One of the largest complaints I hear about posterior composites is in our ability to predictably create tight interproximal contacts. I often joke that when I am ready I take the floss from my assistant, place it in the occlusal embrasure, turn my head and say a prayer before I try and pop it through to the gingival embrasure. Over the years it has been the combination of multiple steps that have helped me overcome this technique challenge. The first thing I do is pre-wedge any tooth that will be prepared with an interproximal box. This step creates adequate tooth separation to overcome the thickness of the band.
One of the most critical factors in the success of posterior composites is adequate isolation. Our ability to achieve acceptable bond strengths and prevent marginal breakdown and leakage are dependent on it. Blood and saliva are the enemy during any adhesive procedure. There are numerous options that all allow us to achieve proper isolation. The tried and true is still placing a rubber dam, and even as I type this I know people are cringing at the thought of it. With practice and proper technique rubber dam placement can become easy and efficient. In addition there is also the option of utilizing a split dam technique. In this approach one large slit is created that goes over multiple teeth and is anchored by a clamp on the most posterior tooth and flossed between the anterior abutment teeth.
By far one of the most common procedures I do in a general practice is a posterior class two or class three. It is also one of the most popular topics to discuss at dental meetings or when a group of dentists gathers together. Why do we focus so on this one type of restoration, with all of the services we offer. Part of the answer is the frequency with which we offer this service. Another reason is that given the frequency we expect a pattern of predictability to develop, the results to be consistent and this process to become less stressful over time.
In the second part to this video series, Dr, Mark Kleive demonstrates a technique for mixing acrylic to fabricate an anatomic appliance. I utilize this exact technique for both anatomic and flat plane occlusal appliances. I have found that acrylic is still the easiest material to use in order to custom fit appliances so they are both passive and fit firmly without any “squish”. Additionally acrylic seems to survive the longest in the oral environment, and allows repairs and changes over time that minimize replacement of the entire appliance.
The topic of my most recent webinar on Dental XP is tissue management. The way we interact with the gingival tissue is a key ingredient in our restorative success. There are distinct aspects of tissue management all of which contribute to the overall result.
Pre-Restorative Tissue Health
Patients may present with generalized periodontal issues that require treatment prior to moving into the restorative phase or localized areas of gingival inflammation. Using a combination of mechanical therapy, which includes scaling and root planing and laser therapy, and adjunctive services including chlorhexidine varnish the goal is to work with tight, healthy gingival tissues.
I use anatomic appliances, sometimes known as Tanner Style appliances, very commonly in my practice. They are the appliance design that allows me to test alterations to the patient’s functional occlusion prior to replicating it on their teeth or in a reconstruction. This appliance design gives me the ability to vary inter-incisal angle, guidance, protrusive and intercuspal contacts and observe the impact on the patient’s muscles and joints. In addition the patient has the opportunity to experience what the proposed occlusion will feel like and add their preferences into the design. The final design of the occlusal scheme can be transferred into a wax-up or a final equilibration.
If it is possible, and not to weird, to be in love with a matrix band, I am. Over the last month I have started to use the Composi-Tight 3D Clear sectional matrix from Garrison and I can not imagine going back to using anything else. I have been a fan of sectional matrix systems for many years, but all of them have had little nuances that had to be overcome clinically. One of these is that the shape of the metal sectional matrix bands does not curve around the buccal and lingual walls of the tooth. Getting the matrix to seal the buccal and lingual walls of the proximal box required a combination of curling it around the handle of a mirror and using the wings of the separator ring.
Veneer preparations that include incisal reduction require a decision about lingual margin design. The two most common designs are a butt joint or a lingual wrap design. There are pros and cons to each of these designs and one or the other may be appropriate depending on the parameters of the case. Creating a butt joint margin is what I prepare more commonly these days. This design allows us to have adequate thickness of porcelain at the incisal edge to allow the technician artistic freedom to create incisal translucency and dentinal effects. Wrapping over the incisal edge also creates the ability for the technician to have artistic freedom, so what are the differences.
One of my goals in practice is to increase my efficiency and effectiveness during restorative procedures. A key ingredient in accomplishing this has been creating my own bur systems that are customized by procedure. So many dental offices I visit have a draw of burs behind the dentists, blocks full of randomly organized burs from front to back. How many times during a procedure are you looking for a different bur, or sending your assistant to find one? If the answer is even once you have lost productive time. My goals are clear-cut. I want to have every bur I need for a given procedure out in a block on my side of the patient. Second, a bur goes into the handpiece one time only. It goes in, is used to completion, and when it goes back into the block it means I am done with it for the remainder of the procedure. It is also grossly inefficient to keep putting the same bur in and out of the handpiece.
I believe it would be a nearly perfect world if the only type of margin I ever cut was supragingival. No retraction issues, no worries about tissue management and margins that any patient can clean with a toothbrush in addition to always bonding to enamel at the margin. Unfortunately I don’t get to always do supragingival margins, but more and more these days I can. In the early years of my practice when my esthetic restoration was a porcelain fused to metal crown with metal margins we placed the margins as far subgingival as possible without violating the biology. Why, to hide the ugly metal ring of the restoration. Today, all ceramic restorations have become esthetic enough that we no longer have to hide our work.