From fractured enamel to controlled rehabilitation
Rubber dam isolation + Class II contact control + adhesive-driven restoration (step-by-step)
1) Diagnosis and risk control
Posterior enamel fracture is rarely “just a chip”. It often comes with marginal breakdown, weakened cusps, and proximal issues (food impaction / open contact). The goal is biomechanical rehabilitation, not simply “closing the hole”. Posterior composite longevity is strongly linked to case selection, cavity size, occlusal load, and execution quality.
Why it matters: long-term data shows posterior composites can perform very well, but failures rise with larger restorations and poor margin/contact control.
References: Opdam et al.; Demarco et al.
2) Rubber dam isolation (non-negotiable)
Rubber dam was placed before any definitive steps. Adhesive dentistry is moisture-sensitive; contamination reduces bond quality and increases risk of marginal staining, post-op sensitivity, and early breakdown.
Clinical tip: clamp stability + floss ligatures + teflon/caulking as needed. Your “bonding field” should look like a controlled laboratory.
References: Van Meerbeek et al.; Pashley et al.
3) Pre-wedge and contact strategy (before cutting more)
Before aggressive refinement, pre-wedging helps:
- protects the papilla
- slightly separates teeth (improves final contact)
- creates a better cervical seal for the matrix
This is one of the simplest ways to avoid the classic Class II disaster: flat contour + weak contact.
References: (Sectional matrix/contact literature and clinical consensus) Loomans et al.; El-Mowafy et al.
4) Conservative caries removal and margin evaluation
Remove unsupported enamel and compromised tissue conservatively. If a deep cervical margin is present, either:
- manage with careful matrix/wedge adaptation, or
- consider margin elevation if indicated (only when isolation and seal are achievable).
The priority is a clean, sealable margin.
References: Magne & Spreafico (biomimetic principles); Van Meerbeek et al.
5) Matrixing: sectional matrix + ring = anatomy, not “a wall”
A sectional matrix system with a separation ring was used to rebuild:
- a tight contact
- correct emergence profile
- proper proximal convexity
Non-negotiable checks before curing the wall:
- wedge fully seated, no rocking
- matrix burnished at contact zone
- ring stable and not distorting the band
References: Loomans et al.; El-Mowafy et al.
6) Adhesive protocol (selective enamel etch + controlled bonding)
A predictable posterior protocol is:
- Selective enamel etch (phosphoric acid on enamel only)
- Dentin bonding with a proven adhesive strategy
Selective etching improves enamel seal while reducing the technique sensitivity and post-op issues that can occur with aggressive dentin etching in some scenarios.
References: Van Meerbeek et al.; Perdigão.
7) Build the proximal wall first (contact is created here)
This is the “restorography” mindset: rebuild anatomy in the correct order.
Step: Place a thin increment to create the proximal wall and cure thoroughly.
Once the wall is stable, you convert the case into a simple Class I, which dramatically improves control of anatomy and shrinkage vectors.
References: Ferracane (composite behavior); Davidson & de Gee (shrinkage stress concept)
8) Dentin core and anatomy: incremental layering to control stress
Posterior composites shrink. You don’t “avoid” shrinkage, you manage it:
- small increments
- proper curing
- anatomical layering (not bulk dumping)
This reduces polymerization stress and improves marginal integrity over time.
References: Ferracane; Davidson & de Gee.
9) Occlusal morphology: function first
Rebuild cusp-fossa relationships with functional anatomy. Avoid heavy centric stops on fresh composite if the tooth is structurally compromised.
Finish line: the restoration should look good, but more importantly it should load well.
References: Magne & Spreafico; Demarco et al.
10) Finishing, polishing, and verification
- Remove the matrix, check contact with floss (snap + resistance)
- Adjust occlusion with thin paper (centric + excursions)
- Polish to reduce plaque retention and staining
- If available: photo documentation and a post-op bitewing for proximal seal/contact verification
References: Heintze & Rousson (performance factors); Demarco et al.
Key takeaway
Posterior rehabilitation becomes predictable when you control three things:
- isolation
- contact management
- adhesive execution
That’s how fractured enamel turns into a stable, functional restoration.
References (selected)
- Opdam NJM, van de Sande FH, Bronkhorst E, et al. Longevity of posterior composite restorations: systematic review/clinical data highlighting restoration size and risk factors. J Dent / Dent Mater (multiple key publications).
- Demarco FF, Corrêa MB, Cenci MS, Moraes RR, Opdam NJM. Longevity of posterior composite restorations: systematic review and meta-analysis. J Dent. 2012.
- Van Meerbeek B, Yoshihara K, Yoshida Y, Mine A, De Munck J, Van Landuyt KL. State of the art of adhesive dentistry and bonding effectiveness. Dent Mater (major reviews, incl. 2011+).
- Pashley DH, Tay FR, Breschi L, et al. Dentin bonding mechanisms and durability (hybrid layer, MMPs, water sorption). J Dent Res / Dent Mater (key reviews).
- Perdigão J. Contemporary adhesive systems and strategies (etch-and-rinse vs self-etch vs selective etch; universal adhesives). J Adhes Dent / Oper Dent (multiple reviews).
- Ferracane JL. Resin composite behavior, polymerization, stress, wear, and clinical implications. Dent Mater (classic and later reviews).
- Davidson CL, de Gee AJ. Polymerization contraction stress: concept and clinical relevance. J Dent Res / Dent Mater (foundational work).
- Heintze SD, Rousson V. Clinical performance of direct composite restorations (factors influencing failure). J Adhes Dent / Clin Oral Investig (systematic reviews).
- Loomans BAC, Opdam NJM and colleagues. Matrix systems, proximal contact quality, and Class II composite outcomes. J Dent / Oper Dent (key clinical/experimental papers).
- El-Mowafy O and colleagues. Sectional matrix techniques and contact tightness in posterior composites. Oper Dent / J Can Dent Assoc (clinical evidence).
- Magne P, Spreafico R. Biomimetic restorative principles for posterior teeth, crack/fracture management, and conservative reinforcement. (Textbook + peer-reviewed concepts widely cited).
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