Successfully Restoring Class III Composites: The

Challenge of Deep Subgingival Margins

Written by Paul C. Belvedere, DDS, and Douglas L. Lambert, DDS

INTRODUCTION
At first glance, a Class III direct composite restoration can appear to be a fairly routine procedure. However,
any preparation that is “through-and-through,” requiring a light attenuating opaque back-up layer, can be
challenging in creating the correct reproduction of the missing tooth structure. Certainly the thickness of the
composite layer (or layers) plays a key role in the end result. However, the ability to utilize a matrix to form
a lingual wall and address the anatomic requirements of the interdental space of the restoration, without
being held by the operator’s fingers, is equally important. Couple that with a subgingival margin, hidden by
the interdental papilla, and the challenge becomes even greater. A matrix that can adapt to a situation such as
this is indispensable.

Fahl1 and Dietschi2 discussed the use of a freehanded “lingual shelf” of composite requiring several steps to
create a wall for Class III and Class IV direct resins by first utilizing an enamel-replacement layer, then a
dentin-replacement layer (opaque) to block the darkness of the oral cavity. Another well-documented and
popular alternative is the use of a putty matrix technique, done by fabricating a vinyl polysiloxane jig or
matrix based on a cosmetic preview or wax-up of the tooth to be restored.3-9 In addition, there are numerous
anterior matrix systems available that are made from plastic, polyester, or Mylar, that can vary from a
straight design to premolded options.

In all anterior restorations, an ideal matrix must create 2 different curves: the Labial Outline Curve (LOC)
and the Cervical Surround Curve (Figures 1 and 2). The common practice of using a straight Mylar strip to
slide interproximally to act as a matrix has severe limitations in meeting these goals. Even if it is bent to a
90° angle, or manipulated by the operator in an attempt to form the correct shape and contact surface, it fails
to accomplish the desired result in many cases due to the inability to both properly seal and to create the
proper anatomic shape. Plus, a straight-strip matrix folded around the complex curve of a tooth creates the
potential for excess “flash” material around the margins, especially in the subgingival area. The key is to
combine all the requirements for an anterior matrix into one: create a lingual shelf, seal the gingival margin,
reproduce anatomic form, and be adaptable to multiple prep designs. One such universal system exists with
the advent of the Margin Perfect Matrix (MPM) (Margin Perfect Matrix) (Figure 3).

CASE REPORT
At the patient’s dental examination, recurrent caries were diagnosed in teeth with existing interproximal
restorations and removed using standard techniques. After caries removal, the external margins were
beveled with a 40-μm diamond (F889-009 [Axis Dental]) to expose additional enamel rods to aid in creating
invisible margins. The through-and-through Class III preparations in adjacent teeth required a lingual wall of
light-diffusing or opaquing composite to block the dark oral cavity (Figure 4).

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Figure 1. The Labial Outline Curve (LOC) Figure 2. The Cervical Surround Curve
created by placement of the Margin Perfect created by placement of the MPM.
Matrix (MPM) (Margin Perfect Matrix).

Figure 3. Diagram illustrating the key Figure 4. Class III lesions with no lingual
landmarks of the MPM “Classic.” tooth structure displaying the through-and-
through preparation.

Figure 5. Manipulating the MPM to create the Figure 6. The proper shape and position of the
lingual roll of the interproximal point. rolled interproximal point, which will ensure
covering the lingual opening of the prep.

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After completing the Class III on tooth No. 10 with the MPM, the adjacent restoration was addressed in a
step-by-step fashion. The matrix was modified in order to create a complete wrap-around effect and act as a
lingual wall to support the placement of the first composite increment. The interproximal point was rolled
into the body of the MPM, which resulted in enough matrix film length to cover the lingual opening of the
preparation when held against the lingual aspect of the tooth (Figures 5 and 6).

The matrix was positioned from the labial approach through the interproximal contact areas and into the
gingival sulcus surrounding the cervical portion of the tooth. A stabilizing collar of a light-curable resin
(Heliobond [Ivoclar Vivadent]) was applied to the outside of the MPM to fixate it to the dried adjacent teeth
and gingival tissues. This created a sealed system for proper isolation of the bonding site and formed the
perfect LOC for the final restoration (Figure 7). It is important to note that placing a preshaped wedge of
plastic (or wood) could distort the final shape of the MPM, creating a negative LOC.

