One of the challenges in successfully placing class five composite restorations is tissue management. Composite requires a clean dry field to achieve optimal bond strengths and ensure long term success. Often when placing a class five composite we encounter prep margins that are in proximity with or below the gingival margin. These clinical situations require us to manage the following individually or in combination:
- Sulcular Fluid
- Tissue Retraction or Removal
There are a variety of techniques we can employ for tissue management in these situations. When the prep margin is equigingival or above with good tissue health the simple placement of a piece of retraction cord can be all we need to create a dry field. Alternatively if the margin of the prep will be at the gingival margin or just below and the tissue is healthy often a well executed rubber dam that has been inverted both retracts and controls fluid contamination. Very often because of the presence of a leaking restoration we will be replacing, decay or inadequate home care the tissue is inflamed and the bleeds due to the trauma of retraction cord or a rubber dam. In addition when we need to prepare below the gingival margin we may need to remove tissue. In these instances we need to combine tissue removal and isolation from sulcular fluid and blood.
My favorite tool in these clinical cases is my DEKA CO2 laser. It allows me to remove tissue with a high degree of accuracy and minimal spread of tissue damage, thereby allowing for rapid healing and maximal patient comfort. I place the tissue margin 1.5mm gingival to the prep margin to control sulcular fluid and the laser energy seals the capillaries and creates hemostasis. If tissue removal is done mechanically with a bur or scalpel make sure that any hemostatic agents you use do not interfere with bonding or cause post-op discoloration of the tooth or composite.