CLINICAL TECHNIQUE

FOR DIRECT CLASS II

COMPOSITE RESTORATIONS

Initial Clinical Procedures

First, an assessment of the expected tooth

preparation extensions (outline forms) should be
made and a decision rendered on whether or not
an enamel periphery will exist on the tooth
preparation.

Second, the preoperative occlusal relationship of

the tooth to be restored must be assessed.

Last, preoperative wedging in the gingival

embrasure of the proximal surfaces to be
restored should occur.

TOOTH PREPARATION

The tooth preparation for a Class II

composite restoration may be either a
conventional or modified preparation
design.

Both preparation designs have the same

objectives:
(1) to remove the fault, defect, caries, or old
material;
(2) to remove friable tooth structure; and
(3) to have cavosurface angles of 90 degrees
or greater.

The tooth preparation has two components, the

occlusal step portion (similar to that already
described for Class I composite tooth preparations)
and a proximal box portion.
Only faulty, carious, or defective tooth structure is
included in the outline form.

Conventional Class II Tooth

Preparation

Occlusal Step: The occlusal portion of the Class II

preparation is prepared similarly as described for the
Class I preparation. The primary differences are
related to technique of incorporating the faulty
proximal surface.

Preoperatively, the proposed facial and lingual

proximal extensions should be visualized,
permitting a more conservative connection
between the occlusal and proximal portions of
the preparation.

Because the facial and lingual proximal

extensions of the faulty proximal surface were
visualized preoperatively, the occlusal extension
toward that proximal surface begins to widen
facially and lingually to connect to those points.
Care is taken to preserve cuspal areas as much as
possible during these extensions.

At the same time, the instrument extends through

the marginal ridge to within 0.5 mm of the
adjacent tooth. This extension exposes the
proximal DEJ and protects the adjacent tooth.

Proximal Box: Typically caries develops on a

proximal surface immediately gingival to the proximal
contact. The extent of the carious lesion and amount
of old restorative material are two factors that dictate
the facial, lingual, and gingival extension of the
proximal box of the preparation.

If all of the fault can be removed without

extending the proximal preparation beyond the
contact, however, the restoration of the proximal
contact with the composite (a major difficulty)
is simplified.

During this entire cutting, the instrument is held parallel

to the long axis of the tooth crown. The facial and
lingual margins are extended as necessary and should
result in at least a 90-degree margin, more obtuse
being acceptable as well.

If the preparation is conservative, a smaller,

thinner instrument is used to complete the
facial and lingual wall formation, avoiding
contact with the adjacent tooth.

The gingival floor is prepared flat with an

approximately 90-degree cavosurface margin.
Gingival extension should be as minimal as possible,
trying to maintain an enamel margin.

The axial wall should be 0.2 mm inside (internal

to) the DEJ and have a slight outward
convexity.
For large carious lesions, additional axial wall
(or pulpal floor) caries excavation may be
necessary later, during final tooth preparation.

The initial tooth preparation is complete at

this point. If no infected dentin remains, and
no proximal beveling is indicated, the final
preparation also is considered complete at this
time.

Because the composite is retained in the

preparation by micromechanical retention, usually
no secondary preparation retention features are
necessary. If an inverted cone instrument has been
used, the facial and lingual occlusal walls are
convergent occlusally, adding to retention form.

No bevels are placed on the occlusal cavosurface

margins, especially the occlusal margins, because
these walls already have exposed enamel rod ends
owing to the enamel rod direction in this area.
Ends of enamel rods also result in more effective
etching.

A bevel placed on an occlusal margin may result

in thin composite on the occlusal surface in areas
of potentially heavy contact. This could result in
fracture or wear of the composite in these areas.
Beveled composite margins also may be more
difficult to finish.

Usually, bevels are not placed on facial and

lingual walls of the proximal box. Bevels can be
placed on the proximal facial and lingual
margins, however, if the proximal box is already
wide faciolingually and if it is determined that
additional retention form may be necessary.

A bevel usually is not placed on the gingival

cavosurface margin, although it may be
necessary to remove any unsupported enamel
rods at the margin because of the gingival
orientation of the enamel rods.

For most Class II preparations, this margin

already is approaching the DEJ, and the enamel
is thin. Care is taken to maintain any enamel in
this area to result in a preparation with allenamel margins.

If the preparation extends onto the root surface,

more attention must be focused on keeping the
area isolated during the bonding technique, but
no differences in tooth preparation are required.

