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oday, patients are seeking a more aesthetic alternative to amalgam when having posterior teeth restored. Teaching trends within the UK and Ireland dental schools are moving toward the placement of composite when restoring Class I and Class II cavities. Adhesive posterior composite restorations offer many advantages over traditional materials such as amalgam, but undoubtedly require a higher skill set to ensure the

COMPETENCE BREEDS CONFIDENCE
Kerr’s Sonic ll allows a simpler approach to Class II restorations, putting aesthetic posterior restorations within reach of all clinicians
resulting restoration is as durable and long lasting compared to amalgam. This article aims to review the techniquesensitive steps involved when placing a Class II composite restoration and provides to enable more predictable restorations.

ProdUCts Used
WedgeGuard (Triodent) Siqveland (Dentsply) Tofflemire (Produits Dentaires) The V3 Ring Sectional Matrix System (Triodent) Sonicfill (Kerr) Oxyguard (Kuraray)
and inexperienced operators will cause some iatrogenic damage to the adjacent tooth when preparing a tooth interproximally¹. Here, a WedgeGuard (Triodent) is used to help protect the adjacent tooth (Figure 2). The WedgeGuard has a dual function as the interproximal metal strip will prevent the bur from causing any damage to the adjacent tooth and as a result, will often facilitate the speedier removal of the old restoration (Figure 3). Secondly, the interproximal gingiva is part protected by the wedge. It is vital that this area

isolation/moistUre Control
The use of a rubber dam is recognised as the optimal way to ensure adequate moisture control when restoring a posterior tooth. One of the common problems experienced when using the rubber dam is the ability to place the matrix band system of choice. However, the use of an active sectional matrix system can often overcome this problem. Ideally, the tooth distal to the tooth to be restored should be clamped, as this will aid the placement of the matrix band (Figure 1).

Pre-WedGinG
Studies have shown that 89% of experienced

Jon Swarbrigg BChD MFGDP quali ed from Leeds Dental Institute in 1992. Following graduation he joined Farsley Dental Practice, a mixed NHS/Private general practice in Leeds, as an associate and became principal in 1999 . Dr Swarbrigg enjoys complex restorative work including Implants and undertakes referral work for simple and complex cases. He currently lectures to dentists in the use of anterior and posterior composite restorations and provides hands-on training. www.farsleydental.co.uk

Figure 1: The tooth distal to the tooth to be restored should be clamped

Figure 3: WedgeGuard, medium (Triodent)

Figure 2: WedgeGuard in situ

Figure 4: The V3 Ring Sectional Matrix System (Triodent)

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Figure 5: Re-establishing the proximal walls

Figure 6: Proximal walls are expertly reformed

Figure 7: Sonicfill (Kerr) in use

(Triodent) uses a sectional matrix band (Figure 4), a wedge and separation ring to enable the clinician to produce a predictably contoured and precise contact point every time when placing a simple Class II composite restoration.

bulk-fill the cavity in increments of up to 5mm (Figure 7). Alternatively, it can be layered in smaller increments to reduce the configuration factor, producing a more anatomic form as required.

Class ii beComes a Class i
Figure 8: Probes and microbrushes can create an occlusal surface

anatomiC shaPe
The final layers can be contoured to produce as detailed anatomy as the clinician prefers (Figure 8). A simple probe and microbrush can be used to gently manipulate the unset composite and create a life-like morphology of the tooth and ultimately create a good anatomical occlusal surface. A layer of Oxyguard (Kuraray) to remove the oxygen inhibition layer will give the final restoration a hard surface that requires minimal polishing (Figure 9). Amalgam will always be a simpler material to place, but as a clinician, you always have to consider which you would prefer to have your tooth restored with. We owe it to our patients to be able to place a composite restoration predictably, and this article will, I hope, help clinicians to achieve consistency in the field of adhesive posterior restorations.

of soft tissue is not damaged, as if nicked by the bur, the resulting bleeding can be difficult to manage and control, which can be an issue when attempting to place an adhesive restoration. Should the gum become traumatised, it can be difficult to achieve a dry cavity in which to place an adhesive restoration. This can cause an improper hybrid layer to form, resulting in a failed restoration.

ChoiCe of matrix system
A widely used matrix system is the traditional 360-degree circumferential band, eg Siqveland (Dentsply) or Tofflemire (Produits Dentaires). These bands were primarily designed for use with amalgam and so, were not designed for placing Class II composites, which would often result in a restoration with poor anatomic form, flat-sided or weak contact points that could lead to food trapping. Studies support the use of a separation ring that is designed to actively separate the teeth². The V3 Ring Sectional Matrix System

Figure 9: A layer of Oxyguard (Kuraray) creates a hard surface

Problems that clinicians often report when placing Class II restorations are the occurrence of voids or overhangs at the base of the cavity or, that the restoration is overbuilt and needs recontouring using a high speed bur to reestablish the occlusion, all requiring extra time in the dental chair. These issues described can be reduced by a technique advocated where, firstly, the lost proximal walls are established to, in-effect, make the Class II restoration a Class I. Secondly, a thin increment of composite is built and cured into place (Figure 5). The separation ring and V3 Sectional Matrix Band are then removed and the anatomical contour can be inspected and checked for voids and overhangs (Figure 6). A size 12 scalpel can be used to trim away any excess, and the height of the marginal ridge can then be established in relation to the adjacent tooth. This is often a critical landmark and can therefore be an essential guide when trying to establish the correct morphology and, therefore, minimise any occlusal adjustment. Sonicfill from Kerr is initially a very flowable composite that becomes stiffer as it regains its initial properties. This means that fewer voids are formed whilst still being able to manoeuvre the composite easily to recreate the original contour of the tooth. The advantages of using the Sonicfill delivery system can be seen in figures 5 and 6, as the precise amount of composite required can be expertly delivered, adapted and shaped to reform the proximal walls. The Class II restoration has now become a Class I that can be simply filled using a stratified or layered approach to complete the restoration. Sonicfill (Kerr) can be used to

referenCes
1. Lussi, A and Gygax M (1998). Iatrogenic damage to adjacent teeth during classical approximal box prepartion, Journal of Dentistry 26:435-441 2. Wirsching et al (2011). Influence of matrix systems on proximal contact tightness of 1 and 3 surface posterior composite restorations in vivo, Journal of Dentistry 39:386-390

www.sonicfill.eu

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