Keep Getting Concavity Under My Wedged Contacts

Transcription

1 Keep Getting Concavity Under My Wedged Contacts A pair of tough restorations has this doc wondering if there s an easier way. Townies share cases and advice naj118 Member Since: 02/26/07 Post: 1 of 47 Tom Mitchell Member Since: 02/16/04 Post: 2 of 47 almunk Member Since: 12/17/05 Post: 3 of 47 Timmy G Member Since: 04/14/02 Post: 4 of 47 Third time over the last few weeks. Preop: #14, huge decay on distal beyond contact, #15 huge MO beyond contact box extending to occlusal. Rubber dam was placed before restoring. Placed a greater curve band to restore #15 first and wedged with a purple wedge to seal the gingival floor. Restored, but after removing the band and examining, the restoration had a definite concavity from where it was wedged with the V3 wedge. If I don t wedge here, the box is open. If I wedge, the box ends up undercontoured. What the heck? Try to refine as best as possible before placing V3 for #14-DO. Again, place V3 molar band for subgingival extension, purple wedge with V3, not sealed on facial. I take some plumbers tape, remove clamp, pack on facial, evaluate and now gingival margin is sealed. Green ring goes on, restored. Remove and there is a huge concavity where it was wedged with the purple wedge again. Again, if I don t wedge it, the box is grossly open on the mesial facial, pack with the plumber s tape finally it s closed, take a look and when we are done it s undercontoured interproximally. I can floss but the contact below dips. After a nightmare 1:15 appointment to get the dam on, patient a gagger, huge restorations defeating. I sat the patient up, explained in all honesty, not much I can do to quickly remove and restore. Patient is a gagger, gags on rubber dam, gags on straw, gags when light is used, all of the above, and even if not, I don t think I could have quickly dropped a box and done it again. It seems the wedge pushed both bands inward and more or less caved in the interproximal embrasures. New problem haven t had this before, but this week have had some really subgingival large Class IIs. Any advice? Dentistry is the worst sometimes. n I ve never needed to use a wedge with the Greater Curve Band. I would have placed either that band if the gingival was very deep, or if not deep a contoured Tofflemire Band and done #15 first as you did. I ve had better luck with Garrison Bean shaped sectional matrix bands lately with just a simple wedge, not the wave wedges that tend to ride up and create that concavity. I really like both styles of rings by Garrison. The contoured ones in green or orange and also the simple ring, which can be very useful to force a flexible wedge against the gingival margin. n You could try Tom Mitchell s technique, line the gingiva of the box with flowable first. This will give you a wall of composite to have the wedge push against without going concave while you fill the rest of the box. n Without getting eyes on it s a guess, but I can tell you one of the first places to at least start. You might be trying to play too many heroics. You stated several times huge decay. There s only so much you can do with a filling. Can t be afraid to say crown or root canal and crown or that it can t be restored. Needs to come out. 36 OCTOBER 2018 // dentaltown.com

2 llmgwc Member Since: 10/23/10 Post: 5 of 47 PDCunited Member Since: 06/29/05 Post: 8 of 47 drpsuedonym Member Since: 09/22/08 Post: 10 of 47 naj118 Member Since: 02/26/07 Post: 11 of 47 Think about the past. What has happened to the tooth in the past? Caries, trauma, previous dentistry, periodontal disease. Now: What state is the tooth in at this moment? Future: What restorative process will give the greatest longevity in the environment in which it s going to be placed? (Taking into account patient factors, dental factors and the difficulty of the repair now and later if the restoration fails.) Can smooth, well-shaped surfaces be achieved by a direct method, or is it necessary to have those smooth surfaces made outside the mouth? n I agree with all of this. Sounds like the patient is lucky to have someone who cares as much as you do, but I think the only thing you needed to inform the patient about was that their huge fillings (that were required because of the huge cavities) aren t going to last forever and it s time to start thinking about crowns or accept the fact that someday those teeth probably will need to be removed. n Yes to Greater Curve and as others mentioned, I typically do not use a wedge in these deep-reach defect cases (heroic fill or buildup phase). Cinch and winch. Now, if that cinching process makes there little to no hope of a proximal contact, then so be it. Still proceed. Gain that bottom of the defect increment in, get that gingival sealed up and bottom increment in that cinched band. Then do a secondary step/sequence with another system (sectional and separator rings, etc). to complete. Two steps planned from the beginning can be more efficient and effective than trying to force a one-step system beyond its capacity for a given case. The fill and cure first increment, then wedge is not a bad concept. David Clark also espoused this in his Bioclear systems, where wedging or separators if used came after gingival seal increment. Still alternatively, Teflon tape proponents have used the white plumber s tape as adjunctive gingival seal aid. Might work if a stiff triangular shape is going to leave a defect. n When I have two back-to-back huge cavities, I restore the most posterior one with just a greater curve, no wedge. What I will do is make a big cotton pellet and shove it into the distal of #14 so that the mesial of #15 doesn t get filled too wide. Then use a sectional matrix for #14. Also, don t feel bad you can only work with what the patient gives you. Tons of decay, not your fault. Patient borderline uncooperative because of gagging or tongue thrusting, it will have an effect on the quality of your work and it s not your fault. We can try our best to mitigate these factors with rubber dam, etc., but a patient who is cooperative is more likely to get a textbook perfect restoration than one who is not. It is unfortunate, but it is reality, we re only human too. n Found this online but sort of helps visualize. Open gingival seal. (Are folks saying to lightly wedge and plumbers tape here and get gingival closed with increment, then step up wedge and ring?) 38 OCTOBER 2018 // dentaltown.com