The preparation portion on the root should have:

(1) a 90-degree cavosurface margin,
(2) an axial depth of approximately 0.75 to 1 mm,
(3) and usually no secondary retention form.

If the gingival floor is extended onto the root

surface, the axial depth of 0.75 to 1 mm must be
obtained by either deepening the entire axial wall
or orienting the instrument inclination more in a
proximal direction.

When the gingival floor is on the root surface

(no enamel at the cavosurface margin), the use of
a RMGI liner may decrease microleakage, gap
formation, and recurrent caries.

If a composite restoration is satisfactorily bonded to

the preparation walls, such as in preparations in which all
margins are enamel, there should be little or no potential
for microleakage, and no need for a liner.
However, a calcium hydroxide liner is indicated to treat a
near exposure of the pulp (within 0.5 mm of the pulp), a
possible microexposure, or an actual exposure.

If used, the calcium hydroxide liner is covered with a

RMGI base to protect it from dissolution during the
acid etching.
Otherwise, neither a liner nor a base is indicated in
Class II tooth preparations for composite. It is desirable
not to cover any portion of the dentinal walls with a
liner, unless necessary, because the liner would decrease
dentin bonding potential.

Modified Class II Tooth

Preparation

For small, initial restorations, an even more

conservative preparation design may be used. A
small round or inverted cone diamond may be used for
this preparation to scoop out the carious or faulty
material. This scooped appearance occurs on both the
occlusal and proximal portions.

The pulpal and axial depths are dictated only by

the depth of the lesion and are not necessarily
uniform. The proximal extensions likewise are
dictated only by the extent of the lesion, but may
require the use of another diamond with straight
sides to prepare walls that are 90 degrees or
greater.

The objectives are to remove the fault

conservatively, create 90-degree or greater
cavosurface margins, and remove friable tooth
structure.

Another modified design is the box-only tooth

preparation. This design is indicated when only
the proximal surface is faulty, with no lesions on
the occlusal surface. A proximal box is prepared
with either an inverted cone or round
diamond, held parallel to the long axis of the
tooth crown.

The instrument is extended through the marginal ridge

in a gingival direction. The axial depth is prepared 0.2
mm inside the DEJ. The form of the box is dependent
on which diamond is used - the more boxlike with the
inverted cone, and the more scooped with the round.
The facial, lingual, and gingival extensions are dictated
by the fault or caries.
No beveling or secondary retention is indicated.

A third modified design for restoring proximal lesions

on posterior teeth is the facial or lingual slot preparation.
Here a lesion is detected on the proximal surface but
the operator believes that access to the lesion can be
obtained from either a facial or lingual direction, rather
than through the marginal ridge in a gingival direction.

Usually a small round diamond or bur is used

to gain access to the lesion. The instrument is oriented
at the correct occlusogingival position and the entry is
made with the instrument as close to the adjacent tooth
as possible, preserving as much of the facial or lingual
surface as possible.

The preparation is extended occlusally, facially, and

gingivally enough to remove the lesion.
The axial depth is 0.2 mm inside the DEJ. The occlusal,
facial, and gingival cavosurface margins are 90 degrees or
greater.

This preparation is similar to a class III

preparation for an anterior tooth.

RESTORATIVE TECHNIQUE

Etching, Priming, and Placing Adhesive

The etching, priming, and adhesive placement

techniques are as described previously.

Matrix Application

In contrast to amalgam, which can be condensed to

improve the proximal contact development,
posterior composites are almost totally dependent
on the contour and position of the matrix for
establishing appropriate proximal contacts.

Early wedging and retightening of the wedge

during tooth preparation aid in achieving
sufficient separation of the teeth to compensate
for the thickness of the matrix band.
Before placing the composite material, the
matrix band (strip) must be in absolute contact
with (touching) the adjacent contact area.

Generally, the matrix is applied before the

etching priming, and adhesive placement.

An ultrathin metal matrix band may be preferred for

the restoration of a Class II composite because it is
thinner than a typical metal or polyester matrix and
can be contoured better than a clear polyester
matrix.

Sectional matrix systems also are available for

Class II composite restorations. These systems may use a
ring to:
(1) aid in stabilizing the matrix band and
(2) provide additional tooth separation while the
composite is inserted.

Inserting and Curing the

Composite

A two-step procedure (applying the enamel/dentin bonding

adhesive, if not already applied, then the posterior composite
material) is followed with either self-cured (seldom used) or
light-cured composite materials.
A light-cured system is used for restoring the class II
preparation.

