I do not know about you but, for me, closing contacts was a problem when first placing Class II composite restorations back in the 1980s. Amalgam could be condensed enough so that we could achieve, for the most part, tight contacts that patients would not complain about. However, when I started placing more composites, my contacts were not turning out so well. It was difficult to wedge as much as needed to facilitate tight contacts. We did finally get the Palodent Ring (DENTSPLY International) (now replaced with others) to help open up the contact area to assist in a better outcome. These rings are able to exert enough pressure to adequately separate teeth well enough to get the outcome needed for a good contact.
Well, how many of us have had a new patient come in complaining of an open (or less than tight) proximal contact with an associated food trap that we could fix? I know that my experience of using the highly improved rings (such as those now made by Garrison Dental Solutions and Triodent) has made a huge impact on my ability to predictably and more easily close any open contacts. In addition, the positive technical result is also accompanied with a grateful patient appreciating that he or she did not have to have an otherwise adequate filling or crown replaced.
A new patient came into our office and stated her exasperation that her former dentist wanted to remake a perfectly good all-ceramic crown (on tooth No. 5, delivered previously by yet another dentist), because of an inadequate proximal contact (Figure 1). It goes without saying that something had slipped by the doctor-technician team who had provided a less than satisfactory outcome for this patient.
Having closed quite a few contacts for patients that included composites and crowns, I explained to the patient that a procedure existed which would alleviate the food impaction. The patient accepted the treatment plan and fee to place composite on the distal of the existing crown (tooth No. 5), and was very hopeful that it would work. Not needing a new crown was a very attractive idea to the patient because of the greater amount of time that would be spent in the chair and the higher cost.
|Figure 1. Open contact on 2 porcelain crowns.||Figure 2. Garrison Ring expands the contact.|
|Figure 3. Brushing porcelain etch thoroughly.||Figure 4. Silane (Pentron Clinical) prepared for addition to etched porcelain.|
|Figure 5. Prelude (Danville Materials) was placed on |
silinated porcelain area.
|Figure 6. Placing flowable |
composite to depth of matrix.
|Figure 7. Placed bulk of |
composite to be condensed.
|Figure 8. Condensing and countouring composite with this this type of instrument.|
|Figure 9. Successfully closed crown contact.|
First, a Garrison Ring (Garrison Dental Solutions) was placed to wedge apart the contact (Figure 2). Then, air abrasion (EtchMaster [Groman Dental]) was used on as much of the proximal surface as possible to clean surfaces, and a diamond strip was used to finish the rest. (Other options would have included using a very narrow diamond [or a sand or diamond disk] as an alternative way to roughen up the surface area not reached by air abrasion). Next, a celluloid strip (Central Dental) was applied because it can be compressed when the composite is placed (unlike a metal band). A wedge was placed to keep the matrix tight at the gingival aspect.
When utilizing a composite for tooth structure, the etching process usually involves using phosphoric acid. However, in this case, we were etching porcelain on the distal surface of the crown (tooth No. 5) using a 9% hydrofluoric (HF) acid gel etchant (in this case, Porcelain Etch [Ultradent Products]; there are others to choose from), carefully placed for one minute (minimum) to achieve an adequate etch of the porcelain surface. Figure 3 shows how a brush (Keystone Dental 50 sable) was used to get the HF acid down toward the gingival margin area. I prefer to use a regular brush (rather than a microbrush) to thoroughly spread the acid, and I also use a regular brush for the silane and primer.
Once the HF acid was completely rinsed off, fresh silane (Pentron Clinical) was placed on the etched porcelain surface (Figure 4). Then, a dual-cure bonding agent was placed (Prelude [Danville Materials]) (Figure 5). (Of course, the choice of silane and bonding agent brands is up to the individual preferences and experiences of the operator.) Follow the manufacturer's directions for curing as it relates to whether you cure (or not) before placement of the composite.
