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Clinical Application of the Closed Sandwich Technique in a Class II Restoration

Case Presentation
A 22-year-old patient presented with extensive decay in several teeth. As a professional rower, her heavy use of sports drinks for electrolyte and hydration management during training had led to this high-risk caries status. On advice, she has replaced the sports drinks with plain water and now uses solid sources to meet her electrolyte and energy requirements. To manage the biofilm imbalance and help in the reestablishment of a healthy biofilm, she has also commenced a treatment program using the CariFree (Oral BioTech) range of pH elevation products.
Figure 1Cavity prepared for restoration with 2 V3 Tab-Matrices stabilized gingivally with Wave-Wedges and retained with a premolar (yellow) V3 separator ring on the mesial and a molar (green) V3 separator ring on the distal.

Procedure
The patient requested a non-amalgam restoration to restore a second premolar that had an asymptomatic, deep lesion close to the pulp. Because of the proximity of the lesion to the pulp, the option of a closed glass ionomer cement (GIC) sandwich, composite restoration was chosen because of the potential remineralization effects associated with GIC placed on deep affected dentin close to the pulp. The second premolar had an asymptomatic, deep lesion, close to the pulp. When the decay had been removed, a 2-mm wide dentin periphery was established and the decision was made to leave a thin layer of affected dentin directly over the pulp horn to avoid potential exposure. Auto-cure GIC creates a sound seal to dentin and, by successfully isolating the depths of the lesion, this techGraeme Milicich, BDS Private Practice Hamilton, New Zealand E-mail: gwmilicich@xtra.co.nz Web site: www.advancedental-ltd.com

nique helps prevent the risks associated with pulpal exposures that often occur when trying to establish a totally sound dentin base in the region of the pulp horn.1, 2 Working with an Isolite (Isolite Systems), sectional V3 Tab-Matrices (Triodent) were placed. The appropriate Triodent Wave-Wedges were inserted to adapt the gingival margins of the matrices to the cavity margins. The pintweezer tabs on the occlusal section of the matrices were then bent onto the occlusal surface of the adjacent teeth to improve visibility. The matrices were stabilized with molar (green) and premolar (yellow) Triodent V3 separator rings and the contact points burnished with a ball burnisher (Figure 1). The occlusal surfaces of the V3 Ring tines have a low profile and sit flush with the occlusal surfaces of the teeth, improving access and visibility. The closed sandwich restoration techniquea layer of GIC completely encased by composite on the occlusal and interproximal surfaceswas chosen to provide a sound, impermeable seal to isolate the deep, affected dentin. Fuji IX GP Extra (GC America, Inc) was used to replace the lost deep dentin and to layer this, with Gradia Direct (GC America, Inc), bonding the 2 layers of the restoration with
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Figure 2Initial phase of the restoration technique. The enamel has been selectively acid-etched and the dentin conditioned with polyacrylic acid. After rinsing, autocure GIC (Fuji IX Extra) has been placed onto the dentin and manipulated into place with a microbrush dipped in Fuji Lining. The GIC is not placed on the proximal box margins. Figure 3Placement of the first increment of composite following the placement of an SE Bond (GBond) and an initial thin layer of flowable.

Figure 4Completed restoration with good marginal ridge contours and sound, wide contact points.

G-BOND (GC America, Inc), a self-etching bonding agent. The alternative technique is to do an open sandwich restoration that leaves GIC exposed in the base of the proximal boxes; however, in high-risk caries individuals with an acidic biofilm, there is a risk that, in the long term, the GIC will begin to dissolve, just like the enamel did in the first place. By enclosing the GIC in the interproximal zone, this dissolution risk is negated, while retaining the advantages of GIC in the depths of the cavity where it is covering the affected zone, aiding in remineralization and avoiding the risk of pulp exposure. The closed sandwich technique in this restoration involved a selective etching concept to create the best bonds possible to both dentin and enamel. The enamel margins were selectively etched with 37% phosphoric acid gel to provide the best bond possible to enamel, and the dentin was conditioned with 10% polyacrylic acid to create the best GIC bond possible. The Fuji IX GP Extra was carefully injected and manipulated onto the dentin with a microbrush dipped in Fuji Lining (Figure 2) and the Fuji Lining was polymerized with an LED curing light. GBOND was then liberally painted over the etched enamel and GIC surfaces. Any dentin that was not covered by the GIC was also effectively bonded at this stage with the GBOND. The G-BOND was air-thinned until there was no movement in the bonding layer, then polymerized. A thin layer of radiopaque flowable was then placed over all the internal surfaces and proximal box margins and polymerized. Composite (Gradia Direct) increments were then placed using the 0.5 C-factor concept. The concept is to ensure each increment of composite is only touching one wall and the floor of the restoration.3-5 This can be done by placing a 1.5-mm thick layer of composite onto the GIC and then sectioning it with a flat-bladed plastic instrument, with the sectioning occurring along the fissure pattern of the tooth (Figure 3). When composite is placed using this concept, polymerization shrinkage tends to occur toward the tooth, reducing polymerization stresses that may cause debonding of the composite. Removal of the rings, matrices, and wedges revealed a restoration that required minimal finishing: just a film of bonding agent on the tooth and some thin flash in the marginal ridge and embrasure regions. The completed restoration had good marginal ridge contours and sound, wide contact points (Figure 4).
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Conclusion
The usage of the Triodent V3 separator ring system makes the creation of sound, anatomical contact points a consistent and predictable event when placing posterior composites.
Disclosure: Dr. Milicich is a consultant for GC Asia, Triodent, SDI, and Henry Schein Shalfoon. He also holds stock in NobelBiocare.

2. Milicich G. A resin impression SEM technique for examining the GIC chemical fusion zone. J Microsc. 2005;217(Pt 1):44-48. 3. Bouschlicher MR, Vargas MA, Boyer DB. Effect of composite type, light intensity, configuration factor and laser polymerization on polymerization contraction forces. Am J Dent. 1997;10:88-96. 4. Versluis A, Tantbirojn D, Douglas WH. Do dental composites always shrink toward the light? J Dent Res. 1998;77: 1435-1445. 5. Versluis A, Douglas WH, Cross M, et al. Does an incremental filling technique reduce polymerization shrinkage stresses? J Dent Res. 1996;75:871-878.

References
1. Ngo H, Mount GJ, Peters MC. A study of glass-ionomer cement and its interface with enamel and dentin using a lowtemperature, high-resolution scanning electron microscopic technique. Quintessence Int. 1997;28:63-69.

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