Effective protocol for daily high-quality direct posterior composite restorations.

The interdental

anatomy of the class-2 composite restoration.

Marleen Peumansa, Pasquale Venutib, Gianfranco Politanoc, Bart Van Meerbeekd

a
Associate Professor; KU Leuven (University of Leuven), Department of Oral Health Sciences, BIOMAT

& UZ Leuven (University Hospitals Leuven), Dentistry, Leuven, Belgium. Wrote the manuscript.

constructed the figures.

b
Dentist in Private Practice, Mirabella Eclano, Avellino, Italy. Developed the concept, constructed the

figures, proofread the manuscript.

c
Dentist in Private Practice, Rome, Italy. Developed the concept, constructed the figures, proofread

the manuscript.

d
Full Professor; KU Leuven (University of Leuven), Department of Oral Health Sciences, BIOMAT & UZ

Leuven (University Hospitals Leuven), Dentistry, Leuven, Belgium. Proofread the manuscript.

Correspondence: Professor Marleen Peumans, KU Leuven (University of Leuven), Department of Oral

Health Sciences, BIOMAT & UZ Leuven (University Hospitals Leuven), Dentistry, Kapucijnenvoer 7, B-

3000, Leuven, Belgium. Tel: +32-16- 332744; e-mail: marleen.peumans@kuleuven.be

1
Abstract

The interdental anatomy of a class-2 direct composite restoration is one of the most underestimated

topics in direct posterior composite restorations. The proximal emergence profile of the restoration

and the contact area should be designed to maximize arch continuity and to minimize food

impaction. Other restorative criteria that must be fulfilled are marginal adaptation compatible with

the dental and periodontal integrity, and geometry of the marginal ridge compatible with the

mechanical integrity of the restoration under load. Shortcomings will result in masticatory

discomfort, caries, periodontal problems and undesired movement of teeth. In-vitro and in-vivo

studies showed that the use a contoured sectional metal matrix band with a separation clamp results

in the tightest contact point. However, this matrix system also has shortcomings and does not give

the expected result in all class-2 cavities. The variation in depth, width of the box, distance between

the cervical cavity margin and the adjacent tooth requires customization of the interproximal space.

In order to realize this, sectional matrix bands with several profiles of curvature, variation of wedges

and separation clamps, and the use of teflon tape are required. In addition, dentists should follow a

protocol allowing them to build a proximal composite surface that fulfills the required restorative

criteria. Pre-wedging, space evaluation, interproximal clearance, correct selection, positioning and

stabilization of the matrix band are important steps in this protocol.

2
Introduction

Satisfactory rehabilitation of a proximal surface when restoring a class-2 cavity with a direct

composite restoration requires fulfillment of several criteria, including attainment of an anatomically

correct contour and tight contact area, adequate marginal adaptation and accurate marginal ridge

placement. Shortcomings in this regard have important implications for the adjacent tissues. Food

impaction in the interproximal area can lead to masticatory discomfort, recurrent caries and

periodontal disease. In addition, an inadequate contact may cause tooth movement and instability of

the dental arch (2,7,13,15,39). One of the issues of masticatory discomfort is ‘neurological switching’.

The patient starts to chew exclusively on the other side of the mouth in order to avoid discomfort,

unbalancing the system (37).

To achieve an adequate proximal geometry, the proximal contour of the class-2 composite

restoration should ideally resemble that of an intact natural tooth (Fig. 1). In the natural dentition

the interproximal contact is suggested to be an area of 1.5-2 mm rather than a point (2)(Fig. 2a). The

contact area is located at the transition between the middle and occlusal third of the proximal plane

in a cervico-occlusal direction, and at the transition between the middle and buccal third in a bucco-

lingual direction (3)(Figs. 2b,c). In addition, the contour of the proximal surface in both directions

should be copied, respecting the natural buccal, lingual, occlusal and gingival embrasure.

It is difficult to define optimal adequate proximal contact tightness as there is large intra- and

interindividual variation (9,20,25,41). The proximal contact tightness in-vivo can be significantly

influenced by location, tooth type, chewing, time of day, the periodontal condition of the tooth and

inter- and intra-arch integrity (9).

