Building Custom Shells for Conservative Tooth

Reconstruction: An Elegant Strategy

Charalambos Papacharalambouss

Summary: This article, focused around case presentations, follows the natural progression/exploration of a single
idea about dealing with the Class II (approximal lesión) composite restoration. The gradual development of this
idea and the integration of a concept from one case to the next may have certain educational valué. Hopefully it
will show the potential for further experimentation and inspire a fresh mentality in using and handiing the main line
of conservative restorative materials today, le, resin composites.

Keywords: composite resin, Class II restoration, polymerization contraction, direct treatment, shell.

]Adhes Dent 2005; 7: 69-84. Submitted for publicatlon: 16.07.03; accepted for publication: 10.02.04.

espite the fuss we make about adhesivo dentistry Lege-artis protocols for working on anterior teeth are
D and the exciting ventura of minimal intervention/the well established and adequatelydernonstrated: mock-ups,
conservative approach, we seem to be held back by oíd creation of a palatal table, structured buildup utilizing
habits. We take pride :in our new materials and tech- different hue and transparency layers.'' Elements of the
niques, we strive to extend the application, exploit the technique comply with the nature of the material, means
esthetic potential, and of course improve long-term dura- intégrate with the purpose, handiing is gentle and delicate.
bility; but we seem to take littie notice of the inherent All of the above put the operator in control of the final
nature of the materials and the delicacy of the task at shape, form, esthetics, and functionality.
hand, beyond expressing the common reservation: "tech- Moving to the posterior "nonesthetic" región and to
nique sensitivo". the typical MOD Class II composite restoration, nothing of
Since the first posterior composite filling was made by the previously described elegance exists. Enthusiasm is
compactinga stubborn white mass into a cavity formed by low, not to say that perplexity prevails. Still, we compact
a fíat metal matrix and a Toffiemire retainer, quite a lot of our fillings and then we carve them - and in many cases
time has passed - but has our understanding followed that is literally true. We treat every posterior cavity from
the changas? the top: a hole that needs "filling". Even the work of the
experts seems to exhaust itself at sculpting the occiusal
anatomy combined with fissure staining. What about con-
trol or being in control?
' Oentisí in prívate practice, Nicosia, Cyprus. Starting with an opaque (metal) matrix is not a good
omen. Now, it seems that we have spent too many years
on the trivial task of pushing the matrix against the
EiHor's note: The following paper, showing a series of cases, has elicited adjacent tooth by some means or other: specially devel-
considerable controversy among the reviewers. Nevertheless, we want to pub-
lísft rt ;n order to show to you, our readers, the limits of what is possible with
oped Instruments, special attachments to the lightguide,
ad/iesive technoíogy, as weil as an application technique which is useful. How- megaceramic "fillers", or even the restorative material
ever, It does not mean that theJournai of Adhesive Dentistry recommends either itself, in a stiff and "compactable" form. It should be
Iherouí/ne use of direct composites in such large cavities or the use of adhesive
(echno/ogy without the application of rubber-dam. in the hands of this very noted that we even have the opportunity to dismiss the
sW/led practltioner, it was feasible, especialiy because there were very sound whole case and resort to a system that uses prefabricat-
|inj/va/ cond/t/ons which prevented bleeding. We a/so want to use this article
as a tesis for discussion. Dear readers, please send us your experience in deal-
ed ceramic proximal walls.
ing with such difficult cases. The notorious "contact point" issue...just accounting
for the proposed ideas and the time all of us have spent
¡FR
trying them out makes one melancholic. Then another
mood may emerge: frustration. Even if we've figured out
Reprlnt requests: Charalambos Papacharalambous, 3 Fiiimonos, 1071 NIcosla,
Cyprus. Tel: +357-22-377266, Fax: +357-22-662526. e-mai7: ch.papacharalam-
the best method and familiarized ourselves with it, even
bous^cytaneLcom.cy if we are not dealing with one of those cases where

Vol 7, No 1, 2005 69
Papacharalambous

Fig A What íf we were a b l e to bring all of our c a v i t i e s to the s t a t e of illustration on the right in o n e initial, swift o p e r a t i o n ?

