“Stamp” Technique to Recreate Accurate Occlusal Topography for Direct Composite Posterior Restorations

Posterior composite restorations are frequently performed in clinical practice.¹ Whether for the replacement of a failed metal-based restoration or the treatment of a carious lesion, modern tooth-colored composite materials are able to meet the esthetic demands of patients while helping to preserve tooth structure in adherence with the concepts of today's minimally invasive dentistry.^2,3

Placing direct composite restorations using an incremental layering technique, however, challenges clinicians to manually achieve the precise occlusal contact and contour complexities necessary to restore the patient's preoperative occlusal anatomy and function. Failure to do so, even if slightly, can result in patient discomfort and, if left untreated, lead to serious functional and structural oral issues.^4,5 For many clinicians, having to perform manual adjustments to re-establish proper occlusal contours and contacts post-composite placement can be frustrating and time-consuming.⁶

The case presented in this article demonstrates an occlusal index, or "stamp," technique that may be used to predictably and efficiently recreate accurate occlusal topography for direct composite posterior restorations.

Reconstructing Preoperative Occlusion

The primary objective of any direct restorative procedure is to restore the form, fit, and function of a tooth compromised by disease. For chairside restoration of disease-compromised dentition in both the anterior and posterior regions, tooth-colored composites have become the universal choice of clinicians for their ability to mimic the esthetics of natural teeth and allow for the removal of minimal tooth structure.⁶ However, unlike indirect restorative treatment modalities where contact, contours, and occlusion are controlled through what is captured via a digital intraoral camera or traditional impression-taking, the direct composite restorative method can pose significant challenges for the clinician-especially in posterior cases-when attempting to reconstruct freehand the exact preoperative occlusal position, proximal contacts, and contours of the restored tooth.⁷ This process can be time-consuming and technique-sensitive and may result in imprecise duplication of the patient's tooth form and occlusion. Although clinicians can use a technique to capture pretreatment occlusal contact points using articulation paper, then commit the form and height to memory for rebuilding with composite during the treatment process, this approach still may result in over- or under-restored surfaces, leading to occlusal discrepancies.

These discrepancies only come to light when patients are asked to open, close, and chew after completion of the direct composite treatment. Keenly aware of whether or not their teeth fit together properly when asked to perform these functions, patients         may report that they are unable to fully close their jaw and/or feel some obstructive interference while moving their lower jaw in a chewing motion. Thus, what began as a routine treatment protocol now becomes more complex as the clinician embarks on the often tedious process of using articulation paper and a bur to return the patient to preoperative occlusal function. Even if the patient reports proper occlusal fit, once home and no longer under the influence of anesthesia, he or she may encounter occlusal problems and return to the practice for further adjustments.

A method known as the stamp technique is a clinical procedure that is intended to reproduce the precise occlusal topography for direct composite resin restorations and minimize postoperative adjustments. The technique involves fabricating an index that copies the occlusal anatomy of the tooth prior to treatment and uses that fabricated index to impress the captured occlusal anatomy onto the final composite increment before curing, thus creating a positive replica of the pre-prepared occlusal topography.^8-12 The technique is demonstrated in the following case presentation.

Case Report

A 32-year-old male patient was referred to the author's practice for treatment of a tooth in his maxillary left quadrant that had become sensitive to cold and sweets. Upon probing, Class 1 occlusal caries was discovered in the central fossa of the occlusal grooves on tooth No. 14 (Figure 1). Bite-wing x-rays were taken to ascertain the extent of the carious lesion and ensure it did not involve the tooth pulp. The patient was informed of the diseased tooth, and the clinician explained that a direct resin composite treatment was needed to relieve the pain and sensitivity and to restore the function and esthetics of the tooth. The patient agreed and was scheduled for treatment the following week.

Because the preoperative occlusal anatomy of tooth No. 14 was intact and would not be affected by the restorative process, it was decided that the stamp technique could be used to efficiently restore the patient to preoperative occlusal function. Although creating a composite "stamp" impression of the patient's preoperative occlusal anatomy adds time to the front end of the restorative process, the technique is designed to save chairside time at the latter end of the restorative process by minimizing or even eliminating time-consuming postoperative occlusal adjustments. This technique may also be beneficial for Class 2 caries with deep grooves or for creating sectional stamps for diagnostic wax-ups on oral rehabilitation/attrition cases.