The reconstruction of a satisfactory anatomically contoured proximal surface in class-2 direct

composite restorations remains an issue for most dental practitioners. This is partly inherent to

polymerization shrinkage and the lack of condensability of the resin composite materials (10,33), the

use of rubberdam (8,34) and the thickness and elastic displacement of the matrix band (17,19).

3
Traditional circumferential straight metal matrix bands, used for placement of amalgam restorations,

showed many shortcomings in the formation of tight proximal contacts in class-2 composite

restorations. The contacts produced with these matrix bands are often narrow occluso-gingival and

the height of contour of the restoration is often right at the occluso-proximal line angle (Fig.

3)(5,26,33). Consequently, the contact area is easily lost when the marginal ridge area is smoothed.

In addition, the thinner marginal ridge formed with a straight matrix band is less fracture-resistant

compared to a more voluminous marginal ridge created with a contoured matrix band (26).

Several techniques and instruments have been proposed to obtain tight proximal contacts: pre-

wedging (9,11,24), the use of condensable composites (36), and proximal box-forming tools among

others (5,20,22,24,33,36). However, all these attempts were not adequate to create a tight contact

area.

According to several in-vitro and in-vivo studies the strongest proximal contact area in class-2

composite restorations is obtained using a sectional metal matrix system in combination with a

separation ring (20,24,25,33,36,41).

Nevertheless, some shortcomings have been described using these modern metal sectional matrix

systems in combination with a separation clamp. When the cavity is wide open in a bucco-lingual

direction, the matrix will be dished in in the cavity by placement of the separation clamp. Chuang et

al. (5) observed that the contacts constructed using a dead soft metal sectional matrix and

separation clamp exhibited good contact tightness, but showed a concave area in the middle of the

contact surface and overextension of composite at the buccal and lingual side. Another in-vitro study

compared different circumferential matrices with a dead soft metal sectional matrix band with

separation ring (16). The sectional matrix reproduced the tightest contact area. However, no system

was able to reproduce a proximal shape similar to that of an intact tooth. In these in-vitro studies,

the use of an easily deformable dead soft metal matrix in combination with a separation clamp were

probably responsible for the not smoothly formed and over-contoured proximal surface with tight

4
contact. A strong metal matrix that does not deform plastically (permanently) is required to

overcome this problem.

Another limitation of the commonly used sectional metal matrix bands is that all these matrices have

approximately the same curvature or maximum contour. Nevertheless, a large variation in

width/depth of the box, in interproximal distance between the cervical cavity margin and the

adjacent tooth is observed in class-2 cavities in daily clinical practice. Consequently, the interdental

area needs to be customized. This implies that the armamentarium for correct build-up of a proximal

box should be extended with sectional matrix bands with a more pronounced curvature. In addition,

the dentist has to be aware of several tips and tricks in order to correctly position, stabilize the

matrix band and achieve a tight adaptation between matrix band and cavity margins. In this article a

protocol is presented that allows the dentist to have control over creating a correctly formed

proximal surface with tight contact area in class-2 composite restorations. This protocol, based on

extensive clinical experience of one of the authors (PV), will be documented by means of several

clinical cases.

Protocol for placing Class-2 composite restorations with an adequate interdental anatomy.

The protocol consists of 8 different steps, which will be described consecutively and in detail.

1. Rubberdam isolation

2. Pre-wedging

3. Space evaluation

4. Interproximal clearance

5. Selection of the matrix band

6. Positioning of matrix band: control position in a cervico-occlusal and bucco-lingual direction

7. Stabilization of the matrix band, interdental separation, evaluation of contact area and fit to

the cavity margins

8. Composite layering

5
It is clear from the literature that interdental separation is the key factor to produce a tight proximal

contact during placement of Class-2 composite restorations. Interdental separation can be obtained

in several ways: pre-wedging, use of a separation clamp, and use of an interdental separator device

(5,6,16,18,30,33,35,36)(Fig. 4).

1. Rubberdam isolation

Rubberdam isolation is a requirement for successful placement of a direct composite restoration

(32). To facilitate the clinical protocol for placement of a composite restoration the teeth should be

isolated under rubberdam before cavity preparation. The dentist has to be aware that rubberdam

placement significantly increases the proximal contact strength (9,34). In an in vivo study of Dörfer et

al. (8) the amount of reduction in contact strength was significantly higher between 1st molar and 2nd

premolar, compared to canine/1st premolar and 1st/2nd premolar. The additional space lost due to

rubberdam placement should be taken into account and requires a strong interdental separation

during cavity preparation and placement of the composite restoration.

