Don’t miss the bigger picture when managing proximal cavities

In everyday restorative dentistry, we all have to manage common class I, II and MOD cavities. Although some of these are more complex than others, the most important thing is to have a good protocol, good tools, and a few tricks up your glove.

style italiano styleitaliano old infiltrated composite filling

Fig.1
This patient came to the office in order to manage the interproximal space between 25 and 26 because of a secondary carious lesion on 25.

style italiano styleitaliano rubber dam isolation before cavity preparation

Fig.2
Each time you have to manage the cleaning of a tooth before restoration, isolating with the rubber dam really helps with better contrast thus improving our control over details, and of course guarantees good adhesion.

style italiano styleitaliano removal of the old composite filling with pre wedging

Fig.3
Some steps of cleaning:
– Choose and insert the wooden wedge
– Start to clean from the center of the old restoration towards the distal wall

style italiano styleitaliano cavity cleaning

Fig.4
– Look for healthy enamel
– Clean and polish the dentin

style italiano styleitaliano modifying and polishing the tooth adjacent to the cavity

Fig.5
Pay attention to the adjacent tooth: in order to guarantee a good contact point, you may have to modify the adjacent wall in order to place the matrix correctly.

style italiano styleitaliano occlusal view to check accommodation of the matrix

Fig.6
A good way to observe this aspect is to see the teeth in lateral view (fig. 5) and with a good occlusal view; this step is very useful to pre-visualize if a matrix would fit without getting deformed.

style italiano styleitaliano adhesive steps

Fig.7
After placing the matrix and the ring (Polydentia), the enamel is etched and then the cavity bonded (iBond from Kulzer).

style italiano styleitaliano flowable composite on the enamel margin

Fig.8
Managing the deepest point with a flowable composite can be very useful. In this case Kulzer Venus Bulk Flow ONE was used to fill the point where the enamel margin meets the matrix.

style italiano styleitaliano kulzer venus Bulk flow ONE one-shade bulk filling composite
style italiano styleitaliano kulzer venus Bulk flow ONE one-shade bulk filling composite
style italiano styleitaliano building of the proximal wall

Fig.9
With OMC dentin from Kulzer the interproximal wall was built.
Thanks to the LM Arte kit you can place the composite with the Modella instrument in the cavity, and then pack it using the Condensa instrument. The Misura Posterior can then be used to even the height of the proximal ridge.

style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
style italiano styleitaliano details of the proximal wall

Fig.10
Then the Modella and the Fissura instruments can be used to improve the inclination of the coronal margin.

style italiano styleitaliano proximal build up after curing with flattened matrix

Fig.11
After the first curing cycle, opening the matrix can be useful to get better curing with a second cycle.

style italiano styleitaliano occlusal modeling

Fig.12
Now you can manage the I class with the A2 composite Venus Pearl from Kulzer:
– palatal side first
– buccal side second

style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
style italiano styleitaliano first polishing tip by kulzer

Fig.13
Good polishing is mandatory. Here the pink rubber polisher from Kulzer was used first.

style italiano styleitaliano kulzer second polishing tip

Fig.14
Followed by their grey polisher.

style italiano styleitaliano check up after restoration and rubber dam removal

Fig.15
Check after rubber dam removal.

style italiano styleitaliano two week checkup after upper molar restoration

Fig.16
Two-week recall and occlusal check.

Conclusions

Even when managing simple cases like this one, an operative protocol is necessary to reach a satisfying final result.

You can apply this operative protocol to more difficult cases too, and you can discover that every case, the complex ones too, are made easier when broken down into easier single steps. If these steps are clear, the game is easy.

As a review of this case, here are the highlights to keep in mind:

1- take a picture before, always!

2- put the rubber dam, always!

3- put the wedge before opening the cavity in order to create a custom wedge!

4- If you have to rebuild both proximal walls, be careful: destroy and rebuild one by one! You may think that you are wasting your time, but I assure you, occlusal check will save you tons! The contacting wall really deserves a thorough look to understand the height of the one you need to rebuild. The Misura Posterior from the LM Arte kit is the tool you want to use for this purpose, but you need that adjacent tooth to be whole.

5- Before restoring a proximal wall, cleaning and modifying (if needed) the adjacent tooth’s surface is a must. The gingival margin almost always has a lot of plaque sticking onto it, and the shape and inclination should be made ideal before proceeding to your restoration. You can use a SofLex disc and/or EVA reciprocating handpiece to ensure a good contact point.

6- Use a good matrix system to guarantee a correct contact point (Polydentia ONE)

7- Use different types of composite to help you do different parts of a restoration. Venus Bulk Flow ONE flowable composite from Kulzer is perfect for sealing the space where the margin meets the matrix because of its adaptation and fluency, OMC Venus Pearl From Kulzer for the interproximal wall is perfect because of its opacity, A2 Venus Pearl for the occlusal part is the right composite for its handling.

8- Don’t forget that, if a composite has good handling it’s due to its properties, of course, but also to the tools you use to handle it! The LM Arte kit from is brilliant to help you create a natural anatomy.

9- The polishing step is fundamental, and the Kulzer pink and grey tips, used in this case, give the restoration a naturally shiny aspect.

The message of this article is to follow a valid protocol, also when dealing with simple cases, in order to increase the predictability of restorations over time.

Bibliography

1.Manauta J, Salat A. Layers, An atlas of composite resin stratification. Quintessence Publishing, 2012

2.Opdam NJ, van de Sande FH, Bronkhorst E, Cenci MS, Bottenberg P, Pallesen U, Gaengler P, Lindberg A, Huysmans MC, van Dijken JW. Longevity of posterior composite restorations: a systematic review and meta-analysis. J Dent Res. 2014 Oct;93(10):943-9

3.Dietschi D, Spreafico R. Restauri adesivi non metallici. Attuali concetti per il trattamento dei denti posteriori. Scienza e Tecnica Dentistica Passirana di Rho, 1997; br., pp. 215

4.Magne P. IDS: Immediate Dentin Sealing (IDS) for tooth preparations.  J Adhes Dent. 2014 Dec;16(6):594. doi: 10.3290/j.jad.a33324

RELATED CASES

style italiano styleitaliano direct anterior restoration class IV restoration class 4 composite restoration single shade direct restoration

Class IV using just a single shade: dream or reality?

Explore the masterful craftsmanship of Dr. Edoardo Yang Fossati as he creates stunning Class IV anterior composite restorations using only a single shade.