Hello fellow dentists.

I thought I would just show you a small case that I did a few days after case 1. It is a massive compromise, I know, to the technique that I use in most situations and described before. At risk of losing all credibility I still think it’s worth seeing because until recently I used to find it easiker with large composites to do the mesial and distal walls at different times. Sometimes you have to break your own rules and usually it’s because the patient pushes you into it.

In this case the patient was reluctant to have the rubber dam placed because she was worried she would feel she couldn’t breathe and so I ended up using cotton wool and suction in order to achieve moisture control. The second compromise was that the case is a replacement for an indirect precious metal onlay and so an indirect restoration was indicated with cuspal coverage. The patient demanded an aesthetic alternative to metal and financial constraints meant my planned ideal bonded indirect composite onlay was not on the cards. I gave in and with significant warnings given to the patient tried to build up a direct composite onlay. I don’t think this case was a great example but it shows the 3D-ring and compositight sectional matrix in a large MOD situation; demonstrating its use in getting tight contact points. In my hands this I used to find this pretty much impossible with a normal Siqveland band.

Case: 59 year old lady. (Sorry no pre-op photos – photographing was an afterthought).

Failing onlay on 25 that I had been warning her for the past year needed replacing. I could get a spoon excavator in at one of the margins probably due to poor original fit and cement washout. There was no radiographic or clinical evidence of caries though. The onlay was ‘flicked’ off with a probe after some gentle persuasion at the edges, clearly showing how much this restoration needed replacing.

 

 

The preparation had thin buccal and palatal walls which would require cuspal protection. I reduced these slightly in order to provide an occlusal thickness of composite of at least a millimetre. I was confident that an occlusal thickness of composite would never offer anywhere near as much resistance to loading as metal so I decided the composite would need to be thicker to serve as an onlay material. Otherwise I did not alter the cavity form other than to freshen the dentine slightly. The following photos show me placing (admittedly in the absence of rubber dam) wedgewands and mesial and distal 3D-Ring and normal Composi-tight ring. I etched, rehydrated dentine, bonded as in case 1 and used a flowable composite lining. I built up the proximal walls first in an enamel shade after burnishing the matrix bands outwards. Dentine shade composite was then placed in incremental buccal and palatal sloping shapes up to the cusp tips with a superficial 1mm thick layer of a lighter enamel shade placed finally. The restoration was then finished placing some secondary occlusal features and polishing with greens, reds and soflex discs. 

I think the result was reasonable and certainly bettter than the previous restoration. It’s longevity will remain unknown for some time! Most importantly the patient was very happy.

Thanks,

Neal

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