2. Pre-wedging

Pre-wedging includes that a wooden wedge is pressed firmly into the interdental space before cavity

preparation and kept in place during preparation (1,6,11,40). This can result in separation of the

teeth of up to 100-200 µm (4,14). The additional space created can compensate for the thickness of

the matrix band, the polymerization shrinkage of the composite, and the negative effect of

rubberdam placement.

Anatomical hard wooden wedges are preferred as they have the most pronounced separation effect

(Fig. 5). The wooden wedge absorbs water during the restorative procedure, resulting in expansion

(swelling) of the wedge. A soft wooden wedge will become weaker and more flexible, causing the

separation effect to decrease. In a clinical trial, Loomans et al. (21) observed that pre-wedging with a

wooden wedge resulted in a significantly lower separation effect than placement of a separation

clamp (with or without a wedge). However, it should be noted that the separation was maintained

6
for only 5 minutes. This is much shorter than the clinical time needed to prepare a class-2 cavity and

place a composite restoration.

Next to the separation effect, the wedge protects the rubberdam and interdental papilla, and

prevents the bur from damaging the adjacent tooth while prepping the cervical cavity margin and

creating interproximal clearance in the cervical area.

3. Space evaluation

Volumetric harmony of the interproximal area is essential for a functional and esthetic class-2

composite restoration. Therefore, the interproximal space available should be evaluated prior to

placement of the matrix band. An over-contoured proximal surface of the adjacent tooth should be

corrected as this can result in an inverted anatomy, and in the formation of a deficient contact area

(dimension, position) (Fig. 6).

If needed the proximal contour of the adjacent tooth will be adjusted using abrasive disks in the

middle and occlusal third (Fig. 6e). In the cervical third, a reciprocating handpiece with diamond-

coated files can be used and/or abrasive strips (Figs. 6f,g).

4. Evaluation of interproximal clearance

Interproximal clearance means that the buccal and lingual margins of the box are accessible (Figs.

6h,i and 7). On the one hand, interproximal clearance allows passive positioning of the matrix.

Forcing the matrix band in an interproximal space without interproximal clearance can result in

deformation of the matrix, invagination of the matrix and inversion of the emergence profile (Fig. 7).

On the other hand, accessible and visible margins facilitate finishing, polishing and re-polishing of the

restoration margins (Figs. 6j-l).

5. Selection of the matrix band

Contoured sectional metal matrices are widely considered to be the most effective matrices for

placement of direct composite restorations involving the proximal surface. For the restoration of a

7
single box, only one thickness of the metal material is encountered instead of two, making contact

generation easier (41). Circumferential contoured matrices, especially when used without a

separation ring, hinder the construction of a tight proximal contact point. In addition, circular matrix

bands produce more capillarity, in many cases nullifying the efforts to obtain optimal isolation.

The sectional matrix should have a correct curved profile, making it possible to create a correct

emergence profile in a cervico-occlusal direction. To select the correct matrix band one must be

aware of its maximum curvature. Figs. 8-9 show different matrix bands (used by the authors) with

their maximum curvature.

As mentioned above, it is important that the matrix band is strong and does not deform plastically

under the typical stress applied during dentist’ handling. A 50 µm-hard steel matrix band can keep its

ideal proximal contour more easily during placement of the wedge and separation clamp and teflon,

compared with a dead metal or soft steel metal matrix (Figs. 10a,b). TORVM (Moscow, Russia)

delivers 50 µm thick hard steel contoured sectional matrix bands (Table 1). The matrix bands are

available in different heights, with and without subgingival extension (Fig 8a). A 6.5 mm high

sectional matrix band has a maximum curvature of ±0.5 mm (Figs. 9, 10c). An increased proximal

curvature (cervico-incisally) of the matrix band is required when the distance between the cervical

cavity margin and the neighbor tooth increases. This is observed when the cervical cavity margin

comes in a more apical position.