(unpredictably) - because of a special combination of benefits and security, is (as always) a matter of self-disci
tooth incünation, tooth convexity, proximity or distance at pline and developing a good professional practice.
the cervical level, broken or unbroken tooth contact - no
system seems to work, frustration before the end result Case 1
is not entirely excluded. Not particularly because of a A first maxillary molar is presented with a deficient com-
gross failure, but maybe because the expertise and effort posite filling (Fig l a ) .
invested cali for a flawless result. After the oíd restoration has been removed and tÍK
Perhaps all of the above were deliberately exaggerat- cavity prepared, a precontoured transparent matrix issí
ed. Nonetheless, it is sad to say that achieving the cured at the cervical part with a wooden wedge, withoií
correct result in repaihng a difficult Class II defect using any form of retainer. The matrix is covered by a thin wasi
resin composite repeatedly, predictably, and affordably of flowable composite, and simultaneously, the two freí
(not to say elegantly) remains a wish rather than a fact. If ends are manually manipulated: they are held against tlK
the requirements for correct proximal contour are not tooth so that a closed loop is maintained and perhaps
exhausted ¡n "tight contact", but aiso address the individ- slid back and forth or even twisted, so that the matrixis
uality of every different case, extending to hygiene, func- always in contact with the cervical part of the tooth. Wheí
tional aspects by providing more elabórate types of con- the correct shape (and contact) is reached and all intef
vexity, or to esthetics, then things seem almost unwork- nal angles between the tooth and the matrix are wd
able. As a result, due to the "difficulty Índex" factor, a filled, it is frozen with a short light exposure; a fewset-
posterior composite restoration is still an option opposed onds are enough. Usually the matrix stays attacheijt
to amalgam (put in this context either by us or by our duly the composite, but even if it does not, fingers can I»
misinformed patients), as if conserving sound tooth removed. One can relax now, finish the polymerizatioi
structure was optional. and think of different ways to treat the new "occiusaf
Back to the drawing board, there are certain benefits cavity (Fig I b ) .
to be gained if we think of matenals and technique in We chose to fill the bulk of the cavity with a syringabi
terms of filling by injecting instead of filling by compact- dual-curing resin (Fig lc)andgivethe "core" material tira:
ing. In this context, first we have to establish (construct) to self-cure. A short light activation of the surface of tti
one thing: a shell. In the most common case this is the dual-curing material before proceeding with a paste-typi
proximal wall of a Class II cavity (Fig A). hybrid composite to complete the occiusal morphologyi
indicated, as this will reduce the thickness of the unpoj
merized layer.
CASE PRESENTATION Figure I d shows the finished result after contourii(
with flexible disks and polishing. Any excess material!
Note: in the following clinical examples, no rubber-dam is the buccal or palatal side was easily accessible sincei
used; working with severely damaged teeth and deep was away from the critical próxima! área. Note the des
interproximal boxes might falsely provide an excuse for able convexity that is rendered by the Hawe-Neos malí
not using it. It is impossible to overemphasize that un- used without any kind of retainer (Kerr-Hawe, Bioggic
compromised moisture control is imperativo for all adhe- Switzerland).
sive procedures. Even if strict moisture control is feasible
with special evacuators/tongue suppressors/saliva ejec- Case 2
tors (as was the case in the following clinical work), the Maxillary posterior teeth of a female patient. After remii:
author acknowledges that ¡ts use, providing additional al of amalgam fillings and secondary decay, teeth aret

70 The Journal of Adhesive Dentisí;

 Papacharalambous

Fig l a Unacceptable c o m p o s i t e r e s t o r a t i o n in left maxillary molar. FIg I b T h e t r a n s p a r e n t matrix h a s b e e n " p a i n t e d " with a thin w a s h
Mesial-buccal c u s p is m i s s i n g . of flowable c o m p o s i t e a n d w a s " f r o z e n " in t h e a d e q u a t e s h a p e w i t h
a s h o r t light e x p o s u r e .

Figle The newly formed 4-wall cavity is filled with a dual-cured Fig I d A paste-type hybrid w a s u s e d for t h e f i n a l la^ei An, uKcess
syringable material using Centrix-type fine tips. from the flowable material at the b u c c a l or palatal w a s e a s i l y a c c e s -
sible.

with thin, concave buccoiingual walls. The pulp has reced- hybrid composite is placed along the occiusal. ridge,
ed below the gum line and pulp horns are clearly visible which will push away the flowable composite for the sake
(Fig 2a). of a more durable, abrasion-resistant contact área and
Sectional transparent matrices are again secured by marginal ridge (Fig 2b). Esthetics can be served as well:
wooden wedges. The importance of this stage should be a halo effect can be created, using one of the "effect" ma-
specificallyemphasized. The wedges (sometimes custom terials offered by many manufacturers, or simply by using
trimmed) should provide separation of the teeth without a whitish opaque, if this is in accordance with the natural
distorting the matrices; the latter are selected from teeth. In case a mistake is made, it is usually possible to
among several types of convexity and/or provisión of an correct it. The unfavorable shape mesial to the second
extensión reproducing the shape below the dentino- premolar was corrected with additional material following
enamel junction (matrices are aiso trimmed - reduced in a manipulation of the wedges: a minute space was creat-
height - so as to bring the contact point to the desired ed between the matrix and the finished proximal surface
level). They are then carefully "tried out" by manipulating and flowable material was injected into this space, along
with the fingers or any suitable instrument. Dividing the with a small quantity of paste, driving it to the deepest
space between the teeth and visualizing the end result, point.
the matrices should be brought to the desired spatial Subsequently, the cavities are filled with the syringable
position easily and repeatedly. The ultímate goal is the core material (Fig 2c). For the final occiusal layer, a more
preparation of the matrices in such a way that manipula- translucent paste material is used, along with some
tion needed during the buildup is minimal. intensivo staining. The end result shows fine contact
We proceed with painting the matrices with the flow- "points", but one would prefer to have them wider,
able composite. But before curing, a stronger, paste-type extending towards the cervical aspect (Fig 2d).

