) thanks to post-polymerization procedures.
A 27-year old male patient with moderate caries propensity was treated. The patient presented with multiple primary and secondary decays on previous incongruous restorations; such decays were evident at both the clinical and radiographic examination by means of bite-wings.
Some of these decays involved the subgingival part of the teeth.
The treatment plan aimed at establishing proper oral hygiene and periodontal conditions by means of scaling, root planing, polishing and hygienic motivation. Then, a complete aesthetic rehabilitation of all intraoral sites was planned using conservative direct and indirect adhesive restorations. Furthermore, a simultaneous periodontal surgical approach was planned to lengthen the clinical crowns of the teeth interested by subgingival lesions. The maxillary third molars were extracted due to their incongruous position, leading to a difficult achievement of a correct home hygienic maintenance; the extraction of such molars did not impair oral functions. Finally, the impacted right mandibular molar was extracted as well.
The orthodontic examination also evidenced a malocclusion but the patient did not accept to treat it.