Case Presentations & Online CE

Case Presentation
by Dr. Len Boksman D.D.S., B.Sc., F.A.D.I., F.I.C.D.

Many articles have addressed the challenges faced by the clinician in placing posterior composites. The inherent chemical nature of todays composite resins still force the clinician to deal with polymerization shrinkage, which can range from 23% for hybrids, microfils, and nanofilled composites1,2,3 and low viscosity or flowable composite resins which are often used as liners, or initial increments in proximal boxes which can demonstrate a volumetric contraction of up to 5% because of their lower filler content4. These shrinkage values are only approximate for each composite, as the shrinkage depends on the polymerization reaction which is proportional to the degree of conversion5 (exposure time x light irradiance or radiant exposure measured in J/cm2).6 To address or compensate for this chemical contraction, many composite insertion techniques have been proposed which usually incorporate an incremental placement of the composite resin such as the three site technique using clear matrices with reflective wedges,7,8 a horizontal layering,9,10 the oblique technique,11,12 or a segmental technique as described by Jackson which may include an initial bulk placement in 3 to 3.5 mm increments.13 In spite of the various techniques used to place these composite resins, these materials challenges can lead to post-operative sensitivity,14,15 wear higher than tooth structure,16 marginal leakage with recurrent caries,17,18 and open contact areas.13,19,20 For posterior Class II restorations especially, open contacts result in food impaction into the interproximal space resulting in periodontal inflammation and disease, due to bacterial ingress into the periodontium,21,22 with subsequent bone loss23,24 (Figure #1), and recurrent caries25 (Figure #2). The high incidence of open contacts with food impaction may be one of the reasons why, as Strassler states, clinical evidence has demonstrated that Class II composite resins have significantly higher rates of caries at the gingival margin when compared to amalgam restorations.26 The clinical challenge of creating tight interproximal contacts has been discussed in many published articles. Liebenberg states that the clinicians achievement of an intact proximal contact when delivering a direct restorative option is reliant on tooth separation greater than or equal to the thickness of the matrix used.27 I would submit that due to post light-cure polymerization
The Use of Separating Rings in the Placement of Class II Composite Resins
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contraction, the separation required for the creation of routinely tight interproximal contacts for direct placement should always be greater than the thickness of the matrix band. The re-establishment of the correct interproximal contact and convex contour (bucco-lingually and occluso-gingivally) requires a properly contoured matrix which is stabilized and adapted gingivally with a properly inserted and contoured wedge.28 The use of a Tofflemire metal matrix and retainer that is not contoured (Figure #3), and even if contoured, stabilized gingivally with a wedge only, without the use of auxiliary tooth separation, will often result in open or light contacts.29 A circumferential matrix will cause the band to flatten out interproximally due to tensioning (it often has to be released somewhat), and when the interproximal contact is wide, an open contact is the only possible clinical outcome. A non contoured circumferential matrix creates a flat interproximal contour which migrates the contact point from the upper middle third to the marginal ridge occlusally (Figure #4).30 This translocation can create an open contact when proper marginal ridge convexity is created and will result in premature interproximal fracture due to lack of support for the marginal ridge which can often be in an area of a centric stop (Figure #5).31 Many authors have looked at various other methods of creating tight interproximal contacts. Early literature looked at the effect of pre-wedging as it not only creates some initial separation of the teeth, but also protects the rubber dam interproximally and the interproximal tissue as well.32 The clinician should note that the wedge should be continually advanced during the preparation phase, as the wedge may back out, or soften due to saliva, if a wooden wedge is placed. Packable composite resins have been evaluated,33,34 but not only did these show increased wear and surface roughness35,36 (being no better than a hybrid), their use did not ensure reliably tight contacts.37 It is important to note that the use of a separating ring when restoring Class II composite restorations has a greater influence on the obtained proximal contact tightness compared to the influence of the consistency of the composite resin.38 Ceramic inserts or pre-polymerized resin particles have been used which can wedge the contacts interproximally as well as decreasing the overall amount of composite used, thereby reducing the overall amount of shrinkage.39,40 Special instruments to help hold the matrix in better adaptation in contact with the adjacent tooth, such as the Contact Pro (Clinical Research Dental, Brookfield CT) can be especially helpful41 when
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the preparation is very wide interproximally, which can negate the use of some small tine matrix rings. The thickness of the matrix band used can have an effect on contacts, as these can vary from .030 mm to .058mm.42 Since Class II posterior composite resin restorations placed with a combination of sectional matrices and separation rings result in the strongest contacts,43,44 and since the use of a contoured matrix results in a stronger marginal ridge45 this article will now look at one of those systems. Of the ring systems currently available, the Garrison Composi-Tight 3D gives the author one of the most predictable results. The Garrison Composi-Tight 3D sectional matrix system has a Soft-Face which is different from other available rings (Figure #6). The ring is made of polished stainless steel which is circular in shape, with the bow section encased in plastic that stiffens the ring (Figure #7). The hard and soft plastic combination of the tine area creates separating pressure while entering the interproximal area to minimize flash and enhances the grip on the contoured matrix band which comes in a number of sizes and shapes. The U-shaped gingival contour of the soft face allows the ring to be placed over the wedge. The system has the option of using the regular contoured bands or the new Slick bands (Figure #8) which are
Figure 6
Figure 8
designed to minimize sticking to the bonding agent.
The Garrison Fender Wedge (Figures #9 and 10) is an excellent way to protect the rubber dam, interproximal gingival tissues, and the tooth surface adjacent to the preparation.
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Case Presentation
A 20-year-old patient presented to the practice with four quadrants of failing composites due to open contacts, interproximal and occlusal decay and pain on chewing (Figures #11, 12). Tooth number 15 had a carious pulp exposure and required endodontic therapy. Rubber dam was applied to the lower left quadrant after anesthesia, interproximal wooden wedges were placed to begin the pre-wedging process, and they were advanced during the operative procedure. After removal of the old restorations and caries in teeth #19 and 20, a BlueView Pinch Matrix (Garrison Dental Solutions, Spring Lake, MI) was applied to tooth #19 (Figure #13) and new wedges inserted to stabilize the band, adapt it gingivally to minimize the chance for composite overhang, and to create interproximal pressure. To facilitate easy access, and since teeth #18 and 20 were going to be prepared and restored, no auxiliary separation was applied. Tooth #19 was etched with Ultra-Etch 35% phosphoric acid solution (Ultradent, Salt Lake City, UT) by applying it to the enamel margins first, followed by placement within the cavity preparation, and washed and gently dried after 15 seconds, leaving a slightly moist surface. G5 desensitizer (Clinicians Choice, Brookfield, CT) a mixture of 5% Gluteraldehyde, 35% HEMA and water was carefully applied, and the excess removed by suction. The G5 acts by coagulating plasma
Figure 11
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Case Presentation
proteins in the tubules, acts as a pre-primer, and has residual antimicrobial effects. MPa (Clinicians Choice, Brookfield CT), a fifth generation bonding agent was placed in a single layer, air thinned with the solvent evaporated, and light cured with a Valo (Ultradent, Salt Lake City, UT) broad spectrum curing light for 10 seconds. A thin layer of DeMark, a hyper-opaque, flowable hybrid lining composite (Cosmedent, Chicago, IL) was teased into the base of the proximal box, into the deeper carious excavation areas, and lightly teased over the pulpal floor (Figure #14) followed by light curing for 10 seconds. Its radiopacity can be clearly seen on the radiograph (Figure #15), which minimizes the chance for erroneous diagnosis of caries under the composite due to radiolucent lining materials. The placement of a flowable liner also creates an elastic cavity wall46 interface which minimizes the effect
Figure 14
of C-factor shrinkage.47 An incremental insertion technique
was used to restore the tooth with Cosmedent Nano A2 (Cosmedent, Chicago, IL), with each layer no more than 2 mm, laterally placed to reduce the C factor, and light cured for 10 seconds. The restoration was shaped on the occlusal with a 7803 multi-fluted bur, and the mesial interproximal shaped with a 7901. On tooth #20 the Garrison contoured matrix was placed, followed by a G-Wedge, and the ComposiTight 3D ring applied to separate the teeth and minimize
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Case Presentation
interproximal flash (Figure #16). After each placement of the contoured matrix band, a ball burnisher should be used to verify contact with the adjacent tooth. The DO restoration was placed following the above protocol (Figure #17). The final excellent contour and contact that can be routinely achieved with this system is shown in Figure #18. Because of a tear in the rubber dam, a new dam was placed to adequately isolate tooth #18 and pre-wedging initiated. Even with the rubber dam clamp on the same tooth, if well placed apically, Figure #19 shows the application of the Garrison contoured matrix and the Composi-Tight ring over the rubber dam clamp.
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Case Presentation
Figure #20 shows the easy 90 degree direct access allowed by the shape and design of the Valo curing light, which allows maximum curing penetration. After restoring tooth #18 as above (Figure #21), and polishing the restorations with an occlusal diamond impregnated Groovy bristle brush (Clinicians Choice, Brookfield, CT), the immediate post operative photo is shown in Figure #22. This article has presented a predictable method of obtaining tight, well contoured, interproximal restorations utilizing separation rings. Clinical predictability is assured when following the above protocol.
Figure 20
Dr. Leendert (Len) Boksman D.D.S., B.Sc., F.A.D.I., F.I.C.D. is a part-time consultant to Clinical Research Dental acting as Director of
Clinical Affairs, an Adjunct Clinical Professor at the Schulich School of Medicine and Dentistry and is in private practice in London, Ontario. He can be reached at lboksman@ clinicalresearchdental.com.
Figure 21
This article is a portion of one previously published in Oral Health November 2010 Figure #5 is courtesy of Dr. David Clark
Figure 22
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Bibliography:
1. Farracane JL. Using posterior composites appropriately. J Am Dent Assoc 1992;123:53-58 2. Stansbury JW. Cyclopolymerizable monomers for use in dental resin composites. J Dent Res 1990;69:844-8 3. Stansbury JW . Synthesis and evaluation of novel multifunctional oligomers for dentistry. J Dent Res 1992;71:434-7 4. Labella R, Lambrechts P, Van Meerbeek B, Vanherle G. Polymerization shrinkage and elasticity of flowable composites and filled adhesives. Dent Mater 199;15:128-137 5. Lim B-S, Ferracane JL, Sakaguchi RL, Condon Jr. Reduction of polymerization contraction stress for dental composites by two step light activation. Dent Mater 2002;18:436-444 6. Sakaguchi RL, Berge HX. Reduced light energy density decreases post gel contraction while maintaining degree of conversion in composites. J Dent 1998;26:695-700 7. Lutz F, Krejci I, Barbakow F. The importance of proximal curing in posterior composite resin restorations. Quintessence Int 1992;23:605-607 8. Lutz F, Krejci I, Luescher B, Oldenburg Tr. Improved proximal margin adaptation of Class II composite resin restorations by use of light reflecting wedges. Quintessence Int 1986;17:659-64 9. Tjan AH, Bergh BH, Lidner C. Effect of various incremental techniques on the marginal adaptation of class II composite resin restorations. J Prosthet Dent 1992;67(1):62-66 10. Lutz F, Krejci I, Barbakow F. Quality and durability of marginal adaptation in bonded composite restorations. Dent Mater 1991;7(2):107-113 11. Spreafico RC, Gagliani M. Composite resin restorations on posterior teeth. In: Roulet JF, Degrange M. Adhesion: The silent revolution in dentistry. Chicago: Quitessence;200:253-276 12. Weaver WS, Blank LW, Pelleu GB.A visible light activated resin cured through tooth structure. Gen Dent 1988;36:236-237
13. Jackson Rd, Morgan M. The new posterior resins and a simplified placement technique. JADA 2000;131:375-383 14. Perdigao J, Anauate-Netto C, Carmo AR, et al. The effect of adhesive and flowable composite on post-operative sensitivity: 2-week results. Quintessence Int 2004;35:777-784 15. Perdigao J, Geraldeli S, Hodges JS. Total etch versus self etch adhesive: effect on post-operative sensitivity. JADA 2003;134:16211629 16. Christensen GJ. Preventing sensitivity in Class II resin restorations. JADA 2001;129:1469-1470 17. Opdam N, Loomans B, Roeters F, Bronkhorst E. Five year clinical performance of posterior resin composite restorations placed by dental students. J of Dent 2004;32(5):379-383 18. Ockson RD, Opdam NJ, Roeters FJ, Feilzer AJ, Verdonschot EH. Marginal integrity and post-operative sensitivity in Class II resin composite restorations in vivo. J Dent 1998;26:555-562 19. Christensen GJ. Overcoming the challenges of Class II resin based composites. JADA 2006;137(7):1021-1023 20. Miller MB, Castellanos IR, Vargas MA, Denehy GE. Effect of restorative materials on microleakage of Class II composites. J Esthet Dent 1996;8(3):107-13 21. Bliedent TM. Tooth related issues. Annals of Perio December 1999;4(1):91-6 22. Padbury A, Eber R, Wang HL. Interactions between the gingiva and the margin of restorations. J of Clin Perio May 2003;30(5):379385 23. Koral SM, Howell TH, Jeffcoat MK. Alveolar bone loss due to open interproximal contacts in periodontal disease. J of Perio 1981;52(8):447-450 24. Nielsen IM, Glavind L, Karhing T. Interproximal periodontal intrabony defects. J of Clin Perio June 1980 7(3):187-198 25. Ash MM. Wheelers dental anatomy, physiology and occlusion. Dental Anatomy, Physiology and Occlusion. 8th ed. Philadelphia: Saunders 2003
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26. Strassler HE. Meeting the challenge of the Class II composite resin proximal contact. Oral Health August 2010;60-73 27. Liebenberg WH. The proximal contact precinct in direct posterior restorations: Interproximal integrity. Pract Proced Aesth Dent 2002;14(7):587-594 28. Varlan CM, Dimitriu BA, Bodnar DC, Varlan V, Simina CD, Popa MB. Contemporary approach for re-establishment of proximal contacts in direct class II resin composite restorations. Timisoara Medical Journal 2008;58(3-4):236-243 29. Wirshing E., Loomans BAC, Staehle HJ, Dorfer CE. Clinical comparison of proximal contacts obtained with different matrix systems. #2860 http://iadr.confex.com/iadr/2008Toronto/ techprogram/abstract_103904.htm 30. Keough TP, Bertolotti RL. Creating tight, anatomically correct interproximal contacts. Dent Clin N Am 2001;45(1):83-103 31. Loomans B, Roeters F, Opdam N, Kuijs R. The effect of proximal contour on marginal ridge fracture of class II composite resin restorations. J Dent 2008;36(10):828-832 32. Eli I, Weiss E, Kozlovsky A, Levi N. Wedges in restorative dentistry: principles and application. J of Oral Rehab 1991;18(3):257-264 33. Sarrett DC, Brooks CN, Rose JT. Clinical performance evaluation of a packable posterior composite in bulk-cured restorations. JADA 2006;137:71-80 34. Francci C, Loguercio AD, Reis A, Carrilho MRDO. A novel filling technique for packable composite resin in class II restorations. J. of Esthet and Rest Dent 2002;14(3):149-2002 35. Cobb DS, McGreggor KM, Vargas MA, Denehy GE. The physical properties of packable and conventional posterior resin based composites: a comparison. JADA 2000;131:1610-1615 36. Ferracane JL, Choi KK, Condon Jr. In vitro wear of packable dental composites. Compend Cont ed Dent 1999;20(supplement 25):S60-S66 37. Leinfelder KF, Bayne SC, Swift EJ Jr. Packable composites overview and technical considerations. J Esthet Dent 1999;11:234-249
38. Loomans BAC, Opdam NJ, Roeters JF, Bronkhorst EM, Plasschaert AJ. Influence of composite resin consistency and placement technique on proximal contact tightness of class II restorations. J Adhes Dent. Oct 2006;8(5):305-10 39. Bott B, Hannig M. Optimizing class II composite resin esthetic restorations by the use of ceramic insert. J of Esthet and Rest Dent 1995;7(3):110-117 40. Prakki A, Cilli R, Saad JO, Rodrigues JR. Clinical evaluation of proximal contacts of class II esthetic direct restorations. Quintessence Int. 2004 Nov-Dec;35(10):785-9 41. El-Badrawy WF, Leung BW, El-Mowafy O, Rubo JH, Rubo MH. Evaluation of proximal contacts of posterior composite restorations with 4 placement techniques. JCDA March 2003;69(3):162-167 42. Boksman L, Margeas R, Buckner S. Predictable interproximal contacts in class II composite restorationsa fusion of separation armamentarium, composite material selection and insertion technique. Oral Health March 2008:10-16 43. Loomans B, Opdam N, Roeters N, Bronkhorst E, Burgersdijk R, Dorfer C. A randomized clinical trial on proximal contacts of posterior composites. J of Dent 2006;34(4):292-297 44. Saber MH, Loomans BA, El Zohairy A, Dorfer CE, El-Badrawy W. Evaluation of proximal contact tightness of class II composite restorations. Oper Dent 2010 Jan-Feb;35(1):37-43 45. Loomans BAC, Roeters JJM, Opdam NJM, Kuijs RH. Effect of proximal contour of restorations on fracture resistance. #0031 http:// iadr.confex.com/iadr/2008Toronto/techprogram/abstract_103114htm 46. Uterbrink GL, Liebenberg WH. Flowable resin composites as filled adhesives: literature review and clinical recommendations. Quint Int 1999;30:249-257 47. Van Meerbeek B, Willems G, Celis JP, Roos JR, Braem M, Lambrechts P, Vanherle G. Assessment by nano-indentation of the hardness and elasticity of the resin-dentin bonding area. J Dent Res 1993;72:1434-1442
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Clinical Solutions to Common Problems Faced When Placing Class II Direct Composites
By Robert A. Lowe, D.D.S., F.A.G.D., F.I.C.D., F.A.D.I., F.A.C.D.
Dr. Robert A. Lowe, DDS, FAGD, FICD, FADI, FACD, maintains a private practice in Charlotte, N.C. A Diplomate of the American Board of Aesthetic Dentistry, Dr. Lowe lectures internationally and is chairman of the Advanstar Dental Medias continuing education advisory board. He can be reached at 704-364-4711 or at boblowedds@aol.com
Introduction: The Class II Challenge Direct composite restorations that involve posterior proximal surfaces are still a common finding in many dental patients. Unlike dental amalgam, which can be a very forgiving material technically and can be condensed against a matrix band to create a proximal contact, proper placement of composite restorative materials present a unique set of challenges for the operative dentist. The adhesion process itself is well understood by most clinicians as far as isolation and execution, however, there are some steps in the placement process that cause difficulty and ultimately lead to a less than desirable end result. In this article we will look at three specific areas, 1) Management of the soft tissue in the interproximal region, 2) Creation of proximal contour and contact and 3) Finishing and polishing of the restoration. Management of the Interproximal Gingival Tissue The most common area for the adhesion process to fail is the proximal gingival margin. Compounding this problem is the inability to gain access to the area to affect a repair without removal of the entire restoration. As stated by Dr. Ron Jackson, bonded restorations are unique in that minor defects (decay or microleakage) at the marginal interface can often be renewed, or repaired by removal of the affected tooth structure and repair with additional composite restorative material. Because of the bond of the restorative material to enamel and dentin, the recurrence is usually self limiting. This is not true with metallic restorations that are not bonded to tooth structure. However, if the defective area is at the proximal gingival margin or line angle, access is not possible. Therefore precise marginal adaptation of the direct composite restorative material and the seal of this margin in the absence of moisture or sulcular fluid contamination is of paramount importance! However, whether due to the subgingival level of decay and/or gingival inflammation, it can be hard to seal the gingival margin with a matrix in the presence of blood.
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Clinical Solutions to Common Problems Faced When Placing Class II Direct Composites Continued By Robert A. Lowe, D.D.S., F.A.G.D., F.I.C.D., F.A.D.I., F.A.C.D.
Proximal Contact and Contour Another challenge for the dentist has always been to recreate contact to the adjacent tooth and at the same time, restore proper interproximal anatomic form given the limitations of conventional matrix systems. The thickness of the matrix band and the ability to compress the periodontal ligaments of the tooth being restored and the one adjacent to it can sometimes make the restoration of proximal tooth contact arduous at best. Anatomically, the posterior proximal surface is convex occlusally and concave gingivally. The proximal contact is elliptical in the bucco-lingual direction and located approximately one millimeter apical to the height of the marginal ridge. As the surface of the tooth progresses gingivally from the contact point toward the cementoenamel junction, a concavity exists that houses the interdental papilla. Conventional matrix systems are made of thin, flat metallic strips that are placed circumferentially around the tooth to be restored and affixed with some sort of retaining device. While contact with the adjacent tooth can be made with a circumferential matrix band, it is practically impossible to recreate the natural convex/concave anatomy of the posterior proximal surface because of the inherent limitations of these systems. Attempts to shape or burnish matrix bands with elliptical instrumentation may help create non-anatomic contact, but only distorts, or indents the band and does not recreate complete natural interproximal contours. Without the support of tooth contour, the interdental papilla may not completely fill the gingival embrasure leading to potential food traps and areas for excess plaque accumulation. Direct Class II composite restorations can present even more of a challenge to place for the dentist because of the inability of resin materials to be compressed against a matrix to the same degree as amalgam making it difficult to create a proximal contact. Finishing and Polishing Composite Restorations Direct composite material does not carve like amalgam, although many clinicians wish that it did! Unfortunately this means that most posterior composites are carved with a bur. This is not part of the finishing and polishing of the restoration. It must be remembered that cuspal forms are convex and cannot be carved with a convex rotary instrument that imparts a concave surface to the restorative material. Composite should be incrementally placed and sculpted to proper occlusal form prior to light curing. The finishing and polishing process is done to accomplish precise marginal adaptation and make minor occlusal adjustments. Rubber abrasives further refine the surface of the composite, and surface sealants are used to gain additional marginal seal beyond the limitations of our instrumentation. Case Report: A Class II Direct Composite Restoration Figure 1:
