Editor's note: Originally published in 2016. Reviewed for clinical accuracy and formatting in 2022.
Nothing makes me dread a day at the office more than having a long appointment with a bunch of Class IIs. They can be difficult and time-consuming, and traditionally, the reimbursements are lower than the reimbursements for indirect procedures (and can sometimes take just as much time).
Whenever I can find a little clinical tidbit that makes Class IIs easier, I am thrilled. Since humankind still seems to hate flossing, I am assuming that I will have days filled with Class IIs for my entire career. Let's talk about some little things that you can do to make your Class II restorations faster and better. Before we jump into the minutiae of Class II tips and tricks, let's first discuss how we got to where we are today.
Traditionally, Class II restorations were done with dental amalgam. Over the last 15 years, amalgam use has (obviously) sharply declined while composite use has risen higher and higher. Amalgam offered lots of advantages in Class II situations. Primarily, amalgam's success was largely independent of contamination with oral fluids. Amalgam doesn't shrink when set, and it also makes a poor substrate for plaque growth. Compare that to resin composite: Success is primarily linked to isolation, polymerization shrinkage is a real problem, and it offers a substrate that attracts plaque growth. Other than being tooth-colored, resin composite has almost no other advantages. I labor under no delusions that amalgam will come into vogue again, but I do think it's worth noting that in difficult Class II lesions, where decay extends below the cementoenamel junction or where isolation is utterly impossible, don't be afraid to consider dusting off your amalgam.
Just like the vast majority of our readers, I use resin composites for almost all of my posterior direct restorations. Now that I have listed a bunch of the disadvantages to using resin composites, let me justify myself so I can sleep at night. One of the main reasons that resin composite has grown to dominate the market is its ability to conserve tooth structure. To me, that is the biggest benefit that composite offers—even bigger than esthetics. I try to remember that every time I prep. Amalgam preps, traditionally, were large and required obliterating a bunch of good, solid tooth structure. With composite, we can prep only the diseased tooth structure and undermined enamel. The principles of "extension for prevention" and "deep isthmuses" can be retired, alongside your old beeper and dot-matrix printer. Resin composite allows us to keep more healthy tooth structure. For that reason alone, I find it worth the headaches of isolation, shrinkage, and time-consuming finishing and polishing.
With that background in mind, let's review a few tips and tricks that, I hope, will make your life easier.
I know, I know—no one wants the rubber-dam lecture. I'm just like the majority of you. I don't use the rubber dam enough, and I know it. We all know it's the best isolation method in history, but it can be cumbersome and time-consuming. When I do use it, I have to talk about it with my patient. A lot of times, it's easier to pick up the handpiece and start cutting. The biggest thing the rubber dam does is hold the interdental papilla down so your 330 bur doesn't annihilate it during prep. Once that tissue is cut, bleeding starts and isolation becomes a problem.
Dent Corp. has heard this complaint and invented the Super Clamp. If you're doing a resin composite on a single tooth or two Class IIs back-to-back, the Super Clamp is a great option. It's basically a mini rubber dam that inverts and covers a cluster of approximately three teeth. It can be seated quickly and keeps the pesky papilla away from your bur, so isolation is no longer an issue.
Pre-wedging is a must. If you aren't doing it, start immediately. It literally takes two seconds and gives you two great benefits. First, it's hugely beneficial to prevent nicking the adjacent tooth. Iatrogenic damage is embarrassing, and I want to prevent it as much as possible, so I do that by pre-wedging. In addition, it starts to push open the contact, so getting a matrix in is easier when the prep is done. Pre-wedging has huge upsides with no downsides. Do it.
Use sectional matrices
Traditional Tofflemire matrices give us sharp, straight walls that aren't anatomical and lend themselves to light or open interproximal contacts. Using a sectional matrix will make it much easier for you to get more anatomical, curvy line angles and embrasures with tighter interproximal contacts. The Composi-Tight 3D XR system (Garrison Dental Solutions) and the Triodent V3 SuperCurve kit (Ultradent) are both excellent choices that will diminish your finishing time while giving you tighter, more predictable interproximal contacts.
Test your curing light
Test your curing light routinely. In my practice, most axial walls are 4-6 mm long. This makes bulk-fill composite materials a viable option. The rub to using bulk-fill materials is making sure your curing light is outputting enough power to cure the gingival portion of the interproximal box. You don't know if you don't check. Leaving the resin at the bottom of the box uncured is a guaranteed failure. Make sure your light can cure everything you are loading. You might be surprised to find that one of your lights is underperforming.
None of these ideas are new or unique. The fundamentals of operative dentistry are always pretty simple. I hope a reminder of these principles will help you shave off a few minutes here or there during your direct restorative procedures, so you can tack a few more dollars onto your bottom line!