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Tetric EvoCeram Bulk Fill Simplifies Posterior Restorations by Jason Olitsky, DMD, AAACD

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Restoring cavity preparations is a main staple of dentistry, and although performed daily, the procedure is riddled with intricate complexities. Dentists most commonly face the potential for polymerization shrinkage, marginal leakage, caries, postoperative sensitivity and potential procedural failure due to the technique-sensitive protocol for placing composite restorations. Due to the multiple steps for proper placement and potentially numerous materials required, direct posterior restorations entail a long procedural time.

While direct composites are a more aesthetic and contemporary form of treatment, some are better suited for the anterior region because of their high polishability and optical characteristics. However, a significant disadvantage is their lack of strength, which precludes their use for posterior restorations. Other composites with enhanced strength and wear characteristics that are better suited for posterior restorations have fallen short in terms of aesthetic qualities.1

The need for more proficient techniques emerged, stimulated significant dental research, and has led to development of today’s bulk-fill materials. Both highly effective and easy to use, dentists can use bulk-filled composites to place restorations faster, more efficiently and more confidently. Presently, bulk-fill composites diminish technique sensitivity, decrease shrinkage-induced failures2-4 and demonstrate first-rate handling and adaptability, contributing to predictable and aesthetic posterior restorations.5,6

Tetric EvoCeram Bulk Fill
Tetric EvoCeram Bulk Fill composite (Ivoclar Vivadent, Amherst, New York) is a highly advanced material consisting of layered silicates for smooth consistency. As a result, it is effortless for filling cavity preparations of up to 4mm in a single-layer application. With Tetric EvoCeram Bulk Fill, dentists can use a flowable composite, but it is not necessary. Additionally, the material has a polymerization booster allowing for complete curing of 4mm thick increments in 10 seconds. The integrated shrinkage stress reliever decreases the shrinkage stress placed along cavity walls and surfaces, reducing the total shrinkage volume experienced during polymerization.

Tetric EvoCeram Bulk Fill enables a dentist to restore Class I and Class II restorations quickly. The material adapts to cavity walls and can be placed easily with conventional dental instruments. This material also displays an enamel-like translucency of 15 percent, and therefore blends seamlessly with a patient’s natural dentition. Restorations are effortlessly polished to a highgloss due to the material’s nano-hybrid filler composition. The material is available in three universal shades (IVA for slightly reddish teeth; IVB for slightly yellowish teeth and IVW for quick deciduous fillings or light-colored teeth). Tetric EvoCeram Bulk Fill supplies the ideal mixture of simplicity, durability and aesthetics.7

Case Presentation
A 21-year-old man in excellent health presented with a failing occlusal buccal amalgam on tooth #30 and occlusal decay on tooth #31 (Fig. 1). After a thorough initial examination and consultation, the decision was made to restore the teeth with a tooth-colored posterior composite and remove the buccal amalgam on tooth #30 to create a more aesthetic result during the treatment. The material selected for this case was Tetric EvoCeram Bulk Fill.

Under rubber dam isolation (Hygienic Non-Latex Dental Dam, Coltène Whaledent), the amalgam and decay were removed entirely using a carbide bur, revealing preparations that were approximately 4mm deep. To improve isolation around the mesial facial of tooth #31, Liquidam material (Discus Dental) was used to complete isolation and prevent saliva contamination of the treatment area. Removal of the old amalgam and all decay in tooth #31 was successful (Fig. 2).

The cavosurface margins were smoothed with a fine grit diamond bur, followed by the total-etch technique. After disinfecting with 2% chlorhexadine gluconate, 35% phosphoric acid gel was applied to the enamel (Fig. 3), then to the dentin for 15 seconds before rinsing (Fig. 4). Etching of the enamel first ensures that the dentin is not over-etched.

In order to decrease the patient’s sensitivity and re-wet dentin, the Telio CS Desensitizer (Ivoclar Vivadent) was used to help form protein plugs in the dentinal tubules. A single coat of desensitizer was scrubbed onto the preparation for 10 seconds (Fig. 5). Next, two coats of a fifth-generation adhesive (Excite F) were placed in each preparation for 10 seconds. The adhesive was air-dried with an A-dec drier to evaporate solvent, and light-cured with the bluephase 20i (Ivoclar Vivadent) for 10 seconds on low power (Fig.6).

