Who is this blog post for? Any pre-dental student, current dental student, and eager clinician motivated to refine their daily practice.
Direct class II composite restorations are one of the most common procedures done in a general dentist office. This “bread and butter” procedure warrants being proficient and investing the time to improve your clinical skills.
It’s my pleasure to re-introduce our guest co-writer Dr. Charlie Cage. In true alignment with her slogan ‘solo dentistry bites’ we are here as an operative and general dentist duo, summarizing (6) clinical tips to help you improve on efficiency and quality of your class II restorations.
I’m constantly reminding myself that dentistry is a lifelong practice of continual learning. That being said, here's why you may find this blog helpful at any stage of mastering dentistry:
For the pre-dental student: If you are shadowing a general dentist for the first time, you will benefit greatly from this short read to familiarize yourself with the steps your dentist takes to excavate decay and restore a tooth's ideal function and esthetic.
For the current dental student (D1-D4): Whether you’re learning to restore a 19 MO composite in sim lab or preparing for your CDCA licensing exam, utilizing these following tips will give you a reliable workflow to reproduce on your test days amidst stressful academic moments in your training.
For the practicing dentist: Mastering the class II restoration is a great tool kit in our arsenal to provide a conservative treatment option that provides longevity to the life cycle of a tooth. When compared to the traditional class II amalgam restoration, the composite relies on a proper adhesive bonding protocol rather than GV Black’s “extension for prevention” i.e adding an occlusal dovetail. These tips will also prevent your patients from suffering from issues such postoperative sensitivity or issues with flossing due to overhangs or poor interproximal contour.
With that being said, here are 6 clinical tips to help you restore your class II composites like a champ!
1. Rubber Dam Isolation:
Despite the eye rolls and sighs, studies (1) have shown that a properly placed rubber dam is the best form of isolation. Though Isolite is more convenient and tempting option, there is a higher risk for contamination from saliva, heme, or moisture from a patient's breathing which can weaken bond strength. *Note: This works great with or without an assistant and the best part is, once you are out of dental school, you can train your dental assistant to place your rubber dams for you.
2. Sectional matrix
Utilizing a sectional matrix system ie. Garrison V3 or Palodent provides reliable contact and embrasures of your restoration. *Burnishing is not needed with this matrix system. It is key to ensure with your mirror or direct vision that your wedge and matrix band fully seal the gingival floor of your preparation.
Pro-tip: if you can, avoid tofflemire for composite restorations as this combination can lead to open contacts in your restoration (reserved for amalgam).
If you use it in a clinical setting where you are limited to only tofflemire matrix and wooden wedges, burnish your contact aggressively after doing a quarter turn release of the band.
Consider restoring using snow plow technique:
Seal floor of preparation using a combination of uncured flowable along edges of preparation layered with packable composite and cure in increments.
Clean up is important to remove flash.
3. Bonding:
This will depend on what materials are offered at your dental school/dental office, but generally reliable bonding results come with using either a 4th, 6th, or 7th generation bonding agent (generally…bonding agents are a bit more complicated to overgeneralize into one category).
In the last year, I’ve been using ScotchBond Universal Plus (7th generation) which is the first radiopaque adhesive agent. This is revolutionary to distinguish recurrent decay vs adhesive agent in your post operative bitewings and at recall exams.
4. Lobe technique for composite placement:
Restoring a composite one “lobe” at a time allows the provider to reduce the C factor of a restoration. The c-factor is the ratio of bonded to unbonded surfaces of the tooth. Decreasing c-factor prevents polymerization shrinkage when photoactivating resin, which can decrease patient post-op sensitivity. *This is a great technique to more accurately mimic the tooth natural anatomy and even incorporate stains for a more realistic tooth.
5. Light cure: When it comes to light curing, distance plays a major factor in the depth of cure. The light’s reach can significantly compromise the full cure of your restorative material. We recommend light curing yourself as your assistant is often farther away from the patient’s mouth. Curing your restoration from different angles will also help to ensure a full cure.
Caution: uncured resin can lead to patient post op sensitivity and staining of restorative material.
6. Finishing and occlusion check
Finish interproximally very carefully with 12 blade or interproximal strip to create smooth margins and occlusal embrasures.
Check occlusion with articulation paper (tells you where the occlusion is) and shimstock (tell you how hard the occlusion is) to avoid minor changes in the patient’s occlusion. Utilize the shimstock before AND after to identify occlusal stops and avoid occlusal changes.
Bonus tip: taking intraoral photos and post-operative bitewing of your restoration is the best way to seek constructive feedback and improve your clinical skills!
If you enjoyed this blog post, check out our latest reel on restoring your class 2 composites like a champ on instagram @thepredentalguide @dr.charliecage.
References:
Falacho RI;Melo EA;Marques JA;Ramos JC;Guerra F;Blatz MB; (n.d.). Clinical in-situ evaluation of the effect of rubber dam isolation on bond strength to enamel. Journal of esthetic and restorative dentistry : official publication of the American Academy of Esthetic Dentistry ... [et al.]. https://pubmed.ncbi.nlm.nih.gov/36325593/