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Custom rings reloaded, updates and indications

Since its introduction by Jordi Manauta in 2013, the custom rings technique enjoys unparalelled popularity among restorative dentists. We see many cases in social media and publications with custom rings used, what demostrates the effectiveness and simplicity of this technique. However, we also see some cases that could have been solved with less effort as well, hence it is important to emphasize the indications and limitations of the custom rings.

As many of us are using these customized rings on a daily basis, the members of StyleItaliano are constantly working to develop and improve the use of this technique.

Another aspect of this article is to give the reader an update of the fabrication steps. The current improvements are based on the work of Jordi Manauta and co-workers and the use of the MyCustomrings kit.

The author wishes to thank Jordi Manauta for his precious collaboration, his constant help and support in professional development.

style italiano styleitaliano dentistry

Fig.1
The MyCustomRings set contains everything you need to achieve perfect approximal surfaces.
Original picture curtesy of Paulo Monteiro.

style italiano styleitaliano dentistry

Fig.2
The basis for the custom ring is the conventional sectional matrix ring, in this case the Polydentia MyRing Classico.

style italiano styleitaliano dentistry

Fig.3
First we need to prepare the ring, cover the feet with flowable resin (MyCustom Resin).

style italiano styleitaliano dentistry

Fig.4
Then I light cure the resin.

style italiano styleitaliano dentistry

Fig.5
The feet of the ring are evenly covered with resin, allowing a better adaptation to the approximal surfaces.
If we have more rings, then one can be prepared like this, so I can save time during the actual treatment.

style italiano styleitaliano dentistry

Fig.6
TIP 1: Start to do the custom ring after seating of the rubber dam. This way, positioning of the ring with the matrix will be easier.
TIP 2: Isolate the approximal surface with a water soluble gel to ensure easy detachment of the custom ring from the tooth.

style italiano styleitaliano dentistry

Fig.7
If necessary, you can easily brake the wedge with tweezers to have the perfect size.

style italiano styleitaliano dentistry

Fig.8
Sometimes a reduced wedge ensures easy seating of the ring.

style italiano styleitaliano dentistry

Fig.9
Leave the wedge in place and inject some resin on the approximal tooth surface. Make sure to capture the whole approximal area. Do not polimerize the resin yet!

style italiano styleitaliano dentistry

Fig.10
Seat the ring into the flowable resin. Ensure the best possible seating by adjusting the ring gently with your hands.

style italiano styleitaliano dentistry

Fig.11
Add some extra resin if needed And polimerize everything together. After this, gently remove the ring from the tooth.

style italiano styleitaliano dentistry

Fig.12
The finished custom ring, with a perfect copy of the approximal surfaces. This ring can ensure a proper adaptation of the matrix also at the axio-approximal cavity walls, replicating the original approximal surface and save time at the finishing phase.
TIP 3: If necessary, you can adapt the ring faces fith a bur or disc.

style italiano styleitaliano dentistry

Fig.13
Keep the ring on the forceps, with the ring faces separated, to avoid damage of the custom ring faces.

style italiano styleitaliano dentistry

Fig.14
Case No. 1
Approximal caries in tooth no. 26, a typical indication for custom ring.
Indications for custom ring
A custom ring is useful every time we have a wide approximal box extending vestibular and oral from the contact area. It is especially helpful in the upper premolar and molar area, where we can capture and replicate the asymmetric approximal surfaces. These would be difficult to reproduce with conventional sextional matrix systems.
Contraindication: there is no use for a custom ring in case of narrow approximal cavities, where the individual resin index would not reach the cavity vertical margins.

style italiano styleitaliano dentistry

Fig.15
Pre-wedging after seating of the rubber dam.
The suggested width of the cavity is big, so a custom ring can help us.

style italiano styleitaliano dentistry

Fig.16
Some resin added to the approximal surfaces.

style italiano styleitaliano dentistry

Fig.17
The custom ring is finished before the start of preparation.

style italiano styleitaliano dentistry

Fig.18
Opening of the cavity.

style italiano styleitaliano dentistry

Fig.19
The cavity is cleaned and checked with caries detector die.

style italiano styleitaliano dentistry

Fig.20
A suitable matrix is chosen and inserted, the custom ring is seated. In this case, slight modification of the ring was necessary before a perfect fit could be achieved.

style italiano styleitaliano dentistry

Fig.21
After the adhesive procedure, the cavity base is lined with flowable composite and the approsimal wall is built up first with a body shade composite (centripetal build up).

style italiano styleitaliano dentistry

Fig.22
TIP 4: You can remove the ring and matrix after polimerisation of the approximal wall, this ensures a better view and access. Leaving the wedge in place prevents bleeding.