An initial layer of flowable composite is believed to decrease sensitivity by also creating an elastic interface between dentin and the higher viscosity restorative materials. Therefore, a single .5mm thick increment of Tetric EvoFlow translucent was placed with a cavifil applicator on the pulpal floor of teeth #30 and #31. This was then light-cured for 10 seconds on high power (Fig. 7).

Shade IVA of Tetric EvoCeram Bulk Fill composite was chosen to achieve a natural shade blend. Choosing from the three available colors allowed for a simplified shade selection process. Beginning with tooth #30, 2mm of material was initially condensed into place with the soft-touch applicator brush, which was slightly moistened with adhesive. The remaining composite material was then placed in order to completely fill the cavity (Fig. 8). However, it is important to note that Tetric EvoCeram Bulk Fill can be placed in single-bulk increments of up to 4mm. The restoration was then contoured with an IPC-TTN instrument to replicate natural occlusal and buccal morphology. The teeth were cured to a depth of 4mm, since curing between layers was not required (Fig. 9). The process was repeated for tooth #31, after which both restorations were cured on high power for five seconds each using the bluephase 20i curing light (Fig. 10).

With the rubber dam removed, the occlusion was checked with 40 micron articulating paper and adjusted with an OS1 carbide bur. The posterior restorations were then polished with Optrapol NG (Ivoclar Vivadent) for 30 seconds to achieve a natural- looking appearance and a high shine. With the ability to use one shade and cure one layer of Tetric EvoCeram Bulk Fill, a significant amount of time was saved and the shade of the final restorations matched perfectly with the rest of the patient’s natural dentition. (Fig. 11).

Conclusion
Bulk-fill composites are an essential component for the easy and problem-free placement of predictable and aesthetic posterior restorations. Tetric EvoCeram Bulk Fill demonstrates many advantages, most notably decreased polymerization shrinkage, high-quality sculptability and premium aesthetics that allow dentists to create restorations that are virtually identical to the patient’s natural dentition.

References
  1. Hervás-GarcÍa A, Martinez-Lozano MA, Cabanes-Vila J, Barjau-Escribano A, Fos-Galve P. Composite resins. A review of the materials and clinical indications. Clinical Dentistry. Med Oral Patol Oral Cir Bucal. 2006 Mar 1;11(2):E215-20.
  2. Roggendorf MJ, Krämer N, Appelt A, Naumann M, Frankenberger R. Marginal quality of flowable 4-mm base vs. conventionally layered resin composite. J Dent. 2011 Jul 27. (Epub ahead of print)
  3. Kuijs RH, Fennis WM, Kreulen CM, Barink M, Verdonschot N. Does layering minimize shrinkage stresses in composite restorations? J Dent Res. 2003 Dec;82 (12):967-71.
  4. Souza-Junior EJ, de Souza-Règis MR, Alonso RC, de Freitas AP, Sinhoreti MA, Cunha LG. Effect of the curing method and composite volume on marginal and internal adaptation of composite restoratives. Oper Dent. 2011 Mar-Apr;36(2):231-8. Epub 2011 June 24.
  5. Idriss S, Habin C, Abduljabbar T, Omar R. Marginal adaptation of class ii resin composite restorations using incremental and bulk placement techniques: an ESEM study. J Oral Rehabil. 2003;30(10):1000-7.
  6. Van Ende A, De Munck J, Mine A, Lambrechts P, Van Meerbeek B. Does a Low shrinking composite induce less stress at the adhesive interface? Dent Mater. 2010;26(3):215-22.
  7. Ivoclar Vivadent. Tetric EvoCeram bulk fill: The bulk composite without Compromises. Scientific Documentation. Amherst, NY: Ivoclar Vivadent.


Author Bio
Dr. Jason Olitsky, The Smile Stylist, is an accredited member of the AACD, as well as president for the Florida Academy of Cosmetic Dentistry. He was a clinical mentor with the Hornbrook Group and is currently faculty with the Gold Dust Clinical Mastery Series. Jason currently works three days a week with his wife and partner, where 80 percent of their production is based off large cosmetic cases. They started Wallsmiles.com, a site that sells wall art for the dental office and teaches dentists how to get their own patients’ pictures on their walls. They created Smile Stylist, a brand committed to promoting, providing and maintaining beautiful smiles for the fashion-forward customer. He is also co-author of The Naked Tooth: What Cosmetic Denists Don’t Want to Know. Check out Olitsky’s technique via his OnDemand Webinar on Dentaltown.com.
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