Occlusal Stamp Fabrication

The patient was anesthetized, and tooth No. 14 was isolated using a rubber dam and a partially reamed rubber dam clamp (Figure 2). A single coat of a separating agent, in this case petroleum jelly, was applied to the entire surface of the unprepared tooth No. 14 with a microbrush (Micro Applicator, Ultradent, ultradent.com). To create the occlusal stamp index, a flowable bulk-fill composite material (Admira Fusion x-base, VOCO, voco.dental) was applied to the tooth surface (Figure 3). Using a microbrush and slight downward pressure, occlusal characteristics and topical anatomy were captured, creating the necessary details on the occlusal stamp. The composite was light-cured for 20 seconds (Bluephase^®, Ivoclar, ivoclar.com) with the microbrush stem embedded in the composite but not touching any tooth anatomy.

It should be noted that embedding the microbrush stem into the occlusal stamp aids in orienting the stamp onto the final composite layer later when it comes time to impress the patient's preoperative occlusal anatomy. Clinicians can also mark the cured stamp with a black ink dot on the buccal or lingual edge to ensure proper orientation. Once cured, the occlusal stamp is lifted off the tooth (Figure 4).

After creating the occlusal stamp, it should be dried and stored in a clean, dry environment to prevent contamination or distortion. To maintain the shape and stability of the stamp, it can be placed on a small wax ball. Ideally, the stamp should be used within 30 minutes after caries removal to ensure accurate replication.

Caries Removal and Restorative Treatment

A caries detection liquid (Snoop^™, Pulpdent, pulpdent.com) was applied to tooth No. 14 to illuminate areas of carious lesions (Figure 5). Dentin caries was removed from the occlusal aspects of tooth No. 14 using a carbide bur (#557 Straight Carbide Bur, Brasseler USA, brasselerusa.com) and electric handpiece (Forza^™, Brasseler USA) (Figure 6).

The cavity was air-abraded (AquaCare, Velopex International, velopex.com) with 29 microns of aluminous oxide for 20 seconds to remove any remaining decay and bacteria. An etchant (Vococid, VOCO) was applied to the excavated site for 20 seconds on enamel and 10 seconds on dentin and then rinsed thoroughly (Figure 7). This was followed by the application of a universal adhesive (Futurabond U, VOCO) (Figure 8). A single layer of flowable composite (Admira Fusion x-base) was then applied. The final composite layer applied was an omni-chromatic bulk-fill packable composite (Admira Fusion x-tra packable, VOCO). The cavity was overfilled with the bulk-fill composite to receive the occlusal stamp (Figure 9).

A thin strip of Teflon tape was placed over the occlusal surface of the tooth to prevent the occlusal stamp, which would now be utilized, from adhering to the composite (Figure 10). The occlusal stamp was oriented to the tooth and pressed down firmly to impress the preoperative occlusal topography into the composite surface (Figure 11 and Figure 12). Excess composite was easily removed using a modeling tip (OptraSculpt^®, Ivoclar) (Figure 13). Prior to final curing, a tint (Creative Color^® Honey Yellow, Cosmedent, cosmedent.com) was applied for esthetic reproduction of occlusal crevices (Figure 14) and the composite layer was light-cured for 20 seconds. The final restoration was finished and polished (A.S.A.P.^® Polishers, Clinician's Choice, clinicianschoice.com).

The patient was then oriented in the chair to a 45-degree angle, and articulation paper was placed onto the restored site. The patient was then asked to make chewing motions with his jaw. The resulting marks on the restored tooth (Figure 15) revealed a proper cusp fossa relationship with the opposing dentition and, thus, the need for any occlusal adjustments was eliminated.

