Managing multiple contact points, step by step

It is difficult to manage multiple contact points in class II cavity restorations. During such procedures, clinicians usually choose an indirect restoration protocol, as workflow is much easier for the technician rather than for dentists. The disadvantage of this method is that you cannot accomplish the work in just one visit. But, if we know the proper way to manage multiple restorations we can achieve a good result even with direct techniques. The main advantage of direct restorations in these cases is the short time needed to get satisfactory results. In this article we will discuss how to make it in a more advanced way.

styleitaliano style italiano second class cavity restoration contact point matrix ring wedge rubber dam stain compobrush fissura instrument single appointment dentist tooth

Fig.1

Just after we took a picture and an x-ray of the working area, we noticed that we have secondary carious processes going on under all previous restorations.
styleitaliano style italiano second class cavity restoration contact point matrix ring wedge rubber dam stain compobrush fissura instrument single appointment

Fig.2

The first step is isolation with the rubber dam. It’s better to place the dam and then start preparation. The most important part is to perform a correct preparation for the future filling. This means we have to carefully prepare and polish all margins to round all internal angles; to precisely remove caries, a diamond bur must be used for enamel and a carbide bur for dentin, then sandblasting with aluminum oxide (27 micron particles) is carried out. Interproximal polishing with strips or discs is advised.
styleitaliano style italiano second class cavity restoration contact point matrix ring wedge rubber dam stain compobrush fissura instrument single appointment dentist tooth

Fig.3

After we complete the restorations, we proceed to step 2: matrix placement.
TIP: If we want all our restorations to have a natural shape, it is strongly suggested to place the matrices at one time. For the best contact points we have to choose the thinnest and soft matrices. In this case we used the Polydentia matrix system.
styleitaliano style italiano second class cavity restoration contact point matrix ring wedge rubber dam stain compobrush fissura instrument single appointment dentist tooth

Fig.4

One by one, we start to restore all contact points. Just after restoring the first tooth (distal wall before, mesial after) we can remove the matrix around the restored tooth.
styleitaliano style italiano second class cavity restoration contact point matrix ring wedge rubber dam stain compobrush fissura instrument single appointment dentist tooth

Fig.5

First, we place a Bulk fill composite as a thick adhesive protection layer and then we proceed to layering of the final mass with an A3 Body shade. A drop of brown stain can give a twist to the natural appearance of your restorations: to precisely swipe it in the sulci, the LM Arte Fissura instrument is ideal before brushing it with CompoBrush (Smile Line)
styleitaliano style italiano second class cavity restoration contact point matrix ring wedge rubber dam stain compobrush fissura instrument single appointment dentist tooth

Fig.6

Now we have to place wedge and ring in order to restore the first molar. What is the main goal of the ring? First, it presses the matrix onto the proximal walls, and second, it creates forces that enhance separation between teeth. This will create higher pressure on the adjacent tooth and, after removing the wedge and ring, we will have a tight contact point.
styleitaliano style italiano second class cavity restoration contact point matrix ring wedge rubber dam stain compobrush fissura instrument single appointment dentist tooth

Fig.7

Final layering of the A3 body shade in first molar
styleitaliano style italiano second class cavity restoration contact point matrix ring wedge rubber dam stain compobrush fissura instrument single appointment dentist tooth

Fig.8

Stain application with CompoBrush (Smile Line) on the 1st molar.
styleitaliano style italiano second class cavity restoration contact point matrix ring wedge rubber dam stain compobrush fissura instrument single appointment dentist tooth

Fig.9

All molars are restored and now it’s all about finalizing the last premolar.
styleitaliano style italiano second class cavity restoration contact point matrix ring wedge rubber dam stain compobrush fissura instrument single appointment dentist tooth

Fig.10

Again we placed wedge, matrix and ring. We start by restoring the distal wall of the second premolar with A3 body shade and the same shade we will use for the restoration of the surface area.
styleitaliano style italiano second class cavity restoration contact point matrix ring wedge rubber dam stain compobrush fissura instrument single appointment dentist tooth

Fig.11

All these 4 restorations could take no more than 3 hours, polishing and occlusal adjustments included.
styleitaliano style italiano second class cavity restoration contact point matrix ring wedge rubber dam stain compobrush fissura instrument single appointment dentist tooth

Fig.12

Final view of restored teeth after rubber dam removal. It is useful to warn the patient that the rehydration process takes time, so the color might not look good at a first glance, but then get to be just mimetic.
styleitaliano style italiano second class cavity restoration contact point matrix ring wedge rubber dam stain compobrush fissura instrument single appointment dentist tooth

Fig.13

Perfectly integrated color, already after 1 day rehydration.
styleitaliano style italiano second class cavity restoration contact point matrix ring wedge rubber dam stain compobrush fissura instrument single appointment dentist tooth

Fig.14

X-ray shows perfect adaptation of the margins of our restorations.

Conclusions

As a conclusion of the article we have to stress again how important it is to recreate a proper shape and contact points when restoring teeth. Three are the things that can really make this procedure predictable and durable:
– a good and thin matrix system, which allow modeling of the matrix itself and good adaptation
– tough rings, that’ll adapt the matrix in an effective way
– wooden wedges, for an efficient separation of teeth

Bibliography

Radhika M, Sajjan GS, Kumaraswamy BN, Mittal N. Effect of different placement techniques on marginal microleakage of deep class-II cavities restored with two composite resin formulations. J Conserv Dent. 2010;13:9–15.
Caixeta RV, Guiraldo RD, Kaneshima EN, Barbosa AS, Picolotto CP, Lima AE, Gonini Júnior A, Berger SB. Push-Out Bond Strength of Restorations with Bulk-Fill, Flow, and Conventional Resin Composites. ScientificWorldJournal. 2015;2015:452976.
Monterubbianesi R, Orsini G, Tosi G, Conti C, Librando V, Procaccini M, Putignano A. Spectroscopic and Mechanical Properties of a New Generation of Bulk Fill Composites. Front Physiol. 2016 Dec 27;7:652.

Manauta J. Back to Basics: Bulk and body. Styleitaliano
Marchetti G. Single shade makeover. Styleitaliano
Manauta J., Salat A. Layers, An atlas of composite resin stratification. Quintessence 2012.
Akhundov M. Bulk and body – 2 years recall. Styleitaliano