This occlusal preoperative view shows a maxillary molar that has radiographic decay on the mesio-proximal surface.
The patient shown in Figure 1 presented with radiographic decay on the mesial proximal surface of tooth number 3. The operative area is isolated using an OptiDam (Kerr Hawe). Next, a unique piece of armamentarium called a FenderWedge is placed in the mesial proximal area prior to preparation with a 330 carbide bur. The decay is minimal, so the operative plan is to keep the preparation very conservative. The Fender Wedge will protect the adjacent proximal surface from the accidental excoriation by the bur while preparing the proximal box of the cavity preparation.
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Figures 25:
2) An occlusal view during cavity preparation. 2a) Note how the FenderWedge protects the adjacent proximal surface while the proximal box is refined with a 330 carbide bur. 3) After the cavity preparation is completed, bleeding is seen in the proximal area. 4) Expa-syl (Kerr Corporation) is placed into the proximal area with the delivery syringe then tapped to place using a dry cotton pellet. 5) After rinsing away the majority of the Expa-syl, (note that a small amount of Expa-syl remains sub marginal for additional hemorrhage control) the proximal tissue is deflected away and bleeding is absent allowing for easy placement of the sectional matrix band.
After removal of the decay, and completion of the proximal and occlusal cavity form, the operative area is isolated with a rubber dam (Figure 2) in preparation for the restorative process. Figure 3 clearly shows that the proximal gingival tissue was abraded during cavity preparation and there is evidence of hemorrhage. It is not advisable to try and wash the hemorrhage away with water and quickly apply the matrix band. Even if this is successful, it is likely that blood will infiltrate into the preparation in the gingival area and make etching and placement of the dentin bonding adhesive without contamination impossible. An excellent way to manage the proximal tissue hemorrhage quickly and completely to apply Expa-syl (Kerr Corporation) to the area, tap it to place with a dry cotton pellet, and wait 1 to 2 minutes (Figure 4). Using air-water mixture, rinse away the Expa-syl leaving a little bit of the material on top of the tissue, but below the gingival margin of the preparation (Figure 5). The Expa-syl will deflect the tissue away from the preparation margin, maintain control of any hemorrhage, and facilitate placement of the proximal matrix without the risk of contamination of the operative field. Class II preparations that need a matrix band for restoration will require rebuilding of the marginal ridge, proximal contact, and often a large portion of the interproximal surface. The goal of composite placement is to do so in such a way that the amount of rotary instrumentation for contouring and finishing is limited. This is especially true for the interproximal surface. Because of the constraints of clinical access to the proximal area, it is extremely difficult to sculpt and correctly contour this surface of the restoration. Proper reconstitution of this surface is largely due to the shape of the matrix band and the accuracy of its placement. After removal of caries and old restorative material, the outline form of the cavity preparation is assessed. If any portion of the proximal contact remains, it does not necessarily need to be removed. Conserve as much healthy, unaffected tooth structure as possible. If the matrix band cannot be easily positioned through the remaining contact, the contact can be lightened using a Fine Diamond Strip (DS25F - Komet USA). The Composi-Tight 3D Matrix System has been chosen to aid in the anatomic restoration of the mesial proximal tooth morphology of this maxillary first molar. The appropriate matrix band is chosen which will best correspond anatomically to the tooth being restored and also, to the width and height of the proximal surface. The height of the sectional matrix should be no higher than the adjacent
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Figures 68:
6) A sectional matrix band gripped by Composi-Tight Matrix Forceps, an instrument that enables precise placement of sectional matrix bands without deformation. 7) The WedgeWand during clinical application with the wedge bent at a 90 angle to the handle. 7a) WedgeWands provide an excellent seal. 8) The Soft Face 3D-Ring in place. Note the precision of the cavosurface and marginal seal by the sectional matrix.
marginal ridge when properly placed. Because of the concave anatomic shape, the proximal contact will be located approximately one millimeter apical to the height of the marginal ridge. The Composi-Tight Matrix Forceps is used to place the selected sectional matrix band in the correct orientation in the proximal area. The positive grip of this instrument will allow for more exact placement than a cotton plier, which could damage, or crimp the matrix band. The sectional matrix band (Garrison Dental Solutions) is positioned and placed using the Composi-Tight Matrix Forceps to the mesial proximal area of tooth number 14 (Figure 6). The orientation of the band and the positive fit in the makes precise placement possible, even in posterior areas with tight access. Next, the gingival portion of the band is stabilized and sealed against the cavosurface margin of the preparation using the appropriate size WedgeWand flexible wedge (Figure 7). The size of the WedgeWand flexible wedge should be wide enough to hold the gingival portion of the matrix band sealed against the cavosurface of the preparation, while the opposite side of the wedge sits firmly against the adjacent tooth surface. To place the wedge, the Wedge Wand is bent to 90 degrees where the wedge meets the handle. The flexible wedge can now be placed with pressure conveniently, without the use of cotton forceps, that often times can be very clumsy. Once the wedge is in the correct orientation, a twist of the wand releases the wedge. The G-Ring forceps is then used to place the Soft Face 3D-Ring into position. The feet of the Soft Face 3D-Ring are placed on either side of the flexible wedge and the ring is released from the forceps. The force of the 3DRing causes a slight separation of the teeth due to periodontal ligament compression and the unique pads of the Soft Face 3D ring hug the proximal morphology of the buccal and lingual surfaces of the adjacent teeth while at the same time creating a unbelievably precise adaptation of the sectional matrix to the tooth cavosurface margins! (Figure 8). The goal of the perfect proximal matrix is to eliminate the need to have to use rotary instruments to remove overhangs due to a poorly adapted matrix. Once the sectional matrix is properly wedged and the Soft Face 3D-Ring is in place, the restorative process can be started. A 15 second total etch technique, 10 seconds on enamel margins and 5 seconds on dentin surfaces is performed using a 37% phosphoric etch.
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Figures 99a:
9) The composite restoration in completed prior to removal of the matrix band. Placement of the matrix precisely reconstructs the proximal tooth form. 9a) The restoration immediately after matrix removal. The Composi-Tight 3D-Ring reduces flash to a minimum.
The etchant is then rinsed off for a minimum of 15 to 20 seconds to ensure complete removal. The preparation is then air-dried and rewet with AcQuaSeal desensitizer (AcQuaMed Technologies) to disinfect the cavity surface, create a moist surface for bonding, and begin initial penetration of HEMA into the dentinal tubules. A fifth generation bonding agent (Optibond Solo Plus: Kerr Corporation) is then placed on all cavity surfaces. The solvent is evaporated by spraying a gentle stream of air across the surface of the preparation. The adhesive is then light cured for 20 seconds. The first layer of composite is placed using a flowable composite (Revolution 2: Kerr Corporation) to a thickness of about .5 millimeters. The flowable composite will flow into all the irregular areas of the preparation and create an oxygeninhibited layer to bond subsequent layers of microhybrid material. After light curing for 20 seconds, the next step is to layer in the microhybrid material. First, using a unidose delivery, the first increment of microhybrid composite (Premise: Kerr Corporation) is placed into the proximal box of the preparation. A smooth ended condensing instrument is used to adapt the restorative material to the inside of the sectional matrix and preparation. This first increment should be no more than 2 millimeters thick. After light curing the first increment, the next increment should extend to the apical portion of the interproximal contact and extend across the pulpal floor. Facial and lingual increments are placed and sculpted using a Goldstein Flexithin Mini 4 (Hu Friedy). A #2 Keystone brush (Patterson Dental) is lightly dipped in resin and used to feather the material toward the margins and smooth the surface of the composite. Figure 9 shows the restoration after completion of the enamel layer prior to matrix band removal. The Composi-Tight Matrix Forceps is used to remove the sectional matrix after removal of the flexible wedge and Soft Face 3D-Ring.
9a
Finishing and polishing will be accomplished using Q-Finisher Carbide Finishing Burs (Komet USA). Typically, 3 grits and correspondingly, 3 different burs are used to finish composite materials. With the Q-Finisher system, the blueyellow striped bur with its unique blade configuration does the work of two burs with one. An excellent surface quality on composite and natural tooth is achieved due to the cross cut design of the cutting instrument.
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Figures 1013:
10) The pointed Q-Finisher carbide finishing bur is used to make minor occlusal adjustments and refine the restorative margins. 11) The ulta fine pointed composite finishing bur is used to further refine and finish the restorations adjusted areas. 12) A fine pointed diamond composite polisher smoothes adjusted areas during polishing. 13) An occlusal view of the direct MO composite restoration after application of Seal-n-Shine sealant.
The small, pointed (H134Q - 014) Q Finisher is used to make minor occlusal adjustments on the restorative surface as needed and to smooth and refine the marginal areas of the restorative material where accessible (Figure 10). The fine, white stripe (H134UF - 014) ultra fine finishing bur is used in the adjusted areas for precise fine finishing (Figure 11). Komet Diamond Composite polishing points (Green Polishing and Gray High Shine) are then used to polish and refine the restorative surface (Figure 12). Once polishing is complete, the final step is to place a surface sealant (Seal and Shine:Pulpdent Corporation) to seal and protect any microscopic imperfections at the restorative marginal interface that may be left as a result of our inability to access these areas on the micron level. Remember, an explorer can feel a 30 micron marginal gap at best. Bacteria are 1 micron in diameter. The purpose of the Seal and Shine is to fill these areas. Figure 13 shows an occlusal view of the completed Class II composite restoration. Conclusion A technique has been described 1) to control proximal tissue bleeding prior to matrix placement with Expa-syl (Kerr Corporation), 2) utilize a sectional matrix system (Composi-Tight 3D, WedgeWand: Garrison Dental Solutions) and a nanofilled microhybrid composite (Premise: Kerr Corporation) to create an anatomically precise proximal surface, and 3) Use the Q Finisher, two bur composite finishing system (Komet USA) to finish then polish with diamond composite abrasives (Komet USA) refining marginal integrity without destroying occlusal anatomic form. The interproximal surface has been recreated with natural anatomic contour and has a predictable, elliptical contact with the adjacent tooth. With proper occlusal and proximal form, this invisible direct composite restoration will service the patient for many years to come.
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A Series of Photos Showing A MO Composite on #3