Hard stainless steel sectional Saddle matrices (TORVM) and the Perforated metal matrices (TORVM)

(6.5 mm height) have a maximum curvature of ±0.7 mm (Figs 8b,c, 9, 11). The maximum curvature

starts more cervically making it easier to reach deeper margins. Here too, 50 µm thick matrix bands

are preferred.

BioFit Matrix bands (Bioclear Matrix Systems, Tacoma, USA) have the highest maximum curvature

(±0.9 mm)(Figs. 8d, 9, 12). These matrix bands are contoured plastic (Mylar) sectional matrices,

available in two thicknesses (BioFit Blue Matrix: 50 µm and BioFit HD matrix: 76 µm) and 3 different

heights (4.5, 5.5, 6.5 mm). Transparent matrices might allow for better light transmission and

8
allegedly more efficient polymerization of the underlying resin composite. The BioFit matrix bands

have a larger bucco-lingual wrap, and can be used in cavities that are more open in a bucco-lingual

direction. In addition, the matrix features a curved occlusal embrasure, which if the matrix is well-

positioned, shortens the finishing time of the occlusal embrasure with burs or discs.

To conclude, the selection of the matrix band will largely be determined by the distance between the

cervical cavity margin and the adjacent tooth. Guidelines regarding selection of the matrix band are

presented in Fig. 13. In line with the extensive clinical experience of one of the authors (PV), a hard

steel metal contoured sectional matrix (Sectional (TORVM), Saddle matrix (TORVM), Perforated

metal matrix (TOVM)) is advised in 90% of the clinical cases, while a BioFit matrix (Bioclear Matrix

Systems) in 10% of the cases.

It is beyond the scope of this article to discuss the treatment of extreme situations with deep cervical

cavity margins (Figs. 11d and 14). This was described in detail by Venuti in 2018 (38).

6. Positioning of the matrix band: control position in a cervico-occlusal and bucco-lingual direction

The matrix band should be positioned into the interproximal space without any friction (with free

axis of insertion) and should have the correct height. This is ±0.5 mm above the marginal ridge of the

adjacent tooth (Fig. 15), in order to give the proximal surface a correct contour in a cervico-occlusal

direction. If the matrix band is too high, there is a risk that the marginal ridge and the occlusal

surface will be modelled too high. Consequently, considerable time will be needed to grind in

occlusion. If the matrix band is too short, there is a risk that the marginal ridge will overlap the

marginal ridge of the adjacent tooth, or even worse, will bond to an existing composite restoration of

the adjacent tooth.

In case a BioFit matrix (Bioclear Matrix Systems) is used, the occlusal embrasure is included in the

matrix band. If the correct height of the matrix band is selected, the dentist has good control if the

occlusal embrasure is in a correct position (Figs. 16a-d).

In addition, the matrix band should be centered bucco-lingually so that the contact area will be in the

correct position in a bucco-lingual direction (Figs. 16c-e).

9
7. Stabilization of the matrix band, interdental separation, evaluation of contact area and fit to

the cavity margins

Stabilization of the matrix band can be obtained using a wedge, a separation ring, teflon tape, and a

flowable block-out resin. The different possibilities and indications are discussed below.

Wedge

The wedge has a double function. First, a separation is realized between the teeth which

compensates for the matrix thickness in order to obtain a strong interproximal contact. Second, the

wedge needs to adapt the matrix accurately to the contour of the tooth all around the cavity floor.

The wedge can be inserted from either the lingual or buccal side or even from both, provided that

the matrix remains closely adapted to the cavity floor. The wedge is most commonly inserted from

the lingual side as the lingual triangular embrasure is wider than the buccal one.

A large variety of wedges is available on the dental market (Fig. 17)

- Wooden wedges

Anatomical hard wooden wedges are preferred as they have a larger separation effect than

soft wooden wedges.

o If the upper part of the wedge is higher than the cavity floor, it will cause a convexity of

the matrix towards the interior of the cavity. In this situation the wedge has to be

customized. (Fig. 18)

o The wedge also needs customization in situations where concavities are present in the

proximal cervical area, such as the mesial side of the upper 1st premolar and lower 1st

molar as well as the distal side of upper 1st molar (30).