Vol 7, No 1, 2005 71
Papacharalambous

Fig 2a M a t r i c e s that have b e e n appropriately t r i m m e d a r e s e c u r e d Fig 2b O n e by o n e , m a t r i c e s h a v e b e e n painted with flowable conv

by w o o d e n w e d g e s . {Although i n t e n d e d to be u s e d with a retainer, p o s i t e , but before light curing, a " r o p e " of p a s t e material h a s beei''
they were cut in half a n d used a s sectional for their favorable p l a c e d a l o n g the marginal ridge a n d c o n t a c t á r e a .
shape).

Fig 2 c C a v i t i e s Have b e e n filled with a s y r i n g a b l e dual-curing " c o r e " Fig 2d C o m p l e t e d r e s t o r a t i o n s at following appointment. Note ti»
material with g o o d wetting capability ( P e r m a l u d e ; Ultradent, S o u t h great d i s t a n c e a t the c e r v i c a l level, a condition that p o s e s additiois
J o r d á n , UT, USA.) difficulty.

Case 3 by other means (Fig 4a). The arrangement depicted isol)

A maxillary premolar with a broken palatal cusp is usually viously very delicate and ¡ts ability to withstand the relativf
treated with indirect methods. In this case, an uncut (full vigor of the bonding procedure and "painting" of the matri
circumference) matrix is used that is adequately trimmed must be "rehearsed" before initiating the procedure pe.
and secured by two wedges. Care has been taken to by blowing water spray). It may be necessary to constant|
match the palatal profile to that of the adjacent teeth hold the free end of the matrix against the buccal side,
(Figs 3a and 3b). As the shell was being formed, a precaution ws
The finished result did not pay much attention to es- taken in anticipation of a loóse contact (no separationj.
thetics; perhaps durability, the most prominent concern, the teeth has taken place). The matrix was somewhí
obscured the esthetic aspect (Figs 3c and 3d). "over-slid" against the adjacent tooth, and the extenda
área around the wide contact that was produced wasnr
Case 4 covered by the flowable composite. We see that the mí
Accepted clinical guidelines suggest that treatment of trix still adheres slightiy to the resin after polymerization
nonvital teeth should provide for remaining cusp cover- After that, the lower proximal part of the shell is reit;
age. However, cost issues or perhaps considerations on torced with additional material (Fig 4b):
behalf of the endodontist, often make conservative build- By doing this, two things have been accomplisheíS
up of such teeth necessary. First, we have a secure base for a wedge to sepárate tN
An endodontically treated hght maxillary molar is pre- teeth; second, we have a constant tensión of the matií
sented with an extended MO defect. A deep proximal box against the adjacent tooth, that will help retain contacta!,
prohibits the use of a wedge, the matrix must be secured the teeth move (Fig 4c).

72 The Journal of Adhesive Dentisti)

 Papacharalambous

FIg 3a A full c i r c u m f e r e n c e matrix is s e c u r e d a r o u n d the broken

palatal cusp of a s e c o n d maxillary premolar.

Flg3e The finished result a l r e a d y p o s e s the critical q u e s t i o n : How Fig 3d T h e r e s t o r a t i o n after 4 y e a r s of s e r v i n g in the l e a s t f a v o r a b l e
long will it last? o c c i u s a l s c h e m e : n o t e the w e a r on c a n i n e .

Then we take time to deal with esthetics: build the Advantages of the Technique
missing cusp with a medium-translucent whitish-gray ma- At this point, it is worth taking stock of where we stand.
terial and the ridge with a more opaque one. From inside We have managed to:
the cavity, we lay a more intense yellow-orange layer
against the cervical part of the transparent wall that will • reduce the risk of contamination of deep proximal cav-
show through (Figs 4d and 4e). Finally, the bulk of the ities by minute quantities of blood or crevicular fluid
cavity is filled with the injectable material (Fig 4f). As the during long procedures, because we seal them; we
tooth is endodontically treated, building it up from the make them watertight from the start.
pulp chamber reinforces the whole structure. It is worth • minimize lengthy, tedious procedures of curing quanti-
notingthat if one chose to make use of endodontic posts ties of photopolymerizing materials in deep cavities;
and had prepared the root canals, posts could have been there is no concern about inadequate polymerization
cemented and embedded in the core matrix during this of the deepest layers.
very same procedure. Figure 4g depicts the final result. • ease the concern and anxiety of producing proper prox-
Cases where an attempt to place a wedge would sim- imal contour and contact. If we "tested" our matrices
ply crush the matrix are unfortunately not rare, and they after we took time to adjust them properly, then we are
always pose a certain difficulty. A different approach in control of the final result.
«ouid have been to finish the restoration without separat- • depart from the customary "blind" procedure of "fill-
ing the teeth, then insert a wedge, carefully "debond" the ing" every posterior cavity from the top, confining
matrix fronn the finished surface, and repair the "defect" esthetics to fissure staining. This oíd customary proce-
as described in Case 2. dure, preventing visualization of the final shape, often

Vol 7, No 1, 2005 73
Papacharalambous

Fig 4 a No w e d g e is u s e d ; i n s t e a d t h e matrix is "tact<ed" a t the FIg 4b T h e free e n d of the matrix w a s m a n i p u l a t e d s o that a wióa
p a l a t a l by a s m a l i b e a d of c o m p o s i t e a n d s e c u r e d at the c e r v i c a l by " c o n t a c t á r e a " w a s p r o d u c e d a n d t h a t á r e a w a s left c l e a r of compoi
l^nitted retraction c o r d . T h e s h e l l is f o r m e d , reproducing the missing ite. T h e thin s h e l l a t the d e e p cavity floor is reinforced with additioní
c u s p wall. material. ,

