Managing multiple contact points, Step by step

Shadeguides - Cases - Direct posteriors
2017-04-24

It is diffucult to make several restorations when we have many areas to restore. During such procedures, clinicians usually choose an indirect restoration protocol, as workflow is much easier for the technician rather than for dentists. The disadvatage of this method is that you cannot accomplish the work in just one visit. But, if we know the proper way to manage multiple restorations we can achieve a good result even with direct techniques. The main advantage of direct restorations in these cases is the short time needed to get satisfactory results. In this article we will discuss how to make it in a more advanced way.

Fig. 1

Img. 1 – Just after we took a picture and an x-ray of the working area, we noticed that we have secondary carious processes going on under all previous restorations.

Fig. 2

Img. 2 – The first step is isolation with the rubberdam. It's better to place the dam and then start preparation. The most important part is to perform a correct preparation for the future filling. This means we have to carefully prepare and polish all margins to round all internal angles; to precisely remove caries, a diamond bur must be used for enamel and a carbide bur for dentin, then sandblasting with aluminum oxide (27 micron particles) is carried out. Interproximal polishing with strips or discs is advised.

Fig. 3

Img. 3 – After we complete the restorations, we proceed to step 2: matrix placement. TIP: If we want all our restorations to have a natural shape, it is strongly suggested to place the matrices at one time. For the best contact points we have to choose the thinnest and soft matrices. In this case we used the Polydentia matrix system.

Fig. 4

Img. 4 – One by one, we start to restore all contact points. Just after restoring the first tooth (distal wall before, mesial after) we can remove the matrix around the restored tooth.

Fig. 5

Img. 5 – First, we place a Bulk fill composite as a thick adhesive protection layer and then we proceed to layering of the final mass with an A3 Body shade. A drop of brown stain can give a twist to the natural appearance of your restorations: to precisely swipe it in the sulci, the Fissura instrument from LM Arte is ideal before brushing it with Compo Brush (Smile Line)

Fig. 6

Img. 6 – Now we have to place wedge and ring in order to restore the first molar. What is the main goal of the ring? First, it presses the matrix onto the proximal walls, and second, it creates forces that enhance separation between teeth. This will create higher pressure on the adjacent tooth and, after removing the wedge and ring, we will have a tight contact point.

Fig. 7

Img. 7 – Final layering of the A3 body shade in first molar

Fig. 8

Img. 8 – Stain application with Compo Brush (Smile Line) on the 1st molar

Fig. 9

Img. 9 – All molars are restored and now its all about finalize the last premolar.

Fig. 10

Img. 10 – Again we placed wedge, matrix and ring. We start by restoring the distal wall of the second premolar with A3 body shade and the same shade we will use for the restoration of the surface area.

Fig. 11

Img. 11 – All these 4 restorations could take no more than 3 hours, polishing and occlusal adjustments included.

Fig. 12

Img. 12 – Final view of restored teeth after rubber dam removal. It is useful to warn the patient that the rehydration process takes time, so the color might not look good at a first glance, but then get to be just mimetic.

Fig. 13

Img. 13 – Perfectly integrated color, already after 1 day rehydration

Fig. 14

Img. 14 – X-ray shows perfect adaptation of the margins of our restorations

 

As a conclusion of the article we have to stress again how important is recreating a proper shape and contact points when restoring teeth. Three are the things that can really make this procedure predictable and durable:
– a good and thin matrix system, which allow modeling of the matrix itself and good adaptation
– tough rings, that’ll adapt the matrix in an effective way
– wooden wedges, for an efficient separation of teeth