style italiano styleitaliano dentistry

Fig.23
Frontal view of the completed approximal ridge.

style italiano styleitaliano dentistry

Fig.24
After this stage, the rest of the approximal box is filled with bulkfill material, and the occlusal anatomy is modeled with suitable instruments and a body shade composite.
It is clearly visible, that the excess on the approximal surface is minimal, we will barely need any finishing.

style italiano styleitaliano dentistry

Fig.25
The restoration after initial finishing and polishing.

style italiano styleitaliano dentistry

Fig.26
One week post-op view of the restoration.

style italiano styleitaliano dentistry

Fig.27
One week post-op view of the restoration.

style italiano styleitaliano dentistry

Fig.28
Case No. 2
In this case the suspected width of the approximal cavity box does not exceed the flat contact area, so a custom ring is not indicated.
Initial situation. Old restorations in teeth 35 and 36, secondary caries distal 35.

style italiano styleitaliano dentistry

Fig.29
The operatory field is isolated with rubber dam.

style italiano styleitaliano dentistry

Fig.30
Old restorations removed. The neighbouring approximal surfaces are protected with a special wedge.
The remnant of the old cavity liner is visible.

style italiano styleitaliano dentistry

Fig.31
Extension of the approximal box before finishing and caries removal.

style italiano styleitaliano dentistry

Fig.32
Cavities cleaned and the margins are finished.

style italiano styleitaliano dentistry

Fig.33
Matrix placed. Please note the good seal of the matrix by placing the MyRing Classico without customized faces as well.

style italiano styleitaliano dentistry

Fig.34
After selective etching of the enamel for 30sec, a sponge with 2% CHX is placed in the cavities for 1 minute to reduce MMP activity. This is followed by application of a simplified adhesive.

style italiano styleitaliano dentistry

Fig.35
Cavity depths are measured with the Posterior Misura instrument. This ensures 1.5 mm space for the final increment. If the cavity does not reach this depth, no dentin mass is placed, the morphology can be built up by body or bulkfill material.

style italiano styleitaliano dentistry

Fig.36
In case of tooth 36, a thin layer of flowable bulkfill material was placed on the base of the cavity to leave sufficient space for final layer.

style italiano styleitaliano dentistry

Fig.37
Approximal ridge build up with the Posterior Misura instrument.

style italiano styleitaliano dentistry

Fig.38
Matrix and ring removed, wedge left in place.

style italiano styleitaliano dentistry

Fig.39
The premolar restoration is finished.

style italiano styleitaliano dentistry

Fig.40
The lingual cusps of the molar are built up together, followed by the buccal cusps (2 in this case).

style italiano styleitaliano dentistry

Fig.41
Finished molar restoration.

style italiano styleitaliano dentistry

Fig.42
A minimal stain was used for the restorations to give the illusion of depth and a natural look.
This step is not necessary, in this case it took about 5 minutes.

style italiano styleitaliano dentistry

Fig.43
The restorations after initial finishing.

style italiano styleitaliano dentistry

Fig.44
Polished restorations after removal of rubber dam and occlusal check.

style italiano styleitaliano dentistry

Fig.45
Restorations 1 week post op.

Conclusions

The custom rings is until now the best and only technique to copy the original approximal surfaces of the teeth to be restored. Prerequisite for the use of this technique is that the proximal surfaces should be present and enamel should be intact, so that it can be copied. It has especially good use in cavities with wide proximal boxes. In these cases, a more difficult situation can be solved with a simple and reliable tool, saving time both at the matrix placement and the finishing stage.

However in cases with narrow approximal box, where the customized part does not reach the cavity margins, similar results can be achieved with conventional simple rings as well.

Last but not least, in those situations in which the approximal surface does not have proper anatomic contour at the beginning, mainly due to previous restorations, iatrogenic damage during previous restorative procedures or defective shape, we do not have a surface to copy. In these cases, we can use other rings with prefabricated anatomic ring faces.

Bibliography

1. Bichacho N. The centripetal build-up for composite resin posterior restorations. Pract Periodontics Aesthet Dent. 1994 Apr;6(3):17-23;

2. Alleman D, Magne P. A systematic approach to deep caries removal end points: The peripheral seal concept in adhesive dentistry. Quintessence Int. 2012 March.

4. Heintze SD, Rousson V. Clinical effectiveness of direct class II restorations – a meta-analysis. J Adhes Dent. 2012 Aug;14(5):407-31.

7. Van Meerbeek B, Yoshihara K, Yoshida Y, Mine A, De Munck J, Van Landuyt KL. State of the art of self-etch adhesives. Dent Mater. 2011 Jan;27(1):17-28.

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