A NOVEL TECHNIQUE OF MAXILLARY MOLAR

CLASS I RESTORATION INCORPORATING

RESIN-COMPOSITE UNDER DENTAL OPERATING
MICROSCOPE
Takahiko Sato, DDS, PhD1

Amalgam has been used as the standard material for filling cavities in poste-
rior teeth for over a century. However, there is growing concern over the use
of amalgam restorations due to the possible release of mercury into the body.
Therefore, clinicians are increasingly choosing resin composites for esthetic
restorations as an alternative to amalgam. However, it remains difficult to recon-
struct the individual tooth shape and achieve functional and individual occlusion
while working in the oral cavity. In addition, both the accuracy of the recon-
structed tooth shape and the risk of secondary caries are known to be signifi-
cantly affected by the skill of the clinician. Therefore, we have devised a novel
technique to achieve the treatment goal of reconstructing the individual tooth
shape and improve outcomes. All the procedures involved in this technique are
performed using a microscope. Dental microscopy greatly improves both ana-
tomical precision and hermetic sealing; consequently, it may help maintain the
long-term stability of treated teeth.
 Int J Microdent 2018;9:6–12

INTRODUCTION gam and direct composite resto-

In recent years, the use of com-
posite resin restorations to repair
decay or caries in molar teeth has
dramatically increased. In contrast,
the use of amalgam restorations
has rapidly decreased because of
its “black” metallic appearance
and biocompatibility concerns1.
Initially, composite resin restora-
tions were chosen for small areas
of decay in molar teeth, but as the
use of amalgam restorations has
declined, composite resin restora-
1
Private practice in Iwate, Japan tions have become more widely
chosen, including for larger areas
Correspondence to: of decay or caries in molar tooth2.
Takahiko Sato The most serious concern when
Taka Dental Clinic choosing composite resin restora-
1-6-26-2F Chuou-dori, Morioka, Iwate, tions is post-filling failure. Manhart
Japan et al. reported on the longevity
E-mail: kuulei@friend.ocn.ne.jp and annual failure rates of amal-
rations for Class I and II cavities.
Their data showed that the failure
rates for amalgam restorations
and composite resin restorations
were almost similar at 0 %–7.4 %
(mean 3 %) and 0 %–9.0 % (mean
2.2%), respectively3. Although
composite resin restorations are
a highly effective method of treat-
ment, it remains difficult to recon-
struct the individual tooth shape
and achieve functional and individ-
ual occlusion while working in the
oral cavity. Therefore, the longev-
ity of composite resin restorations
in molar teeth is affected not only
by the specific materials used, but
also by the operator’s skill.
Direct composite resin res-
torations, referred to as direct
bonding, have ushered in the
"post-amalgam age"4. Regarding

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Fig 1 Key anatomical landmarks on the occlusal surface: centaral pit, mesial pit,
distal pit, distal lingual pit.
materials, composite resins were
introduced as an alternative to sili-
cates and unfulfilled resins in the
late 1960s, which were frequent-
ly used by clinicians at the time.
Light-cured composite resins,
such as NuvaFil (Dentsply, Phila-
delphia, PA), were first developed
in the 1970s. Next, the microfiller-
containing light-cured composite
resins and nanofiller-containing
light-cured composite resins that
are currently used in dental clinics
were introduced. Despite these
dramatic advances, however,
composite resins have not been
highly recommended as restora-
tion materials in posterior teeth.
This is due to the polymerization
shrinkage that occurs during the
placement of composite resins5,6.
Shrinkage stress occurs due
to several factors, including (1)
the cavity configuration factor
(C-factor)7, which expresses the
ratio between the contact and
non-contact surface areas; (2) the
size and shape of the cavity; (3)
the elastic modulus of the mate-
rial; (4) post-shrinkage changes;
and (5) the filling method used.
Several novel techniques have
been introduced to improve the
sealing issues caused by shrink-
age stress in molar restorations.
For example, the oblique layering
technique with increments was
introduced as a technique for re-
ducing the C-factor8,9. This method
p06-13_Sato.indd 7
is suitable for reducing shrinkage
stress, which is a major issue for
composite resin restorations de-
signed for widespread use in pos-
terior teeth; however, it does not
address the issue of accurately
reconstructing the individual tooth
shape. Politano et al. devised the
laminar technique, in which filling
is performed in three layers cor-
responding to dentine, enamel,
and dentino-enamel complex.
The drop cone technique uses
flowable resin to give anatomical
morphology to the molar occlusal
surface. Polymerization shrinkage
is avoided by filling each of the
main and secondary ridges of the
molar occlusal surface individu-
ally; however, this method is not
suitable for reconstructing the
whole tooth. The stamp technique
consists of fabricating an occlusal
matrix to impress the occlusal
anatomy of posterior teeth before
cavity preparation takes place. This
matrix is then pressed against the
final composite increment before
curing takes place. This technique
is suitable in cases where car-
ies are evident during clinical ex-
amination or routine radiographic
examination of teeth with intact
marginal ridges and ideal oc-
clusal anatomy. In contrast, this
technique is not suitable in case
where caries has already caused a
defect in the natural tooth. For this
reason, we have devised a new
Sato
restoration treatment concept us-
ing direct bonding that adequately
fulfills both the treatment goals of
reconstructing the individual tooth
shape and improving outcomes.
TREATMENT CONCEPT
We have devised a new restora-
tion technique for Class I cavi-
ties of the maxillary molars using
direct bonding that adequately
fulfills both the treatment goals
of reconstructing the individual
tooth shape and improving out-
comes. Our proposed restoration
technique avoids the risk of recon-
structing the tooth shape without
clear concept by evaluating the
shape of the occlusal surface both
horizontally and vertically, which
improves the efficacy of the filling
procedure.
The occlusal surfaces of the
maxillary molars contain numer-
ous anatomical landmarks that
are essential for imaging the tooth
shape, including ridges, pits, and
fissures. We propose the use of
the central pit, mesial pit, distal
pit, and distal lingual pit as four
key landmarks for use, in order to
obtain balance between buccolin-
gual and mesiodistal orientations,
in the process of reconstructing
the tooth shape (Fig 1).
In standard clinical practice,
the shape of the remaining tooth
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Fig 2 Shaping the filling on the molar occlusal surface us- Fig 3 Our proposed method of shaping the filling on the
ing the shape of the remaining tooth as an indicator. molar occlusal surface. (A) Deep fissure, (B) gentle curve,
(C) sigmoid curve.