Fig 4 c A wedge c a n now be s a f e l y i n s e r t e d a n d a s the t e e t h m o v e , Fig 4d T h e marginal ridge is built, a l o n g with the tip of the cusp*•
the matrix a u t o m a t i c a l l y r e t a i n s c o n t a c t b e c a u s e of the previously a n esthetically appropriate material. &
i n d u c e d s m a l l d e f o r m a t i o n (flattening) of its p r e f o r m e d convexity.

leads to totally ruining a perfectly worked occiusal posite: we do not disturb any treated surface of the tooí
anatomy, just during occiusion testing. The suggestion (Fig 5c). Some debris will be produced that is harmlesi
made in the next case aiso helps to avoid this. if desired, it maybe washed away with a coatof liquid resi
or a specially developed product (Wetting resin, Ultradeof
Case 5 Why should one do such a thing? Because nowtli.
After removing the oíd amalgam fillings on maxillary pre- final shape of the teeth is much more easily visualizeí;
molars, a small defect is revealed distal to the canine As a result, fine layering and staining of the occiusal ra
(Fig 5a). Transparent matrices for all proximal surfaces phology is not a haphazard task (Fig 5d). ^
are secured from the start; deflection of the matrix distal
to the canine will provide the necessary space to treat Case 6 ' W
that cavity for bonding and to inject a small quantity of It is often interesting to push a concept to its limits. 1 -
composite. next case in particular pushes the limits of the consers
One by one, the proximal walls are built and each time tive approach and challenges the technique (Figs 6a toS
the corresponding matrix is removed, so that the space it
occupied is regained. The task is facilitated by varying the
tensión of the wedges (Fig 5b). The last wall is built and
the last remaining matrix removed. DISCUSSION
At this point, we use a bur to gently trim the excess
height of the composite: the proximal wall is lowered to Ratlonale ^
the correct (estimated) height. We do not use water, nei- Figure 7 depicts the shortcomings of the resin compü
therdo we "burn" the material, and we strictly stay on com- ite/adhesive system from the standpoint of the propos

74 The Journal of Adhesive Dentisí

 Papacharalambous

Fig4e A high c h r o m a o r a n g e h u e m a t e r i a l w a s laid a g a i n s t the Fig 4f T h e c o r e m a t e r i a l filis t h e cavity from t h e pulp c h a m b e r u p .

cervical portion of the thin t r a n s p a r e n t b u c c a l wall. Note the already
finished, fine proximal contour.

technique. Qther issues are aiso of interest, concerning

nnechanical properties (endurance in loading and thermal
fatigue, resistance to wear, thermal expansión coeffi-
cient), esthetic properties (fluorescence, opalescence,
stability of color and surface polish) and biocompatibility
¡cytotoxicity, plaque adherence). Reassuringly, most of
these issues and the adhesive-related inefficiencies are
countered by the knowledge that advances have been
steadily niade during the past years. In contrast, in terms
of the inherent setting contraction of the polymer matrix,
research data and review literature have come to a still-
stand by either confirming the handicap and declaring the
continuing need to resolve it, or questioning the different
proposals to overeóme it.4.28,33
However, it is the author's belief, based on observa-
FIg 4 g T h e final result. M í n i m u m finishing w a s n e e d e d , d o n e m a i n -
tions made during 12 years of clinical experience in the
ly with flexible disl^s rounding off the marginal ridge. No abrasive
exclusive use of tooth-colored materials, that despite the contouring or p o l i s h i n g w a s n e e d e d a t the critical m e s i a l cervical
l<nown shortcomings, the adhesive/resin restorative sys- área.
tem is clinically viable for posterior restorations and
therefore (owing to many other advantages) preferable.
Half of the aforementioned clinical experience con- • Dismissing the indirect (extraoral) polymerization of
cerns adjunctive use of glass ionomers and the rest, the the composite material on the grounds of preserving
"total-etch" concept, is something that reflects the gener- sound tooth structure, this paper suggests the use of
al trend overthis period of time. Research, though, has bulk chemically curing or dual-curing material as the
been steadily investigating the so-called closed/open second best option to defend against polymer matrix
sandwich technique, and recent studies suggest the contraction. It seems that low velocity of polymeriza-
sandwich technique in conjunction with resin-modified tion, a prolonged viscoelastic state, and flow during
glass ionomers,6.8,20 ameliorating the problems of clas- setting result in partial settiing of the internal
sicGIC, namely dissolving, inferior adherence, and no pli- stress.lO'ii'i'^'is However, crack lines on undermined
ability. However, this article suggests the single-material cusps, iatrogenically induced, are sometimes to be
approach and focuses on contraction stress manage- expected (Fig 8).
ment. In any case, since the concept of an adhe- • A delayed, short light activation of the surface of the
sion-based, esthetic, polymorphic, "plástic" restorative chemically cured/dual-cure material will reduce the ox-
material is established (in partnership with conservative ygen inhibition layer and give a better bonding surface
treatment modalities), even if we have to revert to a dif- to the consecutivo layer of light-curing paste material.12
ferent system in the futuro, viable restorative paths will • Among other proven reasons, the use of flowable,
maintain their relevance. low-elasticity modulus material on most of the interfa-
Interpreting the research data associated with the cial part of the restoration may aiso have a beneficial
clinical technique proposed above, the following can be effect on stress, simultaneously preserving the interfa-
noted: cial integrity, since it has been found that the elasticity