By Dr. Rosenfeld Dr. Rosenfeld is a graduate of Cornell University and Northwestern University Dental School. He served a year of General Practice residency and a second year as chief-resident at Long Island Jewish Medical Center. Dr. Rosenfeld has completed additional training in aesthetic dentistry from numerous sources, including the Nash Institute, where he has also served as a mentor. He is a member of the American Academy of Cosmetic Dentistry. He practices privately in Westwood, New Jersey.
Pre-operative image showing failed amalgam with recurrent carries: Figure 1
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A Series of Photos Showing A MO Composite on #3: Continued

By Dr. Rosenfeld
Rubber dam in place: : Figure 2
Tooth is prepped: : Figure 3
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By Dr. Rosenfeld
Matrix band and WedgeWand placed: : Figure 4
Soft Face 3D-Ring in place. Matrix band burnished to adjacent tooth: Figure 5
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By Dr. Rosenfeld
Bond and etch: : Figure 6
Cure bonding agent: : Figure 7
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By Dr. Rosenfeld
Incrementally fill and cure: Figure 8
Restoration immediately after removal of the matrix band. Note the lack of flash: Figure 9
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By Dr. Rosenfeld
Completed restoration: Figure 10
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A Series of Photos Showing A MO Composite on #4

By Dr. Rosenfeld Dr. Rosenfeld is a graduate of Cornell University and Northwestern University Dental School. He served a year of General Practice residency and a second year as chief-resident at Long Island Jewish Medical Center. Dr. Rosenfeld has completed additional training in aesthetic dentistry from numerous sources, including the Nash Institute, where he has also served as a mentor. He is a member of the American Academy of Cosmetic Dentistry. He practices privately in Westwood, New Jersey.
Pre-op image Figure 1
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A Series of Photos Showing A MO Composite on #4, Continued

By Dr. Rosenfeld
Rubber dam in place Figure 2
Tooth is prepped Figure 3
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By Dr. Rosenfeld
Matrix band and WedgeWand in place Figure 4
Soft Face 3D-Ring in place note the excellent buccal/lingual matrix band adaptation Figure 5
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By Dr. Rosenfeld
Bond and etch Figure 6
Cure bonding agent Figure 7
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By Dr. Rosenfeld
Composite placed and cured in increments Figure 8
Restoration immediately after matrix band removal. Note the lack of buccal/lingual flash Figure 9
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By Dr. Rosenfeld
Post operative Figure 10
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Earn
4 CE credits
This course was written for dentists, dental hygienists, and assistants.
The Properties and Selection of Posterior Direct Restorations

A Peer-Reviewed Publication Written by Robert C. Margeas, DDS, FAGD
PennWell is an ADA CERP Recognized Provider
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This course has been made possible through an unrestricted educational grant. The cost of this CE course is $59.00 for 4 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.
Educational Objectives
Overall goal: The purpose of this article is to provide dental professionals with expanded information on direct posterior composites. Upon completion of this course, the clinician will be able to do the following: 1. Describe the modes of failure, advantages and disadvantages of amalgam restorations. 2. Describe the modes of failure, advantages and disadvantages of composite restorations. 3. Describe the properties of an ideal restorative material. 4. Describe the types of composite materials and recent new materials and their application.
Figure 1. Introduction of tooth-colored restorations Acrylic lling material introduced Investigation of epoxy lling materials Introduction of BisGMA composites Dimethacrylate based llings investigated
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Abstract
Early tooth-colored restorative materials were weak and only suitable for anterior teeth. Over time, composites were developed that offered improved properties enabling their use in posterior teeth where subject to occlusal loading and forces of mastication. Secondary caries is the main reason for failure of both amalgam and composite restorations. Amalgam restorations offer ease-of-use but poor esthetics. In the case of composite restorations, minimizing polymerization shrinkage, wear and discoloration increase the longevity of these restorations. Posterior composite resins offer excellent esthetics, the main driver for patients who prefer composite fillings. 1973
UV-cured resins introduced
1970s
Silicate cements and early composites dominate
1980s
Posterior composites in use
1990s
Improved composites and adhesive systems Investigation and introduction of siloranebased material
Introduction
Historically, posterior direct restorations involved the use of amalgam. The first modern tooth-colored restorations used acrylic, which was introduced more than six decades ago. Subsequently, silicates and (di)methacrylate materials were investigated. Silicate cements and early composite materials were suitable only for anterior restorations due to their weak physical properties, and the silicate cements needed to be placed in one movement incremental placement was not an option. Silicate cements had a high failure rate. Old silicate restorations were assessed for longevity in a 1986 study and were found to have an estimated 66% replaced due to marginal discrepancies and lost fillings.1 Early resin-based composite restorations were an improvement over silicate cements; however, they were self-curing and required mixing of a base and a catalyst for curing, resulting in operator error during mixing and difficulties in timely and accurate placement. In addition, strength, bonding and retention were poor. Light-cured dimethacrylate composite restorations were introduced in the 1970s.2 By the 1980s, posterior tooth-colored restorations had been introduced, and these have continued to evolve to offer improved physical properties, user-friendliness and esthetics. Bonding systems and techniques have also evolved.
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2006-2008
The trend over the last decade has been placement of an increasing number of posterior composite restorations and a decreasing number of amalgams. By 1999, at least 39% of direct posterior restorations were composites, compared to at least 11% in 1990 (in both cases, for the purposes of trend analysis, conservatively making the assumption that all amalgam placements estimated in the ADA surveys were posterior restorations) (Table 1).3 Table 1. Trends in posterior composite placement 1999 Number placed Posterior composites Amalgams 46,116,300 70,994,700 % age of total 39.38% 60.62% 1990 Number placed 13,130,200 99,256,900 % age of total 11.68% 88.32%
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Clinician needs and patient demand for esthetic dentistry continue to drive these trends as well as development of products for restorations with improved physical properties and esthetics.
Ideal Restorative Material