Fig 4 Four-layer filling taking account of the histoana- Fig 5 Needles used in the four-tip technique. From left:
tomical structure of the tooth. 23G, 25G, 27G, 30G.

after cavity formation is used as
an indicator when filling the tooth
substance defect in the occlusal
surface (Fig 2). Although using the
shape of the remaining tooth as an
indicator is suitable for fillings that
reconstruct the general anatomi-
cal shape of the tooth, it is of lim-
ited use in reconstructing a shape
close to that of the natural tooth.
Focusing on the reproduction of
the triangular ridge also means
that the volume of the ridges is
too large for the shallow fissures,
and greater occlusal adjustment
may therefore be required, which
runs the risk of destroying the
shape of the tooth. Rather than
performing filling operations with
the aim of harmonizing the cavity
created by the tooth substance
defect with the remaining tooth
substance from the buccolingual
and left-right directions, the au-
thors suggest treating this cavity
as a three-dimensional space in-
cluding the tooth axis orientation
or depth. Images projected on the
retina are two-dimensional; how-
ever, our brain perceives a three-
dimensional world that has depth.
This three-dimensional world is
constructed by the higher visual
cortex that receives perceptual
information from the retina. How-
ever, learning from previous ex-
perience or acquired knowledge
is essential to the construction
of three-dimensional structures
within the higher brain. There-
fore, the authors investigated
numerous natural teeth under a
microscope, which led to the hy-
pothesis that understanding the
shapes of the ridges from the
fissures to the tips of the cusps
might offer a benchmark for rec-
ognizing the three-dimensional
structures of individual teeth. The
shapes of the ridges from the fis-
sures to the tips of the cusps do
not constitute linear inclines, but
trace gentle curves from the deep
central fissure (Fig 3 [A] and [B]),

