“One stage” direct surgical-restorative approach in extensive class II cavities with subgingival margins

Large Class II cavities often present a cervical step, which, once the decay is removed, extends subgingivally, preventing proper isolation with a rubber dam and therefore correct adhesive procedures. The subgingival position of the margin also does not allow sufficient clinical space to easily perform reconstructive maneuvers related to the restoration of contact surfaces and emergence profiles with the aid of sectional matrices, interproximal wedges, and retainer rings. It is therefore necessary to apically displace the periodontal tissues with a surgical technique in order to restore the correct biologic width (12;13), enable the placement of the rubber dam, and simplify the aforementioned operative phases, allowing the completion of the restoration in the same session with resulting advantages in biological and economic terms. Large-sized cavities present a series of clinical and biological issues, primarily related to the management of anatomy, control of material contraction stress (3), and the reliability of dentin adhesion at the cervical level (4).
However, as described in the literature, it is possible to perform extensive direct restorations that cover cusps using multi-layered techniques with the potential use of composite materials with reduced volumetric contraction (5;6;7;8;9;10;11). The difficulty in achieving good field isolation during surgical procedures can be addressed, as suggested by the authors, by using hydrophilic cellulose-based barriers that help contain the possible passage of organic fluids.
This case describes the clinical procedure.

style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
styleitaliano style italiano large amalgam restoration

The described case is characterized by the presence of an incongruous amalgam restoration with evident signs of leakage.

styleitaliano style italiano xray showing fractured amalgam restoration

The X-ray shows material fracture at the occlusal level and chipping of the cervical enamel.

styleitaliano style italiano isolation with rubber dam

First, the field is isolated placing the rubber dam.

styleitaliano style italiano cavity margin lying below isolation

The old restoration is removed, and the carious tissue thoroughly cleaned. The residual position of the cervical step below the free gingival margin makes it impossible to adequately isolate the field and perform the restorative phases.

styleitaliano style italiano situation before crown lengthening surgery

After removing the rubber dam.

styleitaliano style italiano flap elevation for crown lengthening

The margin is surgically exposed.

styleitaliano style italiano sutured tissues after crown lengthening

The osteoresective surgery aims to restore the correct biologic width (12;13) by positioning the bone crest approximately 2.5 mm apical to the cleaned cervical step.
Sutures are performed using EPTFE.

styleitaliano style italiano hydrophilic cellulose based paste for moisture control

The proposed technique involves the application of a hydrophilic cellulose-based paste.

styleitaliano style italiano isolation of deep margin after crown lengthening

This paste acts as a mechanical barrier to improve the seal provided by the immediate postoperative placement of the rubber dam.

styleitaliano style italiano matrix and wedge placed, unable to properly contour the cavity

Considering the extent of the cavity, the sectional matrix may collapse due to lack of support from the axial walls of the interproximal box, making it difficult to construct an adequate contact surface. Capillary bleeding may also occur.

styleitaliano style italiano curcumefential matrix and ring allow to properly contour large cavity

To overcome this issue, a preformed circumferential matrix with the assistance of a separating ring (Garrison 3D) and a compressive interdental wedge is preferred. This allows adherence to the preparation perimeter on both the cervical step and the axial walls of the box, enabling the construction of a congruent contact area.

styleitaliano style italiano lining of deep cavity with flowable composite

The adhesive phase is performed using a self-etch adhesive and enamel pre-conditioning. A maximum 1mm thick layer of flowable composite is applied to seal the dentin at the cervical level.

styleitaliano style italiano proximal wall build-up

A medium-high shade composite mass (A2 Venus Pearl – Kulzer) is used to build the proximal wall up to the marginal ridge in a single step.

styleitaliano style italiano restoration could be contoured better

The dentin body is then stratified in multiple increments using a chromatic mass (Venus Pearl A5 – Kulzer), and the occlusal morphology is completed with one or more increments of enamel (Venus P CL and AM – Kulzer), shaped to achieve proper occlusal anatomy. After polymerization, the grooves are characterized by selective application of intensive stain liquid chocolate.

style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
styleitaliano style italiano transparent matrix for recon touring of proximal restoration

When the cavity is very large, the force exerted by the matrix may deform the morphology of the interproximal transition areas, resulting in an undesirable profile. This can be corrected by placing a second transparent polycarbonate matrix with a wedge.

styleitaliano style italiano recontoured restoration

Which, after adequate adhesive treatment, contains a sufficient amount of composite.

styleitaliano style italiano composite restoration before final touches

The corrected restoration, with a more appropriate contour and emergence profile.

styleitaliano style italiano finished and polished distal restoration

After final polymerization under glycerin gel, finishing is performed using fine-grit diamond burs, abrasive discs, Supra Brown to Grey rubber points at 7500 g/m with water spray, and finally, synthetic and self-polishing brushes impregnated with silica carbide.

styleitaliano style italiano xray showing perfect adaptation of restoration of tooth 46

Radiographic check confirms proper cervical seal and emergence profile.

styleitaliano style italiano check-up of restoration after one month and a half

The 50-day follow-up shows adequate and fast healing of the marginal tissues.