To maintain the MPM as a lingual wall, the operator can hold it against the lingual with a finger or,
preferably, tack it to the surface of the unetched portion of the preparation outside of boundary of the
prepared portion of the tooth. Using an explorer point (or other suitable instrument), hold the MPM against
the lingual portion of the tooth (Figure 8). Apply any one of a number of light-curable unfilled resins (such
as Heliobond, OpalDam [Ultradent Products], or Complete [Cosmedent]) from the edge of the MPM to the
unetched lingual tooth structure; hold it in place while curing the resin to form the lingual wall of the mold.
Cure this resin with an LED light source for 10 seconds (SmartLite Focus [Dentsply Sirona Restorative]).
Creating this fixed mold eliminates the “flash” formed around loose fitting matrices. This minimizes the
need for trimming and polishing in those critical subgingival areas that can occur when noncustom matrices
are not fixed solidly (Figure 9).

With the matrix firmly in place, the Class III composite becomes a straightforward task. Acid-etching
(Email Preparator [Ivoclar Vivadent]) was done using a total-etch technique. Then, the tooth was rinsed and
dried prior to the application of a universal enamel-dentin bonding agent (Prime & Bond Elect [Dentsply
Sirona Restorative]), per the manufacturer’s directions.

An aesthetic layering technique was used in a 2-step modality. The first composite layer was applied in a
thin layer as a lingual wall using a flowable resin (Filtek Supreme Ultra Flowable Restorative shade dentin
opaque [3M]); then cured for 20 seconds with an LED light source of at least 1,000 mW/cm2 (SmartLite
Focus). Next, the dentin-replacement layer (Empress Direct, Dentin Shade A2 [Ivoclar Vivadent]) was
injected using a unit-dose carpule that was preheated over the cured opaque lingual layer to a volume that
was short of the labial form of the tooth. These unit dose carpules were heated to 130°F using a composite
resin warming device (Calset [AdDent]) that greatly enhanced the wetting ability of the body composites.
Prior to the application of the top or enamel layer, this layer was cured for 20 seconds from the labial and
lingual directions using the LED light source. Another heated carpule (Empress Direct Enamel Shade A2)
was applied and compress-formed by using the sides of a paddle-shaped No. 3 brush (Cosmedent) to form
the outer layer of the restoration. Next, the stabilizing resin collar was removed following the completion of
the restoration by tugging at the resin collar with a 7/8 Bates Scaler (American Eagle) and removing the
MPM with a hemostat.

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 Figure 7. Proper placement of the MPM on Figure 8. The explorer holds the
tooth No. 9 from the labial aspect. Note the interproximal point tight against the lingual
excellent seal and creation of the LOC. prior to securing with the light-curable
stabilizing resin.

Figure 9. Applying the stabilizing resin Figure 10. Final view of the completed Class
(OpalDam [Ultradent Products]) and curing II composites.
for 10 seconds to create the lingual wall with
the MPM.

Anatomical shaping is best done using the spiral-bladed finishing burs (such as H48L-010 and H379-016
[Brasseler USA]). The final polish was then imparted using abrasive cups and points (Astropol [Ivoclar
Vivadent]) (Figure 10).

CLOSING COMMENTS
The molding and shaping of plastic parts, be it in industry or in dentistry, demands the use of a fixed and
nonyielding mold to confine the plastic to the desired shape. The matrix system (MPM) discussed and
demonstrated in this clinical case report fulfills the requirement to create a fixed mold for injection molding
using dental composites.

References

1. Fahl N Jr. A polychromatic composite layering approach for solving a complex class IV/direct
veneer-diastema combination: Part I. Pract Proced Aesthet Dent. 2006; 18641-645.
2. Dietschi D. Free-hand composite resin restorations: a key to anterior aesthetics. Pract Periodontics
Aesthet Dent. 1995; 7:15-25.

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