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with a triangular ridge from the
sigmoid curve (Fig 3 [C]) to the
tips of the cusps. Making a visual
study of these ridge shapes at dif-
ferent angles to the tooth axis and
tracing them with instruments to
experience them through touch
enables the construction of a
three-dimensional model within
the brain. This makes it easier for
the dentist to reconstruct a tooth
shape close to that of the natu-
ral tooth, minimizing the amount
of occlusal adjustment required.
We also use a four-layer filling
technique that takes account of
the hard tissue composition of
teeth so that both the shade and
shape closely resemble those of
the natural tooth, enabling maxi-
mum cosmetic satisfaction to
be achieved (Fig 4). Filling is per-
formed for one tooth at a time,
with the aim of maintaining oc-
clusion in the restored area at its
pre-treatment level. At locations
where there is occlusal contact
with tooth substance, efforts are
made to maintain this occlusion.
The superiority of microscopy in
endodontic treatments such as
root canal treatment or apicecto-
my has already been demonstrat-
ed. Moreover, the microsurgical
approach that uses a microscope
during periodontic treatment has
been shown to contribute -to ear-
lier healing times when compared
with conventional methods10. At
present, the use of microscopy
has yet to be shown to lead to su-
perior results in composite resin
restoration, but it is evident that
its use to enable secure caries
removal and fit composite resin
fillings has a significant effect on
outcomes. The method of direct
bonding to Class I cavities of the
maxillary molars that we have de-
vised involves the performance of
all the procedures involved under
microscopic observation.
p06-13_Sato.indd 9
TREATMENT
PROCEDURE
Our procedure for direct bonding
to Class I cavities of the maxillary
molars is as follows.
 1) Caries removal and cavity for-
mation
  2) Rubber dam isolation
  3) Enamel etching and bonding
 4)  Filling of the dentine area with
dentine-colored composite resin,
using incremental filling with
flowable resin to the same height
as the dentine of the natural tooth
 5) Filling of a further layer with
flowable resin to reproduce
the dentino-enamel complex
 6) Filling of the enamel area with
paste-type enamel-colored com­
posite resin
  7) Pit/fissure formation
  8) Filling with tinting resin
  9) Building up of the main and ac-
cessory ridges with flowable
resin
10) Tint enclosure with flowable
resin
11) Hermetic sealing with glycerin
gel and final polymerization by
light curing
12) Shape correction, occlusal ad-
justment, and polishing
This filling technique makes fre-
quent use of flowable resin, using
needles of four different thick-
nesses depending on the area
to be filled, the amount of filling
used, and the purpose of filling.
We call this technique of varying
the needle diameter depending on
the material and location the "4-tip
Technique" (Fig 5).
CASE PRESENTATION
A 41-year-old woman presented at
Taka Dental Clinic (Morioka City,
Iwate Prefecture, Japan) complain-
ing that food was becoming stuck
in the gap between a metal inlay
Sato
and the tooth. There was no spon-
taneous pain or pain when cold or
hot water was applied. A poorly fit-
ting metal inlay was seen in upper
right tooth 16, where secondary
caries was evident (Fig 6a). When
the poorly fitting metal inlay was
removed, caries was visible on the
palatal side (Fig 6b). (1) The caries
was removed, and rubber dam iso-
lation was performed using Der-
madam (Ultradent, South Jordan,
UT) (Fig 6c). (2) Next, 35% phos-
phate gel (Ultra Etch; Ultradent)
was painted onto the enamel and
left for 20 seconds, after which it
was washed off and dried (Fig 6d).
(3) A bonding agent (Bond Force
II; Tokuyama Dental, Tokyo, Japan)
was painted onto the enamel and
dentine and left for 10 seconds,
after which it was dried with air
under moderate pressure until the
bonding layer ceased to move.
(4) A light curing unit was used
to irradiate the bonding agent for
10 seconds (Fig 6e). (5) Dentine-
colored composite resin was used
to fill the dentine area in the cavity.
(6) Flowable resin (Clearfil Majesty
ES Flow A3D; Kuraray Noritake
Dental, Tokyo, Japan) was injected
in several layers to bring it to the
same height as the dentine, and
polymerized by light exposure (Fig
6f). (7) To reproduce the dentino-
enamel complex, a single layer of
flowable resin (Empress Direct
Trans 30; Ivoclar Vivadent, Schaan,
Liechtenstein) was added and po-
lymerized by light exposure (Fig
6g).
This cavity was not completely
Class I in shape. Its shape was
therefore adjusted to make it
Class I, after which Class I fill-
ing operations were performed
(Fig 6h). (8) A paste-type enamel-
colored composite resin (Premise
Clear; KaVo Dental Systems, Bib-
erach, Germany) was used to fill
the enamel area (Fig 6i). (9) The
pits and fissures were formed us-
ing a composite instrument (GDS
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 Sato
Fig 6a Poorly fitting metal inlay in
upper right tooth 16.
Fig 6d Enamel etching.
