CATEGORY 48 AUSTRALASIAN DENTIST Clinical History A 28-year-old woman presented to our office with complaints of sensitivity to cold temperatures and food impaction in her lower right quadrant. Her dental history revealed previous orthodontic treatment and multiple restoration failures in the same quadrant over the past 8-12 years. Clinical examination showed significant mesio-occluso-distal (MOD) defects and Class 2 affecting teeth from #45 to #48. Clinical Findings Tooth #45: A distal carious lesion is suspected, potentially secondary to the adjacent mesial defect observed on tooth #46. No existing restoration is noted in this region, however, early discoloration and anatomical concavity suggest demineralization. Tooth #46: Clinical examination revealed a mesial proximal carious defect with complete loss of the marginal ridge. On the distal aspect, an old composite restoration was observed, appearing underfilled and extended onto the occlusal surface. Evident marginal leakage and localized chipping were present along the restoration interface. Additionally, unsupported enamel was noted on the distobuccal cusp, indicating structural compromise and the risk of cusp fracture. Tooth #47: An existing occlusal composite restoration demonstrated marginal discoloration and leakage. The distal surface exhibited a composite material of a different shade and texture, suggestive of a restoration placed at a later date. Lack of a defined marginal ridge resulted in an improper proximal contact. On the mesial surface, dark discoloration contiguous with the existing mesial pit composite indicated the presence of a recurrent or active Class II carious lesion. Tooth #48: The mesial aspect showed dark discoloration extending into the existing mesial pit composite restoration, consistent with a developing or recurrent Class II carious lesion. Bitewing radiograph confirmed the presence of multiple MOD / Class II carious lesions corresponding to the clinical findings. None of the defects demonstrated radiographic proximity to the pulp. Due to extensive work, we have decided to do this quadrant in two appointments: 1st Appointment – #47 & #48 2nd Appointment – #45 & #46 Appointment 01 – Management of Defects in Teeth #48, #47, and #46 (Distal) Rubber dam isolation was achieved using a wingless B1 clamp and heavy-gauge rubber dam to optimize the adhesive environment and enhance restoration longevity. Adequate isolation is critical for the success of any adhesive procedure. Caries-disclosing dye was utilized to aid in complete removal of carious tissue and residual composite material in teeth #48, #47, and the distal surface of #46. Infected dentin was carefully excavated using a slow-speed round carbide bur. Establishing a well-defined peripheral seal zone, free from infected and affected dentin, was prioritized to ensure maximum bond strength. A minimally invasive strategy for restoring complex MOD defects with the Quad Matrix System By Dr Anand Ramakant Narvekar CLINICAL Dr Anand Ramakant Narvekar Figure 1. Multiple defects starting from tooth #45 to #48 as described above. Figure 2. Multiple class 2 defects starting from tooth #45 to #48 with loss of ideal contacts and contours. Figure 3. The collage displays the prepared teeth after caries removal, addressed as follows: - #48: Mesial tunnel preparation with an occlusal Class 1 defect. - #47: Mesio-occluso-distal (MOD) defect preparation. - #46: Class 2 defect preparation involving removal of unsupported enamel on the distobuccal cusp. All preparations focused on removing caries, establishing a peripheral seal zone, eliminating unsupported enamel, and refining the proximal box. On tooth #46, the distobuccal cusp was selectively reduced until sound, supported enamel and dentin were achieved. For tooth #48, a conservative tunnel preparation was performed on the mesial surface to preserve the integrity of the marginal ridge. All cavity preparations were subsequently refined using a superfine (yellow-band) diamond bur to remove unsupported enamel. Additionally, abrasive finishing discs were used to further eliminate any remaining unsupported enamel and to smoothen the cavity walls. Tooth #48: The mesial tunnel lesion was restored conservatively using Shofu Injectable XSL, followed by Shofu Beautifil LS II packable composite. The occlusal (Class I) defect was rehabilitated using a morphological layering technique with cusp-by-cusp build-up to replicate natural anatomy and to avoid high “C” factor. Following composite placement, the mesial surface was finished using abrasive discs to establish appropriate proximal contact and contour, thereby facilitating ideal contact formation in the subsequent restorative phase for tooth #47.
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