The enamel/dentin bonding adhesive is placed over

the entire preparation (etched and primed enamel and
dentin) with a microbrush, foam sponge, or applicator
tip in accordance with the manufacturer's instructions.

The adhesive is lightly air-dried and polymerized

with a visible-light source, usually for 20 seconds.
Composite insertion hand instruments or a
syringe may be used to insert the composite
material.

After matrix and adhesive placement, small

increments of composite material are added and
successively cured.

It is important to place (and cure) the composite

incrementally to maximize the curing potential
and possibly to reduce the negative effects of
polymerization shrinkage, C-factor, or gap
formation.

For this reason, the first small increment should be

placed along the gingival floor and should extend
slightly up the facial and lingual walls.

This increment should be only approximately 1

to 2 mm in thickness because it is the farthest
increment from the curing light and is most critical
in establishing a proper gingival seal. This first
increment should be cured with a light
exposure of 20 to 40 seconds.

Subsequent additions are made and cured

(usually not exceeding 2 mm in thickness at
a time) until the preparation is filled to slight
excess.

The matrix is removed, and the restoration is

cured from facial and lingual directions. The
restoration can be contoured and finished
immediately after the last increment is cured.
If a light-cured composite is not available,
however, a self-cured composite can be used.

Contouring and Polishing the

Composite

Contouring can be initiated immediately after a

light-cured composite material has been
polymerized, or 3 minutes after the initial
hardening of a self-cured material. The occlusal
surface is shaped with a round or oval, 12-bladed
carbide finishing bur or finishing diamond.

Excess composite is removed at the proximal margins

and embrasures with a flame-shaped, 12-bladed carbide
finishing bur or finishing diamond and abrasive disks.
Narrow finishing strips may be used to smooth the
gingival proximal surface.

The rubber dam (or other means of isolation) is removed

and the occlusion is evaluated for proper contact.
Further adjustments are made if needed, and the
restorations are finished with fine, rubber abrasive points,
cups, and/or disks.

CLINICAL TECHNIQUE
FOR EXTENSIVE CLASS II
COMPOSITE RESTORATIONS
AND FOUNDATIONS

When very large restorations are required, it usually

indicates that:

(1) most of the occlusal contacts will be restored

by the restorative material,
(2) the extensions will be onto the root surface, and
(3) the area probably will be difficult to isolate.

Composite may be the material selected, however,

1- for very large Class II restorations
2- or foundations that will serve under indirect restorations.

Very large Class II preparations may be indicated:

1- when economic factors prevent the patient from
selecting a more expensive indirect restoration.
2- The ability to strengthen the weakened tooth structure
with a bonded restoration sometimes makes this
procedure a logical choice.

This type of restoration also may be indicated as

an interim restoration, while waiting to
determine the pulpal response, or whether or not
the restoration will function appropriately.

Composite also may be considered for use as a foundation

for indirect restorations (primarily crowns) when:
* the operator determines that insufficient natural tooth
structure remains to provide adequate retention and
resistance form for the crown. Thus the tooth is first
restored with a large restoration and then prepared for a
crown.

In addition to the tooth preparation form, the primary

retention form for a very large Class II composite
restoration is the micromechanical bonding of the
composite to the enamel and dentin.

Secondary retention features usually are incorporated

into the large preparation, however, because of:
(1) the increased amount of missing tooth structure;
(2) the decreased amount of tooth structure available for
bonding, and
(3) the increased concern for retaining the composite in
the tooth.

These may include grooves, coves, locks, slots, or pins.

Increased retention form also may be accomplished by
including otherwise sound areas of the remaining tooth
structure (e.g., facial or lingual grooves), or making
wider bevels or flares on accessible enamel margins,
both of which increase the surface area for bonding.

The primary differences for these very large preparations

include the following:
(1) some or all of the cusps may be capped,
(2) extensions in most directions will be greater,
(3) more secondary retention features will be used, and
(4) more resistance form features will be used.
A cusp must be capped if the operator believes it will
likely fracture if left in a weakened state.

Capping a cusp usually is indicated when the

occlusal outline form extends more than two thirds
the distance from a primary groove to a cusp tip.

If the tooth has had endodontic treatment, the pulp

chamber can be opened, and extensions made several
millimeters into each treated canal.
These areas are etched and primed, adhesive is placed,
and composite is inserted and cured incrementally.