3 Open margin with pink wedge and ring in. Can see the rubber dam. Just pink wedge in here, open seal. Again, plumber s tape and small increment? Then ring? I do these all the time but the last contours have me rethinking. FREE FACTS, circle 4 on card FREE FACTS, circle 8 on card dentaltown.com \\ OCTOBER

4 Here the doc wedged from the facial and lingual to finally close the box. Largest purple wedge and white wedge. I feel like when I have done that with two wedges in the past, it is sealed but the embrasure looks like crap. The last picture is more or less what it looked like from the occlusal when I got the band and wedge in, also some plumbers tape on the facial and then the proximal contour was poor. n 7/4/2018 vomer6 Member Since: 10/15/03 Post: 13 of 47 John Kanca Member Since: 06/21/03 Post: 17 of 47 Acelyn Member Since: 04/30/07 Post: 22 of 47 The absolute best solution I found for these near-impossible deep boxes and huge restorations that really need crown lengthening and crown is to aggressively place retraction cord soaked in ferric sulphate. Next, I restore the impossible area with Activa. The gentle squirt technique allows me to get the area restored and cured without having to disturb the blood clot. Once the tooth has been transformed from this deep box that the light might miss or so wide it makes applying the sectional matrix impossible, then I have a more normal-appearing defect to restore. Now this may be restored with whatever material and technique you prefer to use. n Try putting the matrix on with only the wedge and no ring at first. Then seal the box with adhesive and flowable. Then add the ring and do the rest. n No advice for gaggers. That s just tough. As for deep, wide contact areas, I ve just started using Bioclear matrices with heated composite and they seem to work better than V3 in some situations. In case you haven t seen them, they re clear flexible matrices that can be placed apically past your prepped margin, and they extend outward into the contact area while keeping the curve, so you don t get the caved-in thing; and they curve back in at the occlusal, so you have a 7/5/2018 7/5/ OCTOBER 2018 // dentaltown.com

5 preformed occlusal embrasure. Imagine the curvature of the side of a fish bowl, I guess. (Having trouble inserting images to show some teeth I worked on.) n 7/9/2018 We have some anti-gag lollipops from a compounding pharmacy. One of our endodontists got them for us. They work pretty well. Some sort of electrolytes. n Tom Mitchell Member Since: 02/16/04 Post: 24 and 27 of 47 7/10/2018 When assessing whether or not your wedge is denting your matrix, it helps a lot to use your video camera to view it from the buccal and the lingual. n I often find if you remove some of interproximal gingiva with a Thermacut bur (takes a few seconds), the wedge will sit deeper and not cause the concavity. Those burs change many tricky clinical situations into easier ones. n Some suggestions: 1. Restore #14 first. The clamp is on #15 so it won t be in the way. 2. Protect the dam by first using a wedge, then stretching it over the mesial of #14 during final excavation of #14 and Remove interproximal gingiva using a curettage crown prep bur. This will help you control heme and seat the matrix. 4. Use clear ViscoStat to control any residual heme. 5. Invert the Tofflemire retainer and use a GC or extended GC band. 6. Wedge if you need to so you can seal the proximal box and stabilize the band. Fill # Ideal contour #14. This takes a little time but is easier at this point since #15 hasn t been restored yet. 8. Restore #15. If you can, move the dam back over between the teeth. Hopefully you can use a sectional band, but if you can t then use a GC. You will have to remove the clamp from #15 and slide the Tofflemire/GC in place. I never get the contacts I want when using the GC band exclusively. So I might build the floor to just below my desired contact then remove the band, replace the RD clamp, and now use a sectional band with a Garrison ring to restore the final 1 3 increments. (I usually burnish the band first with the side of a scaler and then with a small spoon excavator after building up the proximal box to just below the contact. This allows me to remove any bond that may have cured to the side of the matrix and ensures a broad contact.) 7/13/2018 7/14/2018 drphilip49 Member Since: 09/18/04 Post: 28 of 47 Dampies Member Since: 05/31/07 Post: 30 of 47 Tyler11 Member Since: 05/24/04 Post: 36 of 47 dentaltown.com \\ OCTOBER

6 This case was on a high-anxiety patient who repeatedly requested suction behind the RD. These patients/cases will test you and make you want to quit. You will probably lose money when all is said and done. Always be honest and upfront with your patients. Let them know it will be challenging and restoration with direct methods may or may not be possible. n 7/15/2018 Tom Mitchell Member Since: 02/16/04 Post: 37 and 38 of 47 Tyler11 Member Since: 05/24/04 Post: 39 of 47 Bruce J LeBlancDDS Member Since: 02/24/10 Post: 41 of 47 I stir the flowable with the tip of the flowable syringe. That s much larger than a perio probe. Why invert the retainer? n Sometimes I find that if you use the traditional method, as you cinch the retainer seems to rise up and away from the band. I picked this tip up somewhere on DT. Try it next time, it works great! n Tyler, beautiful case. You are exactly right on the way you placed the band holder. You are the first person I have seen to pick up on this. It makes a big difference to keep the band from unwinding. n 7/15/2018 7/15/2018 7/23/2018 See even more advice about this case online Search: Getting Concavity This doc has been having a tough week full of large Class IIs. Townies drop in with advice on getting through difficult restorations. See more online. To see this entire conversation, go to dentaltown.com and under s, search Getting Concavity This thread will be one of the top results. 42 OCTOBER 2018 // dentaltown.com