- Plastic and silicone wedges

o Several manufacturers have plastic V-shaped wedges available, in combination with

their sectional matrix system. These wedges are open at the gingival side, by which they

do not interfere with the interdental papilla and do not discolate the rubberdam. This

10
 allows them to be pushed further in the interdental area and result in a good fixation of

the matrix band. Their flexibility allows them to adapt the matrix band more easily to

the cervical cavity margin. Their separation effect is less effective than wooden wedges

o The wedges used in combination with the transparent BioFit matrices are the Diamond

Wedges (Bioclear Matrix Systems)(Fig. 19). They are available in different sizes (S, M, L,

XL). In addition, a deep caries/fluting model (the green-coded color) is available, which is

able to adapt the matrix well to deep cavity margins (Figs. 19b-e). The diamond cutout

allows the wedge to pass through the narrow part of the embrasure and then opens to

stay locked in place and apply pressure evenly to avoid line angle overhangs. The

wedges show a low profile in order not to push the matrix inside the cavity.

Separation clamp

Next to the use of a wedge, a separation clamp will create interdental separation and stabilize the

matrix band. A large variability in separation clamps is available on the dental market (Fig. 20). The

rings of the clamp are made out of stainless steel or Ni-titanium. In general, stainless steel rings have

a less strong separation effect compared to Ni-titanium rings and they lose their separation effect

more easily. Most rings are angled to allow stackability in any combination for MOD and multiple-

tooth restorations. The ring prongs can be made out of stainless steel, Ni-titanium, glass fiber-

reinforced plastic or soft silicone. The prongs can be straight or have a V-shaped end. Ring prongs

with a V-shaped end can be placed in a more stable position resulting in more even tension, and

better adaptation of the matrix band to the buccal and lingual surface of the tooth, and will reduce

proximal overhangs (23).

Placement of a separation clamp also has drawbacks. On the one hand, straightening of the matrix

band in the occlusal third is often noticed (Figs. 21a,b). This will strongly reduce the presence of a

natural occlusal embrasure. Contouring the marginal ridge after removal of the matrix band

increases the finishing time. On the other hand, the sectional metal matrix band sometimes opens in

the cervical area after placement of the wedge and positioning of the separation clamp (Figs. 21c,d).

11
It can be difficult and quite time consuming to close this gap at the cervical cavity margin by pushing

teflon tape in between the wedge and the matrix band.

Because of these shortcomings, the following strategy is presented regarding use of a separation

clamp.

1. When two opposite class-2 cavities need to be restored, it is preferred not to use a

separation clamp when restoring the first box. When the matrix band has an ideal contour

after positioning, it will only be stabilized by the wedge. Teflon tape can be placed in the

opposite cavity to stabilize or relocate the matrix (Fig. 22). Some flowable composite or

block-out resin can be used to increase stabilization of the matrix band. Contouring of the

proximal surface after removal of the matrix band will be strongly reduced or even

superfluous (Fig. 22d).

2. To restore a single box in a quadrant using a BioFit Matrix (BioClear Matrix systems) a

separation clamp is required in order to obtain a strong contact area. The V-shaped

separation ring of the Bioclear matrix system (Twinring, Bioclear Matrix Systems) creates a

strong separation force. After positioning of clamp and wedge, one can control the location

of the contact area (Fig. 23).

3. For the restoration of a single box in a quadrant and use of a sectional metal matrix, there

are two options.

a. If after positioning of the matrix band, fixed with a wooden wedge, the matrix band

has an adequate contour and contacts the adjacent tooth, placement of the

separation clamp is not needed (Fig. 24). The interdental separation created by the

wedge (on the condition that also pre-wedging was carried out) will be strong

enough to finally obtain a tight contact area.

b. If the matrix band does not make contact with the adjacent tooth after fixation with

the wedge, a separation clamp is required in order to obtain a strong contact area.

12
 Recreation of a naturally contoured occlusal embrasure with composite finishing

discs may be required.

For the restoration of a MOD cavity, it is preferred to apply matrix and ring at one location as well as

the matrix at the other contact area, then restore the first contact area, remove the first ring and

afterwards apply the second ring. Placement of the two rings simultaneously both mesially and

distally result in a separation effect in the opposite direction and therefore diminish their effect at

the applied contact area (41).