Fig 6g Dentino-enamel complex area Fig 6h Filling to adjust shape to Fig 6i Enamel area filling.
filling.
Flowableart, Tokuyama Dental)
(Fig 6j). (10) Tinting resin (Color
Plus; KaVo Dental Systems) was
used to fill the pits and fissures,
and the shape of the surrounding
resin was adjusted to moderate
the intensity of the color. At the
same time, the width and depth
of the fissures and their natural
curves were also shaped, and the
resin was polymerized by light
exposure (Fig 6k). (11) Flowable
resin (Clearfil Majesty ES Flow
XW; Kuraray Noritake Dental) was
10 THE INTERNATIONAL JOURNAL OF MICRODENTISTRY
p06-13_Sato.indd 10
Fig 6b Palatal caries in upper right Fig 6c Rubber dam isolation.
tooth 16.
Fig 6e Bonding.
Class I.
used to build up the main and sec-
ondary ridges, and was polymer-
ized by light exposure (Fig 6l). (12)
A single layer of flowable resin
(Empress Direct trans 30; Ivoclar
Vivadent) was injected into the fis-
sures to prevent tint loss and cor-
rect the undercut of the fissures
(Fig 6m). (13) The surface of the
filling was covered with glycerin
gel (Oxyguard II; Kuraray Noritake
Dental), and final polymerization
was performed with a light-curing
unit (Figs 6n to 6q). (14) Shape cor-
Fig 6f Dentine area filling.
rection, occlusal adjustment, and
polishing were performed (Fig 6r).
DISCUSSION
Unlike anterior teeth, when direct
bonding is performed in molars,
the fact that tooth has a certain
thickness means that the angle
of incidence of light exposure and
reflected light have little effect,
and large gaps in shade are diffi-
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Fig 6j Pit and fissure formation.
Fig 6m Correction of fissure.
Fig 6p After final polymerization Fig 6q After final polymerization Fig 6r After occlusal adjustment and
(buccolingual orientation).
cult to see. Accordingly, the filling
method and materials described
here, which prioritize shape, are
reproducible and can be used for
almost all Class I fillings. The use
of a microscope improves the ac-
curacy of this treatment, enabling
it to be completed without the for-
mation of any gaps at the bound-
ary between the tooth substance
and the composite resin. The un-
dercut of the deep fissures, which
are key to the shape of the occlus-
al surface, is improved by the ap-
p06-13_Sato.indd 11
Fig 6k Tint injection into pit and fis-
sure area.
Fig 6n Final polymerization after
covering with glycerin gel.
(mesiodistal orientation).
plication of a single layer of clear
flowable resin to the fissure sur-
face, which also helps to prevent
the buildup of food debris. It also
prevents tint loss, and maintains a
good tongue feel.
CONCLUSION
In molar restoration by direct
bonding, the use of a microscope
offers the clinician many benefits.
For example, under microscopy,
Sato
Fig 6l Building up of main and sec-
ondary ridges.
Fig 6o After final polymerization
(occlusal surface view).
polishing.
tooth shaping and marginal prep-
aration can be performed with
greater accuracy and the marginal
fit of the restoration can be more
closely inspected. Imaging of the
molar occlusal surface using our
proposed concept and performing
the “4-tip Technique” can facilitate
the reconstruction of a more natu-
ral tooth shape with composite
resin restorations.
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REFERENCES
  1. Lynch CD, Opdam NJ, Hickel R,  
Brunton PA, Gurgan S, Kakaboura A,
Shearer AC, Vanherle G, Wilson NH,  
Academy of Operative Dentistry Euro-
pean Section. Guidance on posterior
resin composites: Academy of Opera-
tive Dentistry - European Section. J
Dent 2014;42:377-383.  
  2. Opdam NJ, Bronkhorst EM, Loomans
BA, Huysmans MC. 12-year survival of
composite vs. amalgam restorations.
J Dent Res 2010;89:1063-1067.
  3. Manhart J, Chen H, Hamm G, Hickel  
R, Buonocore Memorial Lecture.
Review of the clinical survival of direct
and indirect restorations in posterior
teeth of the permanent dentition.
Oper Dent 2004;29:481-508.
12 THE INTERNATIONAL JOURNAL OF MICRODENTISTRY
p06-13_Sato.indd 12
4. Lutz F. The post amalgam age. Oper
Dent 1995;20:218-222.
5. Bausch JR, de Lange K, Davidson CL,
Peters A, Gee AJ. Clinical signifi-
cance of polymerization shrinkage of
composite resins. J Prosthet Dent
1982;48:59–67.
6. Unterbrink GL, Liebenberg WH.
Flowable resin composites as "filled
adhesives": literature review and clini-
cal recommendations. Quintessence
Int 1999;30:249-257.
7. Feilzer AJ, De Gee AJ, Davidson CL.
Setting stress in composite resin in
relation to configuration of restoration.
J Dent Res 1987;66:1636-1639.
  8. Klaff D. Blending incremental and
stratified layering techniques to pro-
duce an esthetic posterior composite
resin restoration with a predictable
prognosis. J Esthet Restor Dent
2001;13:101-113.
  9. Weaver WS, Blank LW, Pelleu GB Jr.
A visible-light-activated resin cured
through tooth structure. Gen Dent
1988;36:236-237.
10. Burkhardt R, Lang NP. Coverage
of localized gingival recessions:
comparison of micro-and macrosur-
gical techniques. J Clin Periodontol
2005;32:287-293.
2018/06/08 10:59