The ideal posterior restorative material should exhibit a number of features (Table 2). It should be dimensionally stable, with no expansion or shrinkage either during placement or subsequent to placement, and without any wear following placement. It must also offer sufficient compressive and flexural strength in the case of posterior Class I and II restorations, it must resist both occlusal forces and the forces of mastication. Neither the material nor the tooth should be subject to stress during loading of the material and/or tooth. Biocompatibility is important the material should neither deteriorate intraorally nor result in any toxic, teratogenic or other iatrogenic effects. Ideally, the restorative material should offer antibacterial properties against oral bacteria, and preferably should be bactericidal. It should be user-friendly, offering an appropriate operating time and ease of placement. Finally, the material should also be esthetically pleasing to the patient and be color-stable and stain-resistant. Table 2. Ideal Restorative Material Properties Dimensionally stable Resistant to forces and stresses Wear-resistant Retentive and adhesive to the tooth Requires minimal tooth preparation Easily placed Requires minimum time to restore The ideal restorative material does not exist, although material developments have significantly improved how closely products approach these parameters. Cost-effective Biocompatible Bactericidal Esthetically pleasing Color-stable Stain-resistant
decade up to 2001 found an annual failure rate of 1.1% for amalgams, 2.1% for composites and 7.7% for glass ionomer cements.7 Reasons for the failure and replacement of restorations include secondary caries, fracture, wear, marginal defects and postoperative sensitivity. The primary reason for the replacement of direct restorations has been found to be secondary caries irrespective of the restorative material.8,9,10,11 While it has been found to be difficult to reliably diagnose secondary caries, and the condition is responsible for the majority of restoration replacements, the quality of the restoration and the patients (preventive) home care are important factors in precluding further repeat replacements.12 It was found in one study that 65% of direct and indirect (5% of total) restorations placed were replacement restorations, with secondary caries the most frequent reason given, regardless of material used.13 The longevity of restorations depends on clinical technique, materials and patient care. Figure 2. Marginal degradation of amalgam
Figure 3. Secondary caries
Direct Restoration Longevity

Annual failure rates for different materials have been examined in a number of studies. Some studies have found ranges of 0%-7% for amalgams, 0%-9% for direct composites and 1.4%-14.4% for glass ionomer cements in posterior stress-bearing restorations.4 A separate, more recent study, involving only two dentists, found comparable failure rates for composites and amalgams assessed as a five-year survival rate.5 Annual failure rates in a study conducted on restorations predominantly placed since 1990 were 3% for amalgams and 2.2% for direct composites, and it was also concluded that more recent studies demonstrated better results.6 Failure rates in one study covering restoration placement during the
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Amalgam Restorations
Amalgam has been found to be a cost-effective restorative material and to offer good longevity in studies of up to a more than 20-year period.14 Amalgam restorations are less technique-sensitive than composites, less sensitive to the presence of moisture and easier to place. They require less time to place than direct composites; an estimated 2.5 times more time is required for composite placement.15 While improved materials
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and light-curing options may have reduced the time required for composites, more chairside time is still required than with amalgams. Amalgam is also bactericidal, which helps to reduce bacterial colonization and biofilm formation.16,17 Bulk fractures and marginal degradation have been found to be the main material factors in the replacement of amalgam restorations.18 Bulk fracture rates have been found to be similar with or without bonding of amalgams (such as with AmalgamBond Plus) in large restorations, although smaller restorations benefit from bonding.19 Bonded amalgam restorations have been found to offer support of undermined enamel equal to that of composites, but inferior marginal adaptation.20 Creep-fatigue may be a major factor in marginal fracture of amalgam restorations.21 Amalgam restorations are subject to expansion, which can result in cuspal stress over time, depending upon the design of the preparation and/or the location of the initial lesion. Expansion of amalgam results from internal phase changes over time, that must be relieved to reduce stress it is believed this occurs as a result of creep of the amalgam from the confines of the restoration and its subsequent extrusion. On the other hand, development of a reduced amalgam-tooth margin interface gap size over time and improved marginal seal may occur due to such creep.22 Amalgam restorations require more tooth preparation than composites, and careful disposal of the mercurycontaining amalgam is mandatory. The poor esthetic results provided by amalgams are a major concern for patients, and amalgam staining of the tooth over time further compromises the appearance. Corrosion is also an issue. Poor esthetics with amalgam is the main reason why patients increasingly prefer the use of direct posterior composites as well as tooth-colored indirect restorative materials and techniques. Table 3. Modes of failure, advantages and disadvantages of amalgams Modes of Failure Secondary caries Bulk fracture Advantages Ease of use Cost-effective Disadvantages More tooth preparation Poor esthetics Corrosion Mercury disposal Can be bonded Bactericidal Marginal degradation Expansion and cuspal stress
composite restorations have improved over time, and recent studies have shown longevity to more closely reach the longevity of amalgams (albeit over a shorter tested time span). Table 4. Modes of failure, advantages and disadvantages of composites Modes of Failure Secondary caries Bulk fracture Marginal degradation Advantages Less tooth preparation Effective bonding Disadvantages Technique-sensitive Increased chairside time Polymerization shrinkage Increased bacterial adhesion Excellent esthetics No expansion over time Discoloration Loss of anatomic shape and wear
While amalgams expand over time, composite restorations are subject to polymerization shrinkage. This is regarded as the largest problem associated with composite use.24 Polymerization shrinkage results in stresses that can lead to enamel cracks, marginal degradation and microleakage, and postoperative sensitivity. Other associated problems include potential debonding of the tooth-composite interface.25 Polymerization shrinkage occurs due to the affiliation of the resin molecules with one another and the formation of chemical bonds that reduce the materials bulk. Shrinkage and occlusal loading of composites result in cuspal deflection, which results in enamel cracks and hypersensitivity. The amount of deflection has been found to be greater in larger restorations (MODs) than smaller ones (MOs).26 The amount of shrinkage and resulting stresses also varies with the composite filling material used.27,28 It is influenced by the materials flow, chemistry and curing dynamics, and the size and shape of the preparation. The intensity and duration of light curing have been found to affect polymerization shrinkage.29 Shrinkage can be reduced by increasing the amount of filler in composite restorative materials, as well as by having pre-polymerized clusters in the material.30 A recent study by Bouillaguet et al. found that cuspal deflection (tooth deformation) was statistically similar for conventional hybrid composites and flowable composites.31 Table 5. Potential effects of polymerization shrinkage Enamel cracks Marginal degradation Microleakage Postoperative sensitivity Debonding of tooth-composite interface Composite restorations generally offer poor antibacterial properties compared to amalgam. One in vitro study found a minimal antibacterial effect with composites that lasted only a
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Composite Restorations
Material failures accounted for more replacements of composites than amalgams in a review of surveys of dentists across the United States, Scandinavia and the United Kingdom from the 1980s and 1990s. These failures included bulk fracture, marginal degradation, discoloration and loss of anatomic shape.23 Nonetheless, the main reason for replacement is the same as for amalgam restorations secondary caries. In addition,
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few days. It was suggested that this might explain the greater biofilm growth seen on composites compared to amalgams.32 A second study assessed the behavior of three different composites (Charisma, Heraeus Kulzer; Dyract, Dentsply; and Pertac, 3M ESPE) in the presence of three common oral bacteria (S. mutans, S. oralis and A. naeslundii) for up to 35 days and found that the bacteria colonized the composites in a matter of hours and formed deep biofilms. The study also found, using scanning electron microscopy, that the polyacid modified composite demonstrated surface damage and roughness.33 Fluoride-releasing composites appear to offer no benefit over nonfluoride composites.34 While polymerization shrinkage in particular and biofilm formation on the surface of the restoration are disadvantages of composites compared to amalgams, composites still offer several advantages over amalgams superior esthetics, no expansion over time, as well as highly effective bonding systems for adhesion and retention that enable minimal preparation and improved tooth structure preservation. From the patients perspective, the most obvious advantage of composite restorations is esthetics. Improved color stability, luster and stain resistance have further improved esthetics as composites have evolved. Improvements in handling and user-friendliness continue to be developed since the introduction of a choice in bonding agents and unit doses, and recent developments are aimed at overcoming the physical weaknesses of composites.
age is decreased due to the materials chemical composition and polymerization dynamics. Silorane is derived from the combination of siloxane and oxirane and has a compact ring structure (Figure 4a) that unlinks during polymerization. When polymerization shrinkage begins, the silorane ring simultaneously opens up and compensates for material shrinkage by expanding its molecular volume and bulking up the material. Shrinkage has been found to be less than 1% using this material (Figures 4bd).41 An initiator included in the material starts the ring-opening process in a controlled manner and, according to the manufacturer, increases operating time. Figure 4a. Silorane molecule
Figure 4b. Application of primer
Recent Composite Material Developments

Composites have been modified to provide greater physical and biological properties. Biofilm-formation reduction has been tried by modifying composites as well as dentin bonders, such as by including glutaraldehyde in the dentin bonder or incorporating an acidic property.35 Recent investigations have included researching novel posterior composite materials with the objective of finding materials that offer reduced polymerization shrinkage and improved esthetic stability. Silsesquioxane (SSQ)-based nanocomposites have been found in in vitro testing to offer reduced polymerization shrinkage and rigidity, offering potential solutions for stresses and clinical issues associated with shrinkage.36 Similarly, oligomeric thiolene-based materials have been found in in vitro testing to exhibit up to 92% less polymerization stress compared to conventional dimethacrylate-based composites.37 A recently developed composite material based on silorane has been used and tested clinically and has been found to result in reduced polymerization shrinkage and stresses.38
Figure 4c. Silorane-based material in preparation after separate applications and curing of both primer and adhesive
Figure 4d. Light-curing of silorane-based material opens silorane ring structure, reduces shrinkage
Silorane-based Posterior Restorations