In 2 clinical trials the contact tightness of proximal boxes restored by using a metal sectional matrix

band and separation clamp was stronger than before treatment. However, none of the patients

participating in these studies reported any discomfort when such a tight contact area was

constructed (25,41). In a 6-months follow-up Loomans et al. (25) recorded that tighter contacts tend

to loosen and weaker contacts remain almost unchanged. From these results one may conclude that

achieving a tight contact is preferred.

Teflon tape

Teflon is a polymer of tetrafluoroethylene. It is a plastic non-sticky material resistant to high

temperatures. Teflon is largely used in several fields of industry, from aerospace and computer

applications, to cooking pans. During the last decade the classic plumber teflon tape has also been

used in the dental office.

1. Teflon tape can be used to relocate the matrix when two class-2 cavities next to each other

have to be restored in order to obtain a correct position of the matrix band (Figs. 22c, 23h).

2. For the restoration of the proximal box of a class-2 cavity, teflon can be used to push the

matrix towards the tooth to optimize the adaptation of matrix to the cavity margins (buccal,

lingual and cervical)(Figs. 6c, 11d). This results in a minimal excess of composite at the cavity

margins and reduces the finishing time of the restoration. A tight fit should most certainly be

obtained in the cervical area where access with finishing instruments is difficult and can

endanger the integrity of the teeth and the periodontium.

13
It is shown in several in-vitro and in-vivo studies, that despite all efforts to prevent interproximal

overhang, complete prevention of overhang in the cervical third of the box is almost impossible

(12,22,23,27,29). However, in none of these studies was teflon tape used to improve the adaptation

between matrix band and cavity margins. Nevertheless, it remains a difficult task to have complete

control over marginal adaptation in the cervical area in the different clinical situations. If the

marginal overhang is adhesively attached, and is smooth and continuous, the effect on the

periodontal condition can be expected to be negligble.

Flowable or block-out resin

Block-out or flowable resin can be applied in between matrix band and adjacent tooth in order to

help in stabilize the matrix band, especially in these situations where a separation clamp is not used.

(Figs. 12c, 22c).

8. Composite layering

After correct positioning and stabilization of the matrix band, the adhesive system is applied and

composite layering takes place (Fig. 25)(31).

It is the aim of the protocol presented in this article to provide the general dentist with guidelines,

tips and tricks to obtain an adequate interdental anatomy and marginal adaptation in class-2

composite restorations. The protocol is based on extensive clinical experience of one of the authors.

One can remark that the protocol is not completely evidence-based. The only evidence found in the

literature is that using a sectional matrix band in combination with a separation clamp showed the

best results in creating a tight contact point. According to the authors, it is quite impossible to have a

complete evidence-based protocol as the large variation in clinical situations requires customization

of the interdental area.

Conclusion

14
To obtain a tight, well-positioned contact area and anatomically contoured proximal surface in class-

2 direct composite restorations, the following steps in the clinical protocol are important: rubberdam

isolation, pre-wedging, space evaluation, interproximal clearance, selection, positioning and

stabilization of the matrix band. In order to customize the interdental area sectional contoured

matrix bands with different curvature are required. The curvature of the matrix band is largely

determined by the distance between the cervical cavity margin of the class-2 cavity and the adjacent

tooth. The matrix band should be strong and not deform plastically. A separation clamp should be

used depending on the clinical situation. Finally, it is important to obtain a tight adaptation between

matrix band and cavity margins before applying the composite.

Acknowledgments

The authors thank Dr. Javier Tapia Guadix (Restorative dentist, Spain) for sharing the pictures of the

clinical case presented in Fig 6.

15
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25. Loomans BAC, Opdam NJM, Roeters FJM, Bronkhorst EM, Plasschaert AJM. The long-term effect

of a composite resin on proximal contact tightness. J Dent 2007;35:104-108.

26. Loomans BAC, Roeters FJM, Opdam NJM, Kuijs RH. The effect of proximal contour on marginal

ridge fracture of Class II composite resin restorations. J Dent 2008;36:828-832.

27. Müllejans R, Badawi MOF, Raab WHM, Lang H. An in vitro comparison of metal and transparent

matrices used for bonded Class II resin composite restorations. Oper Dent 2003;28:122-126.