Conclusion

The occlusal stamp technique provides clinicians with a valuable tool for copying the occlusal anatomy of an unprepared tooth and then transferring that preoperative anatomy back onto the tooth in direct bulk-fill flowable composite Class 1 or 2 restorations. The cost-effective technique helps minimize or eliminate the time-consuming guesswork of manually attempting to restore exact occlusal relationships in chairside bulk-fill restorative cases, saving clinicians valuable chairtime.

About the Author

Dimple Desai, DDS
Private Practice, Newport Beach, California

References

1. Geena MG, Kevin RG. Building proximal contacts and contours in resin composite restorations: a technical report. J Sci Dent.2014;4(1):62-69.

2. Pizzolotto L, Moraes RR. Resin composites in posterior teeth: clinical performance and direct restorative techniques. Dent J (Basel). 2022;10(12):222.

3. Murdoch-Kinch CA, McLean ME. Minimally invasive dentistry. J Am Dent Assoc. 2003;134(1):87-95.

4. Mary G, Jayadevan A. Microbrush stamp technique to achieve occlusal topography for composite resin restorations - a technical report. J Sci Dent.2016;6(2):76-82.

5. Syrop J. Understanding occlusion. Inside Dentistry. 2013;9(9):46-58.

6. Dilley DC, Vann WF Jr, Oldenburg TR, Crisp RM. Time required for placement of composite versus amalgam restorations. ASDC J Dent Child. 1990;57(3):177-183.

7. Raghu R, Srinivasan R. Optimizing tooth form with direct posterior composite restorations. J Conserv Dent.2011;14(4):330-336.

8. Alshehadat SA, Halim MS, Carmen K, Fung CS. The stamp technique for direct Class II composite restorations: a case series. J Conserv Dent.2016;19(5):490-493.

9. Martos J, Silveira LF, Ferrer-Luque CM, Gonzalez-López S. Restoration of posterior teeth using occlusal matrix technique. Indian J Dent Res. 2010;21(4):596-599.

10. Pompeu JG, Morais RC, Ferreira TO, et al. Occlusal stamp technique for direct resin composite restoration: a clinical case report. Int J Recent Sci Res.2016;7(7):12427-12430.

11. Sonkar M, Mahapatra J, Patel A, et al. Perfecting posterior dental simulacrum: unveiling the stamp technique for tooth restoration. Cureus. 2024;16(6):e62640.

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Figures and Images

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Figure 1

Fig 1. The patient presented complaining of sensitivity and pain in a posterior molar when exposed to sweet or cold stimuli. Class 1 occlusal caries was discovered in tooth No. 14.

Figure 2

Fig 2. Tooth No. 14 was isolated.

Figure 3

Fig 3. After application of a separating agent to the unprepared tooth No. 14, a flowable composite was applied to the surface of the tooth and light-cured.

Figure 4

Fig 4. The light-cured occlusal stamp with attached micro handle was lifted off the surface of tooth No. 14.

Figure 5

Fig 5. A caries detection liquid was applied to tooth No. 14 to illuminate areas of carious lesions for removal.

Figure 6

Fig 6. The final preparation after complete caries removal was confirmed.

Figure 7

Fig 7. After air-abrasion of the excavated tooth, an etchant was applied. It was thoroughly rinsed after 20 seconds on enamel and 10 seconds on dentin.

Figure 8

Fig 8. Following the etching and rinsing, a universal adhesive was applied.

Figure 9

Fig 9. After application of a single layer of flowable composite to the site, a bulk-fill composite was applied and overfilled, as shown, to receive the occlusal stamp.

Figure 10

Fig 10. A thin strip of Teflon tape was laid onto the composite surface to prevent the occlusal stamp from adhering to the composite.

Figure 11

Fig 11. The occlusal stamp was correctly oriented to the tooth and firmly pressed onto the tooth surface to impress the preoperative occlusal topography onto the composite.

Figure 12

Fig 12. A view of the tooth after removal of the occlusal stamp.

Figure 13

Fig 13. Excess composite was removed.

Figure 14

Fig 14. A yellow-brown tint was applied to restore the esthetics of tooth No. 14 prior to final curing and polishing.

Figure 15

Fig 15. The final restoration demonstrating the replication of the preoperative occlusion using the stamp technique