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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 en-
ergy requirements.
To manage the biofilm imbalance and help in the
reestablishment of a healthy biofilm, she has also com-
menced a treatment program using the CariFree (Oral
BioTech) range of pH elevation products.
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 cho-
sen because of the potential remineralization effects asso-
ciated with GIC placed on deep affected dentin close to
the pulp.
The second premolar had an asymptomatic, deep le-
sion, close to the pulp. When the decay had been re-
moved, 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 ex-
posure. Auto-cure GIC creates a sound seal to dentin and,
by successfully isolating the depths of the lesion, this tech-
Graeme Milicich, BDS
Private Practice
Hamilton, New Zealand
E-mail: gwmilicich@xtra.co.nz
Web site: www.advancedental-ltd.com
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Figure 1—Cavity
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.
nique helps prevent the risks associated with pulpal ex-
posures 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 Tri-
odent Wave-Wedges were inserted to adapt the gingival
margins of the matrices to the cavity margins. The pin-
tweezer 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 separa-
tor rings and the contact points burnished with a ball bur-
nisher (Figure 1). The occlusal surfaces of the V3 Ring
tines have a low profile and sit flush with the occlusal sur-
faces of the teeth, improving access and visibility.
The closed sandwich restoration technique—a layer of
GIC completely encased by composite on the occlusal and
interproximal surfaces—was 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
Dental Learning / April 2011 1
 Figure 2—Initial G-BOND (GC America, Inc), a self-etching bonding
phase of the restora-
tion technique. The agent. The alternative technique is to do an open sand-
enamel has been se- wich restoration that leaves GIC exposed in the base of
lectively acid-etched the proximal boxes; however, in high-risk caries individ-
and the dentin condi-
uals with an acidic biofilm, there is a risk that, in the long
tioned with polyacrylic
acid. After rinsing, au- term, the GIC will begin to dissolve, just like the enamel
tocure GIC (Fuji IX did in the first place. By enclosing the GIC in the inter-
Extra) has been proximal zone, this dissolution risk is negated, while re-
placed onto the
dentin and manipu- taining the advantages of GIC in the depths of the cavity
lated into place with a where it is covering the affected zone, aiding in reminer-
microbrush dipped in alization and avoiding the risk of pulp exposure.
Fuji Lining. The GIC is
not placed on the
The closed sandwich technique in this restoration in-
proximal box margins. volved a selective etching concept to create the best bonds
possible to both dentin and enamel. The enamel margins
Figure 3—Placement
of the first increment were selectively etched with 37% phosphoric acid gel to
of composite follow- provide the best bond possible to enamel, and the dentin
ing the placement of was conditioned with 10% polyacrylic acid to create the
an SE Bond (GBond)
and an initial thin best GIC bond possible. The Fuji IX GP Extra was care-
layer of flowable. fully injected and manipulated onto the dentin with a mi-
crobrush dipped in Fuji Lining (Figure 2) and the Fuji
Lining was polymerized with an LED curing light. G-
BOND 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 G-
BOND. 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
Figure 4—Completed restoration with good marginal ridge con- restoration had good marginal ridge contours and sound,
tours and sound, wide contact points. wide contact points (Figure 4).

2 Dental Learning / April 2011 www.dentallearning.net

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.
References
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www.dentallearning.net
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3. Bouschlicher MR, Vargas MA, Boyer DB. Effect of com-
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polymerization on polymerization contraction forces. Am J
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