Silorane-based posterior composite material (Filtek LS Low Shrink Posterior Restorative, 3M ESPE) has been found to reduce polymerization shrinkage and associated stresses,39 which would also reduce microleakage and postoperative hypersensitivity while demonstrating other physical properties comparable to leading composites in in vitro testing.40 Shrinkwww.ineedce.com 5
In vitro testing has found lower polymerization shrinkage and reduced polymerization stress and tooth deformation compared to leading methacrylate-based conventional and flowable composite resin materials.42,43,44 At the same time, adhesion and shear bond strength have not been compromised, and reduced shrinkage helps preserve the tooth bond-composite adhesive interfaces. Other desired physical properties, such as compressive and flexural strength, have been found to be similar to those of leading composite materials. The silorane-based restorative is a microhybrid composite that contains fine silane-coated quartz filler with yttrium fluoride for radiopacity. Bacterial adhesion of common oral bacteria has been found to be reduced in in vitro testing using silorane-based composite, associated with its hydrophobic chemistry.45 One-year clinical testing has found good clinical performance using this new material compared to other posterior composite material.
Figure 5c. Cavity preparation and Composi-Tight matrix and wedge placed
Case Study
The case shown here demonstrated the use of posterior composite material (Filtek LS restorative) in the restoration of a carious upper left first bicuspid. On examination, a distal lesion was identified (Figure 5a). A rubber dam was placed prior to the DO preparation. Figure 5a. Distal lesion in upper left first bicuspid
After the matrix and wedge (Composi-Tight, Garrison Dental) were placed around the distal box, a thin layer of self-etching primer (LS System Adhesive Self-Etch Primer, 3M ESPE) was placed on the dentin in the preparation using a microbrush for 15 seconds, dispersed using air, then cured for 10 seconds. The primer has a pH of 2.7, produces mild etching and increases the hydrophobicity of the area prior to placement of the adhesive (LS System Adhesive Bond, 3M ESPE). Figure 5d. Self-etching primer placed
Figure 5e. Curing of self-etching primer
Figure 5b. Rubber dam placement prior to preparation
The next step is to place a thin layer of the adhesive in the preparation over the cured primer, and to light-cure the adhesive for 10 seconds before placing any composite material in the preparation. Filtek LS restorative is highly hydrophobic
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and the LS System Adhesive must function as a bridging mechanism between the primer and the composite. Only the LS System Adhesive Self-Etch Primer and Bond are compatible with Filtek LS restorative chemistry (the use of other primers and adhesives is contraindicated). The composite shade is selected and injected first as a 2 mm increment in the distal box, where it is condensed using a #9 Garrison. The remainder of the void is filled by injecting more composite, taking care not to overfill the area, and the #9 composite instrument is used to remove flash prior to light-curing the composite for 20 seconds (note: plasma lights, lasers and other high-power curing lights should not be used with Filtek LS restorative). A long working time under operatory light aids detailed shaping and flash removal prior to curing. Figure 5f. Injecting distal box with Filtek LS restorative
Figure 5i. Cured composite after removal of matrix and wedge
Figure 5j. High polish created using Jiffy polisher
Figure 5g. Condensing composite with #9 Garrison
Figure 5k. Final polished restoration
Figure 5h. Flash being removed from filled preparation prior to curing
After removal of the matrix and wedge, the restoration is polished using a Sof-Lex disk (Ultradent) used to remove any flash and a Jiffy Polisher (Ultradent) is then used to create a high shine. The final restoration using the low shrinkage posterior composite offers excellent esthetics and function.
Case Study
The second case here shows replacement of a degrading and fractured amalgam restoration with a silorane-based posterior composite. After preparation and application of a liner, the primer and adhesive were separately applied and separately cured. The restorative material was then
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injected, condensed and light-cured prior to finishing and polishing the restoration. Figure 6a. Fractured, degrading amalgam
Figure 6e. Finished restoration
Summary
Increasingly, composites are being placed in preference to amalgams in large part due to patient demands for esthetics as well as the clinical desire to do minimal preparation where possible and provide patients with bonded, esthetic restorations. Since their introduction, the properties of composites have improved dramatically. Amalgam and composite restorations both have advantages and disadvantages. While amalgam restorations fail by secondary caries and are subject to expansion, composite restorations fail by secondary caries and are subject to shrinkage. Recent developments and investigations of materials are aimed at reducing polymerization shrinkage of composites to increase the longevity of these restorations and reduce the potential for failure.
Figure 6b. Preparation with liner mesially
References
Figure 6c. Application of primer
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Figure 6d. Application of adhesive after primer was cured
Qvist V, Thylstrup A, Mjr IA. Restorative treatment pattern and longevity of resin restorations in Denmark. Acta Odontol Scand. 1986;44(6):351-6. 2 Small BW. Direct resin composites for 2002 and beyond. Gen Dent. 2002;50(1):30-3. 3 ADA Survey of Services Rendered, 2002. 4 Hickel R, Manhart J. Longevity of restorations in posterior teeth and reasons for failure. J Adhes Dent. 2001;3(1):45-64. 5 Opdam NJ, Bronkhorst EM, Roeters JM, Loomans BA. A retrospective clinical study on longevity of posterior composite and amalgam restorations. Dent Mater. 2007;23(1):2-8. Epub 2006 Jan 18. 6 Manhart J, Chen H, Hamm G, Hickel R. Buonocore Memorial Lecture. Review of the clinical survival of direct and indirect restorations in posterior teeth of the permanent dentition. Oper Dent. 2004;29(5):481-508. 7 Hickel R, Manhart J, Garca-Godoy F. Clinical results and new developments of direct posterior restorations. Am J Dent. 2000;13(Spec No):41D-54D. 8 Hickel R, Manhart J. Longevity of restorations in posterior teeth and reasons for failure. J Adhes Dent. 2001;3(1):45-64. 9 Deligeorgi V, Mjr IA, Wilson NH. An overview of reasons for the placement and replacement of restorations. Prim Dent Care. 2001;8(1):5-11. 10 Mjr IA, Moorhead JE, Dahl JE. Reasons for replacement of restorations in permanent teeth in general dental practice. Int Dent J. 2000;50(6):361-6. 11 Allander L, Birkhed D, Bratthall D. Reasons for replacement of Class II amalgam restorations in private practice. Swed Dent J. 1990;14(4):179-84.
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12 Kidd EA, Toffenetti F, Mjr IA. Secondary caries. Int Dent J. 1992;42(3):127-38. 13 Forss H, Widstrm E. Reasons for restorative therapy and the longevity of restorations in adults. Acta Odontol Scand. 2004;62(2):82-6. 14 Roulet JF. Benefits and disadvantages of tooth-coloured alternatives to amalgam. J Dent. 1997;25(6):459-73. 15 Ibid. 16 Beyth N, Domb AJ, Weiss EI. An in vitro quantitative antibacterial analysis of amalgam and composite resins. J Dent. 2007;35(3):201-6. Epub 2006 Sep 25. 17 Willershausen B, Callaway A, Ernst CP, Stender E. The influence of oral bacteria on the surfaces of resin-based dental restorative materials: an in vitro study. Int Dent J. 1999;49(4):231-9. 18 Qvist V, Thylstrup A, Mjr IA. Restorative treatment pattern and longevity of amalgam restorations in Denmark. Acta Odontol Scand. 1986;44(6):343-9. 19 Lindemuth JS, Hagge MS, Broome JS. Effect of restoration size on fracture resistance of bonded amalgam restorations. Oper Dent. 2000;25(3):177-81. 20 Franchi M, Breschi L, Ruggeri O. Cusp fracture resistance in composite-amalgam combined restorations. J Dent. 1999;27(1):47-52. 21 Williams PT, Hedge GL. Creep-fatigue as a possible cause of dental amalgam margin failure. J Dent Res. 1985;64(3):470-5. 22 Osborne JW. Creep as a mechanism for sealing amalgams. Oper Dent. 2006;31(2):161-4. 23 Deligeorgi V, Mjr IA, Wilson NH. An overview of reasons for the placement and replacement of restorations. Prim Dent Care. 2001;8(1):5-11. 24 Giachetti L, Scaminaci Russo D, Bambi C, Grandini R. A review of polymerization shrinkage stress: current techniques for posterior direct resin restorations. J Contemp Dent Pract. 2006;7(4):79-88. 25 van Dijken JW. A 6-year clinical evaluation of Class I polyacid modified resin composite/resin composite laminate restorations cured with a two-step curing technique. Dent Mater. 2003;19(5):423-8. 26 Gonzlez-Lpez S, Vilchez Daz MA, de Haro-Gasquet F, Ceballos L, de Haro-Muoz C. Cuspal flexure of teeth with composite restorations subjected to occlusal loading. J Adhes Dent. 2007 Feb;9(1):11-5. 27 Rttermann S, Krger S, Raab WH, Janda R. Polymerization shrinkage and hygroscopic expansion of contemporary posterior resin-based filling materials: a comparative study. J Dent. 2007;35(10):806-13. Epub 2007 Sep 10. 28 Cadenaro M, Biasotto M, Scuor N, Breschi L, Davidson CL, Di Lenarda R. Assessment of polymerization contraction stress of three composite resins. Dent Mater. 2008;24(5):681-5. Epub 2007 Aug 31. 29 Visvanathan A, Ilie N, Hickel R, Kunzelmann KH. The influence of curing times and light curing methods on the polymerization shrinkage stress of a shrinkage-optimized composite with hybrid-type prepolymer fillers. Dent Mater. 2007;23(7):777-84. Epub 2006 Aug 17. 30 Kleverlaan CJ, Feilzer AJ. Polymerization shrinkage and contraction stress of dental resin composites. Dent Mater. 2005;21(12):1150-7. Epub 2005 Jul 22. 31 Bouillaguet S, Gamba J, Forchelet J, Krejci I, Wataha JC. Dynamics of composite polymerization mediates the development of cuspal strain. Dent Mater. 2006;22(10):896-902. Epub 2005 Dec 20. 32 Beyth N, Domb AJ, Weiss EI. An in vitro quantitative antibacterial analysis of amalgam and composite resins. J Dent. 2007;35(3):201-6. Epub 2006 Sep 25. 33 Willershausen B, Callaway A, Ernst CP, Stender E. The
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influence of oral bacteria on the surfaces of resin-based dental restorative materials: an in vitro study. Int Dent J. 1999;49(4):231-9. Imazato S. Antibacterial properties of resin composites and dentin bonding systems. Dent Mater. 2003;19(6):449-57. Ibid. Soh MS, Yap AU, Sellinger A. Physicomechanical evaluation of low-shrinkage dental nanocomposites based on silsesquioxane cores. Eur J Oral Sci. 2007;115(3):230-8. Carioscia JA, Lu H, Stanbury JW, Bowman CN. Thiolene oligomers as dental restorative materials. Dent Mater. 2005;21(12):1137-43. Epub 2005 Jul 25. Bouillaguet S, Gamba J, Forchelet J, Krejci I, Wataha JC. Dynamics of composite polymerization mediates the development of cuspal strain. Dent Mater. 2006;22(10):896-902. Epub 2005 Dec 20. Ilie N, Jelen E, Clementino-Luedemann T, Hickel R. Lowshrinkage composite for dental application. Dent Mater J. 2007;26(2):149-55. Ilie N, Hickel R. Silorane-based dental composite: behavior and abilities. Dent Mater J. 2006;25(3):445-54. Weinmann W, Thalacker C, Guggenberger R. Siloranes in dental composites. Dent Mater. 2005 Jan;21(1):68-74. Musanje L, Sakaguchi RL, Ferracane JL et al. Light-source, material and measuring-device effects on contraction stress in composites. IADR 2005;Abstract 0294. Bouillaguet S, Gamba J, Forchelet J, Krejci I, Wataha JC. Dynamics of composite polymerization mediates the development of cuspal strain. Dent Mater. 2006;22(10):896-902. Epub 2005 Dec 20. Ernst CP, Meyer GR, Klcker K, Willershausen B. Determination of polymerization shrinkage stress by means of a photoelastic investigation. Dent Mater. 2004;20(4):313-21. Lang R, Groeger G, Rosentritt M, Handel G. Adhesion of S. mutans to dental restorations. CED 2005, abstract 0426.
Author Profile
Robert C. Margeas, DDS, FAGD Dr. Robert Margeas currently serves as Adjunct Professor in the Department of Operative Dentistry at the University of Iowa College of Dentistry. He is also the Clinical Director and Instructor at the Center for Esthetic Excellence, Chicago, IL. Dr. Margeas has published numerous articles on esthetic dentistry and is a highly sought after international lecturer on the subject. His credentials include board certification by the American Board of Operative Dentistry and he is a Fellow of the Academy of General Dentistry (AGD). Dr. Margeas is a consultant in Oral Health matters for the country of Canada. He maintains a very successful private practice, with a focus on comprehensive esthetic restorative dentistry, in Des Moines, IA.
Disclaimer
Dr. Margeas has been a speaker on behalf of 3M ESPE as well as other composite manufacturers.
Reader Feedback
We encourage your comments on this or any PennWell course. For your convenience, an online feedback form is available at www.ineedce.com.
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Questions
1. Historically, posterior direct restorations involved the use of _________. a. filaments b. amalgams c. composites d. all of the above 2. Old silicate restorations were found in a 1986 study to be replaced due to _________ and _________. a. expansion, microleakage b. expansion, lost fillings c. marginal discrepancies, lost fillings d. expansion, contraction 3. Posterior tooth-colored restorations had been introduced _________. a. by the 1960s b. by the 1970s c. by the 1980s d. none of the above 4. By 1999, at least 59% of direct posterior restorations were composites. a. True b. False 5. The ideal posterior restorative material should offer _________. a. ease of placement b. biocompatibility c. appropriate flexural and compressive strength d. all of the above 6. Posterior Class I and II restorations must resist _________ and _________. a. occlusal forces, buccal forces b. occlusal forces, forces of mastication c. buccal forces, forces of dysphagia d. none of the above 7. Annual failure rates in a study of direct posterior restorations predominantly placed since 1990 were _________ and _________. a. 2% for amalgams, 4.5% for composites b. 1% for composites, 3% for amalgams c. 3% for amalgams, 2.2% for composites d. none of the above 8. As a result of recent developments, the ideal restorative material now exists. a. True b. False 9. The quality of a restoration and the patients (preventive) home care are important factors in precluding repeat replacement of restorations. a. True b. False 10. The main material factors in the replacement of amalgam restorations have been found to be _________ and _________. a. bulk fractures, marginal degradation b. polymerization shrinkage, microsopic fractures c. bulk fractures, polymerization shrinkage d. all of the above
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11. The longevity of restorations depends only on clinical technique. a. True b. False 12. Bonded amalgam restorations have been found to offer support of undermined enamel equal to that of composites, with _________. a. superior marginal adaptation b. inferior marginal adaptation c. inferior obtusion d. none of the above 13. Creep-fatigue may be a factor in _________. a. marginal fracture of amalgam restorations b. bulk fracture of amalgam restorations c. reducing stress caused by expansion of amalgam restorations d. a and c 14. Poor esthetics with amalgam is the main reason why patients increasingly prefer direct posterior composites over amalgams. a. True b. False 15. Reasons for composite restoration failure include _________. a. marginal degradation b. discoloration and loss of anatomic shape c. bulk fracture d. all of the above 16. Secondary caries is the single most common reason for the replacement of both amalgam and posterior composite restorations. a. True b. False 17. Polymerization shrinkage of composites results in stresses that can lead to _________. a. enamel cracks b. postoperative sensitivity c. marginal degradation d. all of the above 18. Polymerization shrinkage occurs due to the affiliation of resin molecules with one another and the formation of chemical bonds that reduce the materials bulk. a. True b. False 19. Polymerization shrinkage is influenced by the _________. a. intensity and duration of light curing b. materials shade c. materials chemistry and curing dynamics d. a and c 20. A recent study by _________ found that cuspal deflection (tooth deformation) was statistically similar for conventional hybrid composites and flowable composites. a. Bourguignon et al. b. Bouillaguet et al. c. Black et al. d. Bellman et al.
21. Composite restorations generally offer superior antibacterial properties compared to amalgam. a. True b. False 22. Fluoride-releasing composites appear to offer substantial benefits over nonfluoride composites. a. True b. False 23. Currently-available composites offer _________ compared to the earliest composites. a. improved color stability and esthetics b. improved physical properties c. improved handling d. all of the above 24. Biofilm-formation reduction on composites has been tried by _________. a. modifying composites b. modifying dentin bonders c. including glutaraldehyde in the dentin bonder d. all of the above 25. Silsesquioxane-based nanocomposites and oligomeric thiolene-based materials have been investigated for reductions in shrinkage. a. True b. False 26. Silorane-based posterior composite material has been found to reduce polymerization shrinkage to <1%. a. True b. False 27. Shrinkage using silorane-based composite material is decreased due to _________. a. the silorane ring simultaneously opening up and compensating for material shrinkage during curing b. the oxygen content compensating for material shrinkage during curing c. a condensation of the material during bonding d. none of the above 28. Silorane-based composite materials can be used with any bonding agent. a. True b. False 29. A long working time under operatory light aids detailed shaping and flash removal prior to curing of composite materials. a. True b. False 30. Composites are being placed in preference to amalgams in large part due to _________. a. patient demands for esthetics b. easier placement than with amalgams c. an increased ability to do minimal preparations and provide bonded restorations d. a and c
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ANSWER SHEET
The Properties and Selection of Posterior Direct Restorations

Name: Address: City: Telephone: Home ( ) Title: E-mail: State: Office ( ) ZIP: Specialty:
Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.
Educational Objectives
1. Describe the modes of failure, advantages and disadvantages of amalgam restorations 2. Describe the modes of failure, advantages and disadvantages of composite restorations 3. Describe the properties of an ideal restorative material 4 Describe the types of composite materials and recent new materials and their application
Mail completed answer sheet to
Academy of Dental Therapeutics and Stomatology,

A Division of PennWell Corp.
P.O. Box 116, Chesterland, OH 44026 or fax to: (440) 845-3447

For immediate results, go to www.ineedce.com and click on the button take tests Online. answer sheets can be faxed with credit card payment to (440) 845-3447, (216) 398-7922, or (216) 255-6619. P ayment of $59.00 is enclosed. (Checks and credit cards are accepted.) If paying by credit card, please complete the following: MC Visa AmEx Discover Acct. Number: _______________________________ 0 0 0 0 0 0 Exp. Date: _____________________ Charges on your statement will show up as PennWell
Course Evaluation
Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. 1. Were the individual course objectives met? Objective #1: Yes No Objective #2: Yes No 2. To what extent were the course objectives accomplished overall? 3. Please rate your personal mastery of the course objectives. 4. How would you rate the objectives and educational methods? 5. How do you rate the authors grasp of the topic? 6. Please rate the instructors effectiveness. 7. Was the overall administration of the course effective? 8. Do you feel that the references were adequate? 9. Would you participate in a similar program on a different topic? 5 5 5 5 5 5 4 4 4 4 4 4 Yes Yes Objective #3: Yes No Objective #4: Yes No 3 3 3 3 3 3 2 2 2 2 2 2 No No 1 1 1 1 1 1
10. If any of the continuing education questions were unclear or ambiguous, please list them. ___________________________________________________________________ 11. Was there any subject matter you found confusing? Please describe. ___________________________________________________________________ ___________________________________________________________________ 12. What additional continuing dental education topics would you like to see? ___________________________________________________________________ ___________________________________________________________________ PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.
AUTHOR DISCLAIMER Dr. Margeas has been a speaker on behalf of 3M ESPE as well as other composite manufacturers. SPONSOR/PROVIDER This course was made possible through an unrestricted educational grant from 3M ESPE. No manufacturer or third party has had any input into the development of course content. All content has been derived from references listed, and or the opinions of clinicians. Please direct all questions pertaining to PennWell or the administration of this course to Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.com. COURSE EVALUATION and PARTICIPANT FEEDBACK We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please e-mail all questions to: macheleg@pennwell.com. INSTRUCTIONS All questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification forms will be mailed within two weeks after taking an examination. EDUCATIONAL DISCLAIMER The opinions of efficacy or perceived value of any products or companies mentioned in this course and expressed herein are those of the author(s) of the course and do not necessarily reflect those of PennWell. Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. COURSE CREDITS/COST All participants scoring at least 70% (answering 21 or more questions correctly) on the examination will receive a verification form verifying 4 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 3274. The cost for courses ranges from $49.00 to $110.00. Many PennWell self-study courses have been approved by the Dental Assisting National Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet DANBs annual continuing education requirements. To find out if this course or any other PennWell course has been approved by DANB, please contact DANBs Recertification Department at 1-800-FOR-DANB, ext. 445. RECORD KEEPING PennWell maintains records of your successful completion of any exam. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt. CANCELLATION/REFUND POLICY Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. 2008 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell
AGD Code 253
REST0807PAT
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3D Case Picture Study

By Dr. Jeffrey M. Rosenberg, DDS
Temple University School of Dentistry 1982 Private Practice Dentistry 25yrs. The Dental HealthCare Group, Philadelphia PA Fellow - Academy of General Dentistry Diplomat American Academy of Pain Management. Member American Dental Association Member American Academy of Cosmetic Dentistry Founder/CEO Quanotech Research & Development Company. Holds 3 patents.
Pre-Op Radiograph of Proximal Distal Caries: Figure 1
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3D Case Picture Study: Continued...

Pre-Wedge: Figure 2
Mark Occlusion and Place Dam: Figure 3
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Conservative Preparation: Figure 4
Sectional Band and 3D Ring Placed: Note contour of proximolingual-ooclusal of band to compensate for rotated tooth position. Figure 5
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Tooth Prepared For Adhesion: Figure 6
Conservative Resin Filled: Figure 7
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Initial Contour Before Polishing: Figure 8
Final Restoration: Figure 9
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Restoration of a Class II Lesion

By Dr. Robert G. Ritter, DMD Robert G. Ritter D.M.D. received his dental degree from The Medical University of South Carolina College of Dental Medicine in 1994. He has served as the Clinical Director for IOAD, The Institute for Oral Art and Design in Sarasota, Fl with Master Ceramist Lee Culp C.D.T. He has been the program leader of PowerPAC for the Pacific Aesthetic Continuum (P.A.C.~Live.) He has taught at TEAM dental seminars and 3:1 Foundation hands on programs helping dentists implement the newest esthetic dentistry into their offices. Dr. Ritter is also an Editorial member of REALITY. Dr. Ritter has a practice that focuses on adhesive esthetic dentistry. He promotes esthetic dentistry as part of his mainstream dental care. He was raised in Palm Beach County and now resides in Palm Beach Gardens.
A 50-year-old female patient presented with a Class II lesion on the distal surface of tooth #21. Restoration with Ivoclar Vivadents Tetric and Garrison Dental Solutions direct restorative materials was treatment planned. A Class II lesion on the distal of tooth #21.
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By Dr. Robert G. Ritter, DMD
A Garrison Dental Solutions FenderWedge was placed.
Facial view of the FenderWedge in place.
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A Class II preparation was created. Note the bur marks on the FenderWedge.
Garrisons Wedge Wand in place.
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Garrisons Composi-Tight 3D matrix in place. Note the adaptation of the Soft Faced tine.
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Using the total-etch technique, phosphoric acid was applied to the cavity for 15 seconds.
Excite bonding agent was applied.
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After light curing for 10 seconds, the bonding agent exhibits a shiny appearance.
Tetric EvoFlow flowable composite (Shade A1) is applied.
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Tetric Color (Ochre) is appled with an endodontic file.
Excess composite is removed before light curing.
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Heres the restoration immediately after matrix removal. Note the absence of buccal or lingual flash.
The final result offers exceptional esthetics, broad tight contact
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and excellent shade match.
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Segmental Matrices for Primary and Permanent Class II Composite Restorations

By Fred S. Margolis, DDS, FICD,FACD, FADI
Dr. Fred Margolis received his B.S. and D.D.S. from The Ohio State University and his certificate in pediatric dentistry from the University of Illinois College of Dentistry. Dr. Margolis is a Clinical Instructor at Loyola Universitys Oral Health Center. He is a fellow of the Pierre Fauchard Academy, International College of Dentists, American College of Dentists and the Odontographic Society. He is the author of a course manual, Beautiful Smiles for Special People, and has written articles for both lay and professional publications. He is a product evaluator for several dental manufacturers. Dr. Margolis is director of the Institute for Advanced Dental Education and has lectured both nationally and internationally. He is a consultant to the ADAs Council on Dental Practice and an ADA Seminar Series Lecturer. Dr. Margolis is in full-time private practice of pediatric dentistry in Buffalo Grove, Illinois.
Introduction: When restoring Class II restorations in children, teenagers and adults, the goal is to provide tight contacts, good contours, and proper anatomy of the restoration. There are many types of matrices which one may use. The author has found, in restoring thousands of restorations in children and teenagers, segmental metal matrices provide all three of the goals previously mentioned. The purpose of this article is to review several previously published articles and illustrate several examples of metal matrices. Case 1: T-bands The T-bands that provide the best contacts are the .001 brass matrices. These bands can provide quick and easy matrices and are used by the author for young children. These bands are used with wedges and provide tight contacts for Class II restorations in young children. (Firgure 1) Figure 1
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Segmental Matrices for Primary and Permanent Class II Composite Restorations. Continued...
By Fred S. Margolis, DDS, FICD,FACD, FADI
Case 2: Segmental Matrix Bands Figure 2 According to Loomans, B.A., et al; The use of sectional matrices combined with separation rings resulted in tighter proximal contacts compared to when circumferential systems were used. (1) The author has found this to be true in both primary and permanent teeth when restoring Class II resin composite, compomer, resin modified glass ionomers, and glass ionomer materials. Figure 2 illustrates the use of the segmental matrix system in primary class II restorations in children.
Case 3: GDS Matrix System Figure 3 The author has lectured throughout the world and has asked his audience which matrices give the best contacts they had ever experienced. In EVERY case, the segmental metal matrices is the answer given. The segmental matix, when used with a wedge and separation rings, gives tighter proximal contacts in permanent Class II restorations as shown in figure 3. The author recently discovered another advantage in using segmental matrices. Many of our teenage and adult patients are undergoing orthodontic treatment and therefore may have bands, brackets, and archwires in place when a Class II restoration may be needed. With a segmental matrix the operator does not have to remove the wires and or bands and brackets, but can utilize the segmental matrix to provide the required contour and proximal contacts. (Figure 4) Figure 4 Garrison Dental Solutions has newer 3D-Rings that can be used for permanent teeth, however due to their shape, the author prefers the Gold or Grey rings for primary molars. The Soft Face 3-D ring (orange) is more difficult for primary molars and around orthodontic appliances. In these cases, the Composi-Tight Gold or Grey thin tine G-Rings are indicated. Reference: 1) Loomans, B.A., et al. Comparison of proximal contacts of Class II resin composite restorations in vitro. Oper Dent. 2006 Nov.-Dec; 31(6):688-693.
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Case Presentation

by Dr. Len Boksman D.D.S., B.Sc., F.A.D.I., F.I.C.D.

The Use of Separating Rings in the Placement of Class II Composite Resins

Putting ideas into practice.

150 DeWitt Lane Spring Lake, MI USA 49456

Call toll free or online at www.garrisondental.com

The Use of Separating Rings in the Placement of Class II Composite Resins

Putting ideas into practice.

150 DeWitt Lane Spring Lake, MI USA 49456

Call toll free or online at www.garrisondental.com

The Use of Separating Rings in the Placement of Class II Composite Resins

designed to minimize sticking to the bonding agent.

Putting ideas into practice.

Call toll free or online at www.garrisondental.com

The Use of Separating Rings in the Placement of Class II Composite Resins

Putting ideas into practice.

Call toll free or online at www.garrisondental.com

The Use of Separating Rings in the Placement of Class II Composite Resins

of C-factor shrinkage.47 An incremental insertion technique

Putting ideas into practice.

Call toll free or online at www.garrisondental.com

The Use of Separating Rings in the Placement of Class II Composite Resins

Putting ideas into practice.

Call toll free or online at www.garrisondental.com

The Use of Separating Rings in the Placement of Class II Composite Resins

Putting ideas into practice.

Call toll free or online at www.garrisondental.com

The Use of Separating Rings in the Placement of Class II Composite Resins

Putting ideas into practice.

150 DeWitt Lane Spring Lake, MI USA 49456

Call toll free or online at www.garrisondental.com

The Use of Separating Rings in the Placement of Class II Composite Resins

Putting ideas into practice.

150 DeWitt Lane Spring Lake, MI USA 49456

Call toll free or online at www.garrisondental.com

Garrison Dental Solutions

Call Today Toll-Free 888.437.0032

Mention code CS004

Garrison Dental Solutions

Call Today Toll-Free 888.437.0032

Mention code CS004

Garrison Dental Solutions

Call Today Toll-Free 888.437.0032

Mention code CS004

Garrison Dental Solutions

Call Today Toll-Free 888.437.0032

Mention code CS004

Garrison Dental Solutions

Call Today Toll-Free 888.437.0032

Mention code CS004

Garrison Dental Solutions

Call Today Toll-Free 888.437.0032

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A Series of Photos Showing A MO Composite on #3

Pre-operative image showing failed amalgam with recurrent carries: Figure 1

Garrison Dental Solutions

Call Today Toll-Free 888.437.0032

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A Series of Photos Showing A MO Composite on #3: Continued

Rubber dam in place: : Figure 2

Tooth is prepped: : Figure 3

Garrison Dental Solutions

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Case Presentations & Online CE

Case Presentations & Online CE