The combined surgical-restorative approach in a single session allows for effective and predictable clinical management of extensive cavities with subgingival margins. Performing immediate post- or intra-operative direct restoration offers the following advantages:

  • Clinical Benefits: Surgical exposure of the margin and/or osseous recontouring (with restoration of biologic width when violated) enables effective isolation with rubber dam and facilitates subsequent adhesive procedures, placement of matrices, interproximal wedges, and retainer rings, as well as refinement and interproximal polishing.
  • Biological Benefits: Post-surgical healing occurs under ideal conditions, facilitated by consistent and adequate interproximal contact points, correct emergence profiles, and refined and polished surfaces, resulting in reduced morbidity and faster aesthetic and functional restoration (1;2;12;14). The extent of osseous recontouring can be minimized when combined with coronal relocation of the cervical margin using composite increment (14;15;16). The direct restorative approach allows for greater preservation of healthy residual tissues compared to indirect techniques and ensures adherence to the fundamental principle of immediate dentin sealing (IDS), thereby improving the reliability of adhesive performance (13).
  • Ergonomic and Economic Benefits: Performing the procedure in a single session optimizes operative time by eliminating interim provisional restoration phases and avoids laboratory costs, thereby reducing overall costs for the patient. This makes the approach appealing, dynamic, and efficient (1).


(1). Veneziani M. Eur J Esthet Dent. 2010 Spring;5(1):50-76 Adhesive restorations in the posterior area with subgingival cervical margins: new classification and differentiated treatment approach.
(2). Pontoriero R, Carnevale G. J Periodontol. 2001 Jul;72(7):841-8. Surgical crown lengthening: a 12-month clinical wound healing study.
(3). Spreafico RC, Krejci I, Dietschi D. J Dent. 2005 Jul;33(6):499-507. Epub 2005 Feb 2. Clinical performance and marginal adaptation of class II direct and semidirect composite restorations over 3.5 years in vivo.
(4). Ricardo M. Carvalho et all. Endodontic Topics 2012, 21,62-88 Dentin as a bonding substrate (5). van Dijken JWV, Pallesen U. Dent Mater. 2017 Aug;33(8):944-953. Durability of a low shrinkage TEGDMA/HEMA-free resin composite system in Class II restorations. A 6-year follow up.
(6). van Dijken JW. J Dent. 2000 Jul;28(5):299-306. Direct resin composite inlays/onlays: an 11 year follow-up.
(7). Pallesen U, Qvist V. Clin Oral Investig. 2003 Jun;7(2):71-9. Composite resin fillings and inlays. An 11-year evaluation.
(8). Deliperi S. Oper Dent. 2012 Jul-Aug;37(4):425-31 Functional and aesthetic guidelines for stress-reduced direct posterior composite restorations.
(9). Deliperi S, Bardwell DN. J Esthet Restor Dent. 2006;18(5):256-65 Clinical evaluation of direct cuspal coverage with posterior composite resin restorations.
(10). Contraction stress of a low-shrinkage composite materials assessed with different testing systems. Dent Mater 26 (2010) 947-953
(11). Spreafico RC, Krejci I, Dietschi D. J Dent. 2005 Jul;33(6):499-507 Clinical performance and marginal adaptation of class II direct and semidirect composite restorations over 3.5 years in vivo.
(12). Vacek JS, et all. Int J Periodontics Restorative Dent. 1994 Apr;14(2):154-65. The dimensions of the human dentogingival junction.
(13). Oakley E1, Rhyu IC, Karatzas S, Gandini-Santiago L, Nevins M, Caton J. Int J Periodontics Restorative Dent. 1999 Dec;19(6):529-41. Formation of the biologic width following crown lengthening in nonhuman primates.
(14). Brägger U, Lauchenauer D, Lang NP. J Clin Periodontol. 1992 Jan;19(1):58-63. Surgical lengthening of the clinical crown.
(13). Magne P. J Adhes Dent. 2014 Dec;16(6):594 IDS: Immediate Dentin Sealing (IDS) for tooth preparations.
(14). Frese C, Wolff D, Staehle HJ. Oper Dent. 2014 JanFeb;39(1):22-31 Proximal box elevation with resin composite and the dogma of biological width: clinical R2-technique and critical review.
(15). Dietschi D, Spreafico R. Int J Esthet Dent. 2015 Summer;10(2):210-27 Evidence-based concepts and procedures for bonded inlays and onlays. Part I. Historical perspectives and clinical rationale for a biosubstitutive approach.
(16). Magne P, Spreafico RC Am J Esthet Dent 2012, 2, 2, Deep margin elevation
(17). Bichacho N. Pract Periodontics Aesthet Dent. 1994 Apr;6(3):17-2 The centripetal build-up for composite resin posterior restorations.


styleitaliano style italiano snowplow technique direct posterior restoration bulk composite Kerr SimpliShade Bulk Fill composite restoration

Bulk flow for Snowplow

Bulk fill composites and the Snowplow technique make it seem easy to get optimum marginal seal and anatomically accurate restorations.