Vol 7, No 1, 2005 75
Papacharalambous

Fig 5 a Maxillary right p r e m o l a r s a n d c a n i n e a r e p r e p a r e d a c c o r d i n g Fig 5b S t a r t i n g from the " h i d d e n " cavity d i s t a l to the canine, tlie
to minimally invasive principies. proximal w a l l s are strategically built one by one and the corresponí'
ing matrix r e m o v e d , t h u s regaining the s p a c e it o c c u p i e d .

Fig 5 c A s s o o n a s t h é l a s t s h e l l h a s b e e n built a n d the matrix Fig 5d Final e s t h e t i c r e s t o r a t i o n of the remaining occiusal asp«i,
r e m o v e d , the e x c e s s c o m p o s i t e on the marginal ridge is gently is d o n e with a d d e d a s s u r a n c e a n d control.
t r i m m e d down to the a p p r o p r i a t e level.

modulus (stiffness) of the setting material correlatos shell (buildup of the occiusal ridge/contact área) befo»
with stress development moderation.2.8,25 bulk filling repeatedly seems to have a beneficial efíed;
• Polymerization in layers or incremental techniques in retaining stable contact, possibly because of a partij
remain a controversial issue.i5,i6,34 i_aws that govern modification of the C-factor of the cavity. Although linea
"direction" of polymerization and induced stress ap- contraction is expected from the setting of the light-cii.
pear to be too complicated, mainly concerning cavity ing paste matehal (which in this case means "straiglí^
configuration and quality of established bond.i.3.35 ening" of the are and subsequent looseningof contac|
While transdental curing is aiso an unresolved issue,2i the overall effect is to our benefit. However, as a geneii
reduction of light intensity appears to be effective in rule, the high pliability of the thin shell should bepit.
polymerization contraction management.5.2i,27,3o served at its máximum (use intensivo staining instes .
• Using dual-curing instead of self-curing material and of high chroma paste material in Figs 4c and 6i).
avoiding simplified-step adhesivos minimizes the re-
ported incompatibility problems.23.29,31,32 |t would Direct Treatment /Wode
perhaps be practical to stay with one manufacturer's There is a certain satisfaction for the practicing dentil
line of products. with the direct as opposed to the indirect treatmeiiv
• In retaining contact áreas in spite of the anticipated mode. When Dietchi'' presents a finely sculptured n
contraction of a large quantity of material, the essence storation with perfectly embedded layers and stains,al,:
of consecutivo removal of the matrices and acquisition achieved in the unfriendiy environment of the oral cav¡|
of the occupied space in the case of múltiple cavities he probably feeis this pleasure. The fact that its beaut
should be self-evident. An important clinical observa- may possibly be of shorter duration than that of a cerará'
tion is that reinforcement of the occiusal part of the prosthesis does not negate the fact that he was ablel

76 The Journalof Adhesive Dentisí).

 Papacharalambous

Fig6a Maxillary posterior teeth in a n adult m a i e after c o m p l e t i o n FIg 6b T h e s e c o n d p r e m o l a r is s e v e r e l y d e c a y e d . D e n t i n s c a r c e l y

of periodontal treatment. R e m o v a l of the g l a s s - i o n o m e r m a t e r i a l e x i s t s a b o v e t h e g u m line a n d t h e e n a m e l s h e l l is m i s s i n g to a g r e a t
reveáis a distal defect on the first premolar. extent.

Flg6c Matrices are s e c u r e d by w o e d e n w e d g e s , t a k i n g c a r e to FIg 6d Buccal view of the matrices. Note the pre-designated
adjustnotonlyforheight but a i s o f o r i n c ü n a t i o n . A f u l l - c i r c u m f e r e n c e c o n t a c t point height in a c c o r d a n c e with a d j a c e n t tooth profile.
matrix is used for the s e c o n d premolar.

FIgSe To place the bonding agent in the hidden cavity, the matrix Fig 6f T h e r e c o n s t r u c t e d proximal contour of the first premolar,
isdeflected and a microbrush u s e d . Note the s m a l l e x c e s s ; it i s e a s i l y r e m o v e d with p o l i s h i n g d i s k s .

Vol 7, No 1, 2005 77
Papacharalambous

Fig 6 g Two fingers hold the matrix buccolingually a n d a d j u s t for F i g 6li We c a n c h o o s e to h a v e a wider c o n t a c t á r e a i n s t e a d of ttie;
proximal c o n t a c t a n d b u c c a l profile. (The matrix of the first premolar typical c o n t a c t " p o i n t " (it is obvious t h a t we were not successfii
h a s already b e e n r e m o v e d . ) here).