28. Nash RW, Lowe RA, Leinfelder K. Using packable composite for direct posterior placement. J Am

Dent Assoc 2001;132:1099-1104.

29. Opdam NJM, Roeters FJM, Feilzer AJ, Smale I. A radiographic and scanning electron microscopic

study of approximal overhangs of Class II resin composite restorations placed in vivo. J Dent

1998;26:319-327.

30. Patras M, Doukoudakis S. Class II composite restorations and proximal concavities: clinical

implications and management. Oper Dent 2013;38:119-124

31. Peumans M, Politano G, Bazos P, Severino D, Van Meerbeek B. Effective and simplified protocol

for daily high-quality direct posterior composite restorations. ‘The simplified layering and

finishing protocol’. J Adhes Dent, Accepted.

32. Peumans M. Politano G, Van Meerbeek B. Effective and simplified protocol for daily high-quality

direct posterior composite restorations: Cavity preparation and design; the ‘hidden quality’ of

the posterior composite restoration. J Adhes Dent, Accepted.

33. Peumans M, Van Meerbeek B, Asscherickx K, Simon S, Abe Y, Lambrechts P, Vanherle G. Do

condensable composites help to achieve better proximal contacts? Dent Mater 2001;17:533-

541.

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34. Rau PJ, Pioch T, Staehle HJ, Dörfer CE. Influence of the rubberdam on proximal contact

strengths. Oper Dent 2006;31:171-175.

35. Saber MH, El-Badrawy W, Loomans BAC, Ahmend DR, Dörfer CE, El Zohairy A. Creating tight

proximal contacts for MOD resin composite restorations. Oper Dent 2011;36:304-310.

36. Saber MH, Loomans BAC, El Zohairy A, Dörfer CE, El-Badrawy W. Evaluation of proximal contact

tightness of Class II resin composite restorations. Oper Dent 2010;35:37-43.

37. Santana-Mora U, López-Cedrún J, Mora MJ, Otero XL, Santana-Penín U. Temporomandibular

disorders: the habitual chewing side syndrome. PLoS One 2013;8:e59980

38. Venuti P. Rethinking deep marginal extension (DME). IJCD 2018;7:26-32.

39. Von Bethlenfalvy ER, Staelhe HJ, Dörfer CE. Einfluss marginal parodontitis auf die approximale

kontaktstärke. Dtsch Zahnartzl Z 2000;55:411-416.

40. Wang JC, Charbeneau GT, Gregory WA, Dennison JB. Quantitative evaluation of proximal

contacts in class 2 composite resin restorations: a clinical study. Oper Dent 1989;14:193-202.

41. Wirshing E, Loomans BAC, Klaiber B, Dörfer CE. Influence of matrix systems on proximal contact

tightness of 2- and 3- posterior composite restorations in vivo. J Dent 2011;39:386-390.

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Tables

Table 1: List of several commercially available sectional metal matrix bands

MATERIAL SIZES THICKNESS

Palodent Plus Soft stainless steel 3.5, 4.5, 5.5, 6.5, 7.5 mm 38 µm

(Dentsply Sirona, Konstanz, Germany)

Garrison Sectional Matrices Soft stainless steel 3.2, 3.8, 4.6, 5.5, 6.4 mm 38-40 µm

(Garrison Dental Solution, Übach Palenberg, Germany) 3.2, 3.8, 6.0, 6.4, 8.7 mm with ledge

TorVM Hard stainless steel Small, medium, large 35-50 µm

(TorVM, Moscow, Russia) Soft stainless steel small, medium, large with ledge

Quickmat Sectional Matrix Soft stainless steel 5, 6.4 mm 25-40 µm

(Polydentia, Mezzovico-Vira, Switzerland) 6.4 mm with ledge

Contact Matrix Stiff flex 5.5, 6.5 mm 60 µm

(Danville, Saint-Paul, MN, USA) Dead soft 8.75 mm with ledge 40 µm

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Figures

Figure 1: In a natural dentition with normal tooth position, the contact areas in the premolar/molar

region are located at the transition middle-buccal third in a bucco-lingual direction, and at the

transition middle-occlusal third in a cervico-occlusal direction (white rings).