When placing the composite in these proximal contact repair situations, I have found that placing a flowable composite resin (Gradia Direct Flo [GC America]) initially (Figure 6) ensures that composite actually gets to the cervical-most aspect of the isolated area to the gingival margin area. After a flowable composite was applied, it was light-cured and then a paste composite (Gradia Direct [GC America]) was applied (Figure 7). It is preferred to bulk this a little and to compress it against the celluloid matrix as much as possible for added tightness since the celluloid is slightly compressible. After that is done, the margins are contoured and cleaned up (Figure 8) before final light-curing is done.
When the procedure is complete, and the ring, wedge, and matrix are removed, it's showtime (Figure 9). However, the proof of a good outcome is discovered by testing the new contact area with floss (Figure 10). In this case, it was a great feeling to get a tight "snap" through what had been a loose contact. Be sure to check the occlusion carefully to avoid any premature contact that could lead to yet another iatrogenic postoperative problem.
Figure 11 shows an open contact in a patient who complained about food impaction, and no restorations had been done. The consideration here is, which tooth do we choose for a composite resin addition? I prefer to choose bicuspids over molars because it is easier to place composite against the matrix from the mesial rather than the distal. Also, note that the celuloid strip is contoured around the molar, not the tooth being added to. What I have found is that it depends on the space to close, the spread at the gingival aspect, and wedging. In an open contact, but one that is relatively narrow, I do not use a flowable composite. This is so I can condense all the composite at one time to the wedge, remembering that the light (when curing) will only go down so far, and any composite that is, by any chance, near the gum, will not cure. Figure 12 shows the closure. Critical to not losing the addition, is any occlusal adjustment needed (Figure 13).
|Figure 10. Testing the tightness of the closure.||Figure 11. Ring wedging 2 |
|Figure 12. Closed contact of |
|Figure 13. Bite check to avoid loss of newly placed contact.|
|Figure 14. An example of a large open contact needing addition to both teeth.||Figure 15. The closed contact using both teeth for addition.|
|Figure 16. An example of an open contact to be checked in the mouth.|
When closing a contact with an intact composite, after etching I place a prebonding agent (CompositRestore [All Dental Prodx]) designed for adding to old composite. If a larger space between teeth exists (Figure 14), one can add to both contacts (Figure 15). In this case, 2 different surfaces had additions: enamel and porcelain. Figure 16 shows another example of a contact in need of closing, where there is a choice of bonding to porcelain or enamel. I prefer enamel.
The clinical benefit of closing these open contacts are twofold: patient satisfaction of not having food stuck between the teeth; and, perhaps more importantly, less inflammation caused by chronic irritation. In our practice, if patients are asked during a hygiene visit, "Do you get food caught between any teeth?" an offer is made to help them by closing the contact.
The closure of a contact is not only used for new patients but our own restorations that may, upon the patient's experience of eating, trap food. This has happened to me, and I do not want to remove an otherwise good restoration. The time spent doing this contact addition procedure is approximately 10 to 15 minutes.
The question of retention will naturally come up. I can tell you that I have had very good outcomes from this proceedure. If done thoroughly as outlined, one can have confidence that these will be retained (unless the patient happens to chew on something that hits the contact with great force and/or the occlusion is not properly adjusted). Finally, although these photos do not show the use of an Isolite, I use it the majority of the time for these procedures as well as most of my other restorative procedures.
Throughout my 40 years in dentistry, problems have been solved by inventive people who come up with practical solutions. In the case of closing contacts, the people who invented the rings that can adequately spread contacts have done us a great favor. When these are used, our patients have less frustration with food traps. And, as dentists, we have less frustration with those same patients not returning because of an inadequate proximal contact. In addition, from a minimally invasive point of view, one can see that no prepping is needed to accomplish the contact closure, and patients really appreciate that. Furthermore, closing a contact involving a porcelain crown is dramatically less expensive, and patients will immediately appreciate proper contact closures with the very next meal that they will eat.
Disclosure: Dr. Whitehouse reports no disclosures.