' •

F i g 6i From i n s i d e the cavity, a warmer, o r a n g e - h u e p a s t e material Fig 6j From i n s i d e the cavity a g a i n , the u n d e r m i n e d palatal enamel.
is laid a g a i n s t the c e r v i c a l part of the s e m i t r a n s p a r e n t , newly s h e l l is reinforced with c o m p o s i t e , c u r e d through the e n a m e l stiel:
constructed shell. before bulk filling the cavity. T h e marginal ridge is already recoo,
structed.

1
Fig 6k A correction to the profile of the p r e m o l a r b e c a m e n e c e s - F i g 61 After t r i m m i n g o f the e x c e s s with flexible d i s k s and lowrevs
s a r y in order to gain s p a c e for a n e s t h e t i c , layered buildup of the the internal á r e a of t h e c u s p i s built with " d e n t i n " material.
cusp.

78 The Journal of Adhesive Dentlslj'

 Papacharalambous

Flg6m Buildup of " e n a m e l " : a m é d i u m t r a n s l u c e n c y whitisin m a t e - Fig 6n Finally, a thin, challa white layer, mainly on the t i p s of t h e
riaiwithopaiescent properties ( O p a l e s c e n c e peari white, Ultradent). c u s p s , to m i m i c the a d j a c e n t natural t e e t h .

Fig 60 Tiie final result after m i n i m a l c o n t o u r i n g with flexible disi<s F i g 6 p L a t e r a l view of the f i n i s h e d t e e t h . A l o ó s e c o n t a c t point does
and fine diamond burs, a n d polishing. not c a u s e any c o n c e r n a s it will d í s a p p e a r s o o n : the teeth are
periodontally a f f e c t e d a n d p r e s s u r e from the w e d g e w a s g r e a t .

FIg 6q This picture, taken at the next a p p o i n t m e n t , r e v e á i s a typical Fig 6r Fortunately, this is e a s i l y r e m e d i e d , j u s t by removing s o m e
mistake; matching color a n d t r a n s l u c e n c y with d e h y d r a t e d t e e t h . of the c h a l k - w h i t e m a t e r i a l from t h e top of the c u s p . However, a
warmer hued material would have been more appropriate for
"enamel".

Vol 7, No 1, 2005 79
 Intemal
R (residual)
e sircss gap fomiation postoperative
stress on tooth sensitivlty
Volumetríc shrinkage
s stress on bond
I Tooth/
material fatigue propagation o f
S; Resin
I inleríace enamel cracks/
i stress Crown fracture

restoration
chipping/
A bulk fracture

d Variabiiity o f bonding substrate microlcakage/

h "Hamiful" residuals on tooth discoloration/
e Prone to mistakcs technique recurrent decay
s
i
V
e Fig 7 The resin composite/adhes
system: selective representation
shortcomings.

guiding principie - one that encompasses the limitatim

and inadequacies of our means and efforts - should
conservation. Conservation does not distinguish betwes
large- and small-defect .cases. It would be ¡nteresting
discuss alternativo treatment options for Case 2 (Figs
to 2d), especialiy for tooth 2 5 . There is definitely m
enough tooth to consider an inlay/onlay restoration, a
this option is readily rejected particularly with respectt
a limited pulp-vitality prognosis. As we foresee lti3
preparation for a crown will practically elimínate theW
walls, electivo root-canal treatment is called for; É
would lead us to post buildup abutment and eventuallyt
a crown that sits entirely upon the reconstructed part
the tooth; thus, in addition, crown lengthening is ai
called for....
Fig 8 Cract< l i n e on a palatal cusp, noticed at the end of the
s e s s i o n , u n c h a n g e d f o u r y e a r s later. Tooth i s a s y m p t o m a t i c ( C a s e 2,
The assessment of the two treatment options in term
tooth 2 5 ) .
of time required, cost, long-term prognosis, psychologia
impact on the patient or even esthetics, is so devastati
that one option is almost immediately discarded - hojf
offer his patient tliis kind of work with his own hands, af- fully not oniy on behalf of our patient. ;
ter a single, possibly long session. On the one hand, the armamentarium for proper
When completing extensivo reparativo v/ork in a partic- sessment of first-intervention defects is readily availab
ular patient's mouth with direct procedures, and there is nonrotary oscillating instrumentation, air-abrasive mk/
just one last large cavity that may cali for an inlay or oniay, mentation, chemomechanical instrumentation, andl(
you might be tempted to continué with the direct treat- drokinetic (láser) instrumentation.24 As for already está
ment mode. Many times, a well-done direct restoration lished large defects (Figs 9a and 9b), facts make usp
utilizing different layers and staining is esthetically better more and more trust in our materials and techniqi
than any external staining ceramic work. direct restorations applied won't break. This ¡s by
The direct treatment mode in dental work repeatedly means a heretical ¡ncantatlon against the statisticali
and decisively translates to minimally invasive dentistry. ta.13 As we must constantly question the conclusivenes^
Er¡cson,9 providing insight on the subject of minimally of research results, let us put forth a "what if" projecti|
invasive dentistry, discreetly notes that these highiy polit- on the spot: what if all the studies that compared Ü
ically correct terms do not necessarily imply a technically relativo longevity of composite vs amalgam restoratiáf
oriented approach and should not be misinterpreted a s vs gold/ceramic inlays considered this factor: was|;^
pointing oniy to variations of established treatment op- "mean" quality of the composite restorations (by curra"
tions. standards) comparable to that of the other types of rest
We can rest assured though, once the decay process rations examined (le, amalgam, gold/ceramic inlayá
or any other destructive factor has been established, the Usually it is not.