Figure 2: (a) In the natural dentition the interproximal contact is suggested to be an area of 1.5-2 mm

(blue circle). (b) Occlusal view: A correct contour of the proximal surface in a bucco-lingual direction

results in a contact area that is located at the transition between the middle and the buccal third.

The buccal and lingual embrasure are indicated by the red lines. (c) Buccal view: The proximal

contact area is positioned at the maximum contour of the proximal surface. This is located at the

transition between the middle-occlusal third in a cervico-occlusal direction (blue circle). A correct

proximal emergence profile and well-positioned contact area results in the formation of an occlusal

and gingival embrasure (red lines).

Figure 3: X-ray taken after placement of several large MOD direct composite restorations with a

straight circular matrix band. Notice narrow contact areas occluso-gingivally (white arrows). The

height of contour of the restorations is right at the occluso-proximal line angle. The patient

complained of food impaction in the large interproximal areas.

Figure 4: (a-c) Three interdental separation techniques demonstrated on a manikin model. (a) using a

wooden wedge, (b) a separation clamp and (c) an interdental separator (Elliot separator; Carl Martin,

Solingen, Germany). The tips of the separator are covered with blue plastic rings in order to have

better grip. (d) The Elliot Separator (Carl Martin) without plastic tips. (e) Clinical situation with use of

the Elliot separator to obtain interdental separation before placement of a DO composite restoration

on the 2nd premolar. Next to the separation function, the tips stabilize the matrix band. (f-g) After

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placement of the restoration and removal of the matrix band, a well-formed proximal surface and

tight contact area can be observed. (f) Buccal view, (g) Lateral view.

Figure 5: Pre-wedging with an anatomical hard wooden wedge before the start of the cavity

preparation creates interdental separation and helps to compensate for the thickness of the matrix

band. In addition, it protects the gingiva and the adjacent tooth during prepping and finishing of the

proximal cavity margins.

Figure 6: (a) Initial situation: a 30-year old female patient requested replacement of the existing

amalgam restorations. (b) Rubberdam isolation and cavity preparation. The area of hypomineralized

enamel at the mesio-palatal cusp of the 1st molar was not included in the preparation. One can also

notice erosive cupping on the cusps. (c) Placement of a soft stainless steel matrix in combination with

a separation clamp with prongs with V-shaped end (Palodent Plus; Denstply Sirona; Konstanz,

Germany). The matrix was adapted to the cavity margins using teflon tape. The matrix was too wide

open in the occlusal third, resulting in proximal over-contour in this area. A slight plastic deformation

of the matrix is noticed. This is caused by pushing the teflon tape in between matrix band and

separation clamp. (d) The MO cavity on the molar was filled with composite and the matrix band

removed. An over-contoured proximal surface can be noticed. This should be corrected in order to

obtain a correct proximal contour of the DO restoration on the premolar. (e) In the middle and

occlusal third, the proximal contour of the adjacent tooth can be adjusted using abrasive discs (Soflex

2382 C+M; 3M Oral Care, Saint Paul, Minnesota, USA). (f and g) Diamond-coated files with different

grit sizes connected on a reciprocating handpiece (Komet, Brasseler, Lemgo, Germany) are used to

recontour the cervical and occlusal third. (h) The mesial surface of the 1st molar was recontoured

resulting in volumetric harmony of the interproximal area. Notice the interproximal clearance of the

DO cavity on the premolar. (i) Evaluation of the mesial contour of the 1st molar from the palatal side.

(j) Interproximal clearance results in accessible restoration margins at the buccal and lingual side. The

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excess of adhesive and flowable/composite (white arrows) can easily be removed with a composite

finishing disc (Soflex 2382 C+M, 3M Oral Care). (k) Final class-2 composite restorations showing an

anatomical proximal contour and a tight contact area. The form of the natural buccal and lingual

embrasure has been respected. (l) Palatal view of the final restorations.

Figure 7: a. The absence of interproximal clearance at the buccal side interferes with passive

positioning of the matrix. b. The matrix is forced interproximally resulting in deformation of the

matrix and inversion of the emergence profile. c. Interproximal clearance is created.

Figure 8: (a) Hard steel sectional matrix bands (TORVM; Moscow, Russia) with a thickness of 50 µm.

The matrix bands are available in different heights and with subgingival extension. This matrix band

shows a slight