CATEGORY 64 AUSTRALASIAN DENTIST CLINICAL Introduction Subgingival posterior teeth defects are always challenging due to their accessibility, isolation, and bonding strength. When you get adjacent subgingival defects, the situation becomes even tougher. With the proper technique of rubber dam isolation and an advanced matrix system like Strata-G from Garrison, these things become easier and, most importantly, predictable. e key to success lies in achieving a wellsealed restoration with good contact and contours. erefore, the restoration of deep interproximal areas on posterior teeth requires stringent preoperative evaluation of the tooth and defect size, location of contact and tightness, adjacent tooth position and contours, and gingival location. In the end, it is most important to avoid migration of teeth after restoring proper contacts specially when there is a space next to the tooth. is article aims to provide a simple and predictable protocol when dealing with adjacent deep subgingival Class II direct resin restorations in routine clinical practise. Clinical History: A 55-year-old patient visited the dental o ce with a chief complaint of sensitivity in his lower right quadrant from a cold stimulus. Clinical examination revealed that tooth no. 46 had been missing for a long time, which moved tooth no. 47 with an old Class 2 DO composite restoration with marginal leakage, and improper contours and contact (Pic 01). It is a clear sign of not using the proper matrix system and technique. An IOPA X-ray was taken, and it found a deep subgingival defect in close proximity to the bone level on tooth no. 47 along with subgingival decay (well above the bone crest) in the mesial of tooth no. 48 (Pic 01a). ere was no pain from percussion and no sign of periapical infection. Step 1: Locating deeper defects Removal of old composite from tooth no. 47 and locate the subgingival defect. Using a laser, trim the gingival tissue in order to see the defect clearly. Step 2: Preparation of the defects After applying a caries detection dye on both teeth, remove caries endpoints to achieve a peripheral seal zone free from infected and a ected dentin. is is necessary in order to get the best bondingstrength and complete the seal at the periphery. All unsupported enamel is removed with Super Fine Diamond Bur (yellow band) and proximal walls were nished with Super-Snap Disk Violet, to ensure optimal bonding to the enamel which will avoid potential micro leakage too. Step 3: Isolation Isolation was performed using a wingless clamp and a heavy rubber dam. is is important to achieve optimal bonding to increase the longevity of the restoration. Since subgingival defect isolation in between teeth (47, 48) was challenging, we were left with two options in such a clinical scenario: 1st. Delay matrices: is means you rst do DME (deep margin elevation) using either wedges or a special DME Reel Matrix by Garrison, then place the sectional matrix system, and nish the restoration. e drawback of such a technique is that once you remove the wedge or the Reel Matrix, the bleeding will start immediately, and then it’s di cult to control. Even if you control it in the end, there is the possibility of contamination, and you will have to start the bonding procedure again. 2nd.: Sub-gingival Extension Matrix Band: Garrison Dental has special gingival extension bands to deal with such cases, and they are available in various sizes for molars as well as premolars with di erent lengths. By using this technique in the rst instance, we are sealing the proximal boxes with an appropriate wedge. With this, we will save time and achieve predictable restorations. Step 4: Selecting and Placing the Matrix Band e Split Dam technique was chosen in order to place the bands perfectly. e dam is split between teeth 47 and 48. Bleeding is controlled by using a retraction paste. Air particle abrasion is done with 25-micron aluminium oxide powder. is will clean the cavity prep and the microporosity will increase the bond strength, especially from the root dentin. Garrison Firm Matrix Bands, Molar w/ Extension, 6.1 mm/ 7.7 mm (extension) were selected for this case. Managing Deep Subgingival Adjacent Class 2 Defects Pic 01 Pic 01a With the rmness of the band material, it’s easy to place and secure two bands together. Two bands were placed between the teeth while holding with one nger (so that the bands don’t move during wedge placement), and then the wedge (StrataGTM Medium Orange) was inserted in between to secure both bands perfectly. is way you get a tight seal at the oor of the cavity. (If you see any gaps, you can push the band further down or simply put in a larger wedge.) Step 5: Selection of the Matrix Ring Strata-G blue ring was selected to control the excess ash of composite. In addition to its new material, it moves the tooth further Dr Anand R Narvekar By Dr Anand R Narvekar
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