80 The Journal of Adhesive Der

 Papacharalambous

Fig 9a How long will it l a s t ? R e s t o r a t i o n of the p a l a t a l c u s p in a Fig 9b S a m e c a s e , lateral view, s h o w i n g the i n t e r c u s p i d a t i o n .

maxillary premolar, s e r v i n g for more t h a n eight y e a r s .

Matrices handiing should be chosen, decisively departing from the

Leaving the Toffiemire retainer behind, a great step has harsh sense that RD fórceps releasing the tines in place
been made since the switch to sectional pre-contoured leaves us with.
inatrices, with metal still generally advocated. Working in Common preference for metal matrices is largely
tándem with rings or tines of different design and philos- associated with Class II cavities with unbroken contact; in
ophy, they serve adequately in standard cases, but often such a case, a metal matrix may appear to be the oniy
fall short of responding to the many adverse situations way of dealing with it - and then after several failed
encountered in everyday practice: depth of the cervical attempts.
floor in relaiion to proximity of adjacent tooth, in relation In general, trie work associated with this is taking time
tothe width of the cavity's opon ends, in relation to bro- to sepárate the teeth. Furthermore, these considerations
ken or non broken contact, and so forth. Compared to cel- should be noted:
lulold matrices, they do not come in a variety of shapes
(to this day), they are less flexible, and they are not easily a) Statistics demónstrate that the proximal surface of a
trimmed. Finally, they are not transparent. tooth next to an established cavity (either newly devel-
Since light curing of restorative materials has become oped or treated in the past) already has some kind of
standard, it would be preferable if we could at any time be defect,22,26 necessitating either restoration or recon-
ableto polymerize through our matrices. It has been not- touring/polishing, and allowing for remineralization.
ed that with the advent of conservative approaches, pre- b) Unless one utilizes nonrotary instruments^^'^^ to pre-
pared cavities are becoming progressively smaller, "hid- pare the buccoiingual margins in contact with the adja-
den", and not as easily accessible. Sometimes there is cent tooth, damage to the latter is inevitable.
no cavity as such: we may oniy intend to improve upon the c) Even if a metal protector is used, nonexlstence of de-
proximal contour of a tooth. In all these cases, polymer- mineralized enamel at the marginal área of remaining
ization of the material is oniy possible through the matrix, contact cannot be verified.
and of course, treating the tooth surfaces and loading the
material favors the more flexible matrices. In addition, Perhaps we are thus not unfaithful to the ¡deal of conser-
transparency of the matrix allows for visual inspection of vativo dentistry if we deliberately break contact with near-
the cohesión and marginal adaptation of the restorative ly all Class II cavities. Ideally, this takes the form of gentle
material, of possible voids or air bubbles. In the case of stripping, by working a soft contouring/polishing disk
large conventional cavities, extended manipulation (and inserted between the teeth after they are separated by
therefore flexibility) of the matrix is equally essential. some means. The filling material (flowable composite)
The extreme adversities faced should in fact lead us will have a large bonding área on this finely prepared, long
towards the most flexible system, the most "open" ap- vertical bevel, and in addition, the composite/tooth Inter-
proach, where we are invited to improvise every time: cus- face will now be accessible to inspection. There is even
tom trimmed wedge, either from the start or at a second another benefit: this will act to "brace" the tooth, helping
stage; a wedge inserted'from the buccal (or whatever side to avoid the typical breakage of thin, unsupported cusps
is narrower) with retraction cord (or any other suitable due to lateral torces.
means) securingthe matrix along the other side; and, as One predicament associated with all precontoured
, standard practice, expert trimming of the matrices, matrices is this: In adverse conditions (ie, buccolingually
following selection from a logical collection of different wide cavity margins in relation to proximity of adjacent
shapes and convexities. In addition, the most delicate tooth), precontoured matrices often present the familiar

Vol 7, No 1, 2005 81
Papacharalambous

Fig l O a Molar is impinging on the s p a c e of s e c o n d p r e m o l a r ; teeth Fig l O b Free s p a c e h a s b e e n c r e a t e d b e t w e e n the molar and tti
c o n t a c t at the level of free gingiva. An imaginary c u r v e drawing the 2nd p r e m o l a r ; a s m a l i d e f e c t distal to the 2nd premolar has bes
m e s i a l s h a p e of the 2nd p r e m o l a r c o l l a p s e s into the s p a c e of the assessed. Ist and 2nd p r e m o l a r s c a n e x t e n d a proper con»'
I s t premolar. shape.

Fig 1 0 c M a t r i c e s fit nicely a r o u n d the prepared teeth. Wedge Fig l O d S i n c e the e n d of t h e p r o c e d u r e , w e d g e s have been puslit-
b e t w e e n p r e m o l a r s h a s b e e n i n s e r t e d from the narrower s i d e ; atten- further in, a t t h e right t i m e . "Dirty worl<" h a s finished. Timeí
tion h a s to be paid at the d i s t a l - b u c c a l margin of the I s t p r e m o l a r artistic e n d e a v o u r .

