When restoring the posterior dentition, care must be taken to ensure development of proper occlusal,

anatomical, and aesthetic surface contours. The creation of ideal proximal contours and interproximal contacts can, however, be challenging when using a direct technique. The formation of tight contacts is critical to prevent subsequent periodontal involvement as a result of food impaction and lodging between the posterior teeth. Therefore, the implementation of an established restorative approach combined with the selection of a reliable restorative material is paramount.

Material SelectionContemporary composite resin materials (eg, Gradia Direct, GC America, Islip, IL; Tetric EvoCeram, Ivoclar Vivadent, Amherst, NY; Venus, Heraeus Kulzer, Armonk, NY) have evolved to provide optimal handling proper-ties, strength, polishing characteristics, and increased wear resistance. While the literature has proven that overall clinical success is often reliant upon the restor-ative material’s handling and ease-of-use,1-3 direct

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DEVELOPMENT OF PREDICTABLE TOOTH ANATOMY AND INTERPROXIMAL CONTACTS USING A DIRECT RESTORATIVE TECHNIQUE

Christopher Ramsey, DDS*

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Figure 2. Rubber dam isolation was achieved to ensure maintenance of the operative field, and the existing decay was removed.

Figure 1. Preoperative occlusal appearance. The patient pre-sented for treatment of pain and discomfort associated with the decay in the distal aspect of tooth #29 (45).

techniques require careful tooth reduction in order to properly distribute the intraoral stresses present in these regions.4 With the increased focus on a mini-mally invasive approach to all restorative procedures, a composite material that will provide optimal wear resistance within the narrow tooth preparation that is limited to the removal of the carious structures is imperative (Figure 1).

Clinical TechniqueProper IsolationReliable rubber dam isolation is imperative to prevent potential contamination and ensure sufficient moisture control (Figure 2).5 Any necessary moisture can be sup-plied using a wet gauze that can be periodically applied should an extended treatment period be required.6 While many dental professionals continue to eschew the use of proper isolation, it is the author’s opinion that rubber dam isolation remains a critical step in the restorative procedure that will provide improved results and an optimal working field.

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Composite RestorationThe development of an accurate shade match is crucial to the success of any restoration, in both the anterior and posterior regions. If the patient has previ-ously undergone whitening procedures for the entire arch, the selection of a bleached composite shade (eg, Gradia Direct BW, GC America, Islip, IL; Tetric EvoCeram Bleach XL, Ivoclar Vivadent, Amherst, NY; Venus Super Bleach, Heraeus Kulzer, Armonk, NY) will allow the clinician to accurately mimic the existing struc-tures while adding internal characterizations as neces-sary to replicate natural anatomy (Figures 6 and 7). Excess resin can then be removed prior to light curing. Final finishing and polishing is then performed using a tapered diamond finishing bur to smooth the interproxi-mal regions, followed by a series of rubber cups and points to develop the necessary tooth anatomy. Once occlusion is verified and adjustments made as needed,

Use of a Retainer RingBecause the composition of many resin materials pro-vides little internal force to counteract deformation prior to polymerization, the use of a matrix band (ie, V-Ring, Triodent, Los Angeles, CA) is critical to the development of proper proximal physiological form.7,8 Additional space can also be achieved using a simple wedge device to ensure sufficient access to the inter-proximal regions following placement of the retainer ring (Figure 3). Once the operative field is properly prepared for direct resin buildup, a total-etch technique can be applied using a 37% phosphoric acid material for approximately 15 to 20 seconds in order to ensure a formidable bond during adhesion and resin layering (Figure 4). A desensitizing agent (ie, Gluma, Heraeus Kulzer, Armonk, NY) can then be applied to further prevent postoperative sensitivity prior to placement of the adhesive agent (Figure 5).

Figure 4. The prepared structures were subsequently etched for approximately 15 seconds to ensure predictable bond strength.

Figure 3. A sectional matrix system (ie, V-Ring, TrioDent, New Zealand) and wedge were positioned to facilitate interproximal access during direct buildup.

Figure 6. A bleached composite shade was applied to the internal aspect of the interproximal region to provide an accurate shade match with the adjacent tooth.

Figure 5. A desensitizing agent was applied to occlude the peripheral dentinal tubules and prevent postoperative sensi-tivity prior to adhesion.

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a surface sealant (eg, Embrace WetBond, Pulpdent, Watertown, MA; ClearMatch, Shofu, Menlo Park, CA) can be applied to provide additional protection from subsequent bacterial infiltration (Figure 8).

DiscussionThe use of scientifically proven treatment approaches and materials will ensure that each patient present-ing for minimally invasive restorative procedures will receive optimal care. By following recommended guidelines regarding the usage of rubber dam isola-tion and retainer ring or matrix band placement, the clinician can predictably develop optimal interproximal anatomy that will improve overall pulpal health, occlusal stability, anatomical restitution, marginal perfection, and interproximal integrity.8 Because current resin formulations and handling properties provide minimal internal force to counteract the rigidity of the matrix device, the composite material can be easily main-tained within the circumferential matrix band. Thus, although tight contacts in small-to moderate-sized cavities may be possible for posterior composites using circumferential matrices, contemporary matrix systems and wedging techniques allow the clinician to establish a proper contact regardless of the size of the interproximal cavity.9

ConclusionDirect restoration of the posterior region requires care and diligence when creating interproximal contacts. Restorations with open contacts are the preeminent fac-tor in premature failure of posterior composites. The maintenance of interproximal integrity will ensure that

Figure 8. Postoperative appearance demonstrates natural aesthetics and interproximal contacts.

Figure 7. Internal tinting and characterization were placed within the incisal layer of the occlusal surface.

the patient will be able to maintain optimum hygiene via flossing and interdental cleaning while provid-ing as little space as possible for impacted food to become lodged in the existing spaces. Ensuring optimal contacts—combined with the selection of a durable restorative material—will, therefore, eliminate the need for re-treatment and increase overall patient satisfaction and oral health.

References 1. Jackson RD, Morgan M. The new posterior resins and a sim-

plified placement technique. J Am Dent Assoc 2000;131(3):375-383.

2. Peumans M. Do condensable composites help to achieve better proximal contacts? Dent Mater 17(6):533-541.

3. da Rosa Rodolpho PA, Cenci MS, Donassollo TA, et al. A clinical evaluation of posterior composite restorations: 17-year findings. J Dent 2006;34(7):427-435.

4. Koczarski M. Achieving natural aesthetics with direct resin com-posites: Predictable clinical protocol. Pract Proced Aesthet Dent 2005;17(8):523-525.

5. de Lourdes Rodrigues Accorinte M, Reis A, Dourado Loguercio A, et al. Influence of rubber dam isolation on human pulp responses after capping with calcium hydroxide and an adhe-sive system. Quint Int 2006;37(3):205-212.

6. de Araujo EM, Baratieri LN, Monteiro S, et al. Direct adhe-sive restoration of anterior teeth: Part 2. Clinical protocol. Pract Proced Aesthet Dent 2003;15(5):351-357.

7. Krauss S. Achieving optimal interproximal contacts in posterior direct composite restorations. J Am Dent Assoc 1998;129(10):1467.

8. Liebenberg WH. The proximal precinct in direct posterior com-posite restorations: Interproximal integrity. Pract Proced Aesthet Dent 2002;14(7):587-594.

9. Strydom C. Handling protocol of posterior composites—Part 3: Matrix systems. S Afr Dent J 2006;61(1):18-21.

* Private practice, Palm Beach Gardens, Florida.

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