"bounce back" or "bounce the other way" phenomenon: pect), and of course kept to a manageable size. A nota*,
because there is no room to extend their preformed con- effort comes from Hawe-Neos in their latest assortmtf
vexity, they snap the other way due to internal torces. This (Kerr Hawe).
is usually accompanied by an alerting "clicking" sound, Regardiess of the matrix system used, consi(Jer|
but if the deflection is minimal, it will unfortunately be simple forms of odondoplasty before attempting to plae
discovered much later, usually when loweringthe proximal the matrices helps the most in achieving a proper resit
ridge duhng occiusion testing. (Even a fíat matrix might while providing better hygiene conditions. Figures lOat/
present this just after the placement of a wedge, due to lOd present the most frequently encountered adversiti-
lack of preformed convexity.) Depending on the extent of and the remedy in terms of simple odondoplasty. ^•
malformation, it may be possible to overeóme this by
holding the matrix against the next tooth. Again, this is
I
Peace of MInd
something to be avoided, since small anomalies are
There is quite a lot to be said about peace of mind.Sn.
usually inevitable and will lead to frustration oniy after
veys talk about the progressively greater number ofpd
they are discovered at the end of the session. The real
terior composite fillings performed by general dentistsi;
remedy for this is to chango the matrix to one with a
opposed to amalgam fillings. Dentists report thatltiisí,
different contour.
because of patient demand - but how do the dentiS:
A cleverly systemized transparent matrix system is
themselves feel about this? It is common knowledgetlí'
needed, allowing for customization by trimming, definitely
dentists feel uneasy with posterior composite restu
departing from the standard spherical design in the cervi-
tions, and that is some 20 years after the advent of tl«.
co-occlusal aspect (perhaps even in the buceo-lingual as-
general application. Of the different reasons that m|
82 The Journal of Adhesive Dentist
 Papacharalambous

bementloned which sustain this mindset, it is interesting SYNOPSIS

to concéntrate on one: difficulty.
Difficulty is an objection oniy If we still continué to 1 . Use of sectional transparent matrices that aíte prompt-
ttiink of posterior composite restorations a s an alter- ly manipulatable, enable visual inspection of cohesión
native to amalgam restorations - which they are not, and marginal adaptation of the filling material, and
since health and esthetic issues are more prominent promote light curing through the médium, particularly
and the concept of adhesive dentistry and preservation serving minimal intervention procedures.
of healthy tissue is self-evident. We do not question any 2. Use of flowable materials with low modulus of elastic-
other contemporary dental procedure as such because ity, that ensure better adaptation along external cavity
of its difficulty when there is no alternativo providing sim- margins and internal line angles (simultaneously con-
ilar benefits. If a dentist's working day with amalgam fill- tributing to moderation of stress and long-term bond
ings used to pass straightforwardiy, and now with com- integrity) to form a shell for the missing tooth struc-
posite restorations it is challenging and - in numbers - ture.
less productive, his objection to modern times is irrele- 3. Use of self-curing dual-curing resin to fill the bulk ofthe
vant. He is asked to deliver a different treatment; time cavity (a self-imposing idea as soon as the shell has
schedule, cost, fees, ergonomics, office organization, been built) as the preferred method of providing
must all be reassessed, along with requisito operator favorable polymerization contraction, while immediate-
focus. ly translating into legitímate time savlngs.
But more is needed from us: we have to familiarize our- 4. Development of a technique that is "neat" - for com-
selves with the material, learn about its ways beyond the puter nerds, it is "WYSIWYG" (acronym for "What You
Consolidated knowledge from basic research - like any See Is What You Get"); departing from the blind proce-
good craftsman does. Putting our trust in a proposed idea dure of "filling" all posterior cavities from the top;
of a compactable resin composite material and starting giving the operator the option of being in control.
topush it against a recalcitrant matrix is a bad idea, long 5. Esthetics well served: By disconnecting the laborious
before reports arrive about porosity and unacceptable task of producing proper contour and marginal adapta-
marginal adaptation. Instead, a different mentality should tion from the artistic work of layering, staining and fine
prevail, as in being able to make things happen, being in sculpting, not in one but in all three dimensions. Un-
control. . " disturbed, one can devoto oneself to the latter, much
more pleasing task.
Final Note 6. As a concept demand, leading to new material devel-
Letus remind ourselves that we are dealing with plástic opment: Structured buildup of missing tooth sub-
materials. There is a special meaning of the word plastic- stance that is coherent with the distinct tissue struc-
íty, applied in fine arts: it means agility, fluidity, malleabil- ture of natural teeth. Best matching of material prop-
ity, and perhaps variabiiity, muta,bility, volatility (it would erties to selective dental tissues:
be interesting to start using more expressive language to - Self-curing core material (dentin): Lower modulus of
describe specific qualities and state our preference for a elasticity, higher flexural strength, higher chroma,
specific product, instead of "scientifically" addressing lower translucency.
the requirements of the physical behavior and dellvery - Light-curing hybrid composite (enamel): Higher mod-
form). ulus of elasticity, higher compressive strength, high-
The single basic material is offered to us in many er abrasión resistance, lower chroma, lower opacity.
different forms. Ideally, we should be able to make the
cholee which best suits each application, not oniy in the
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84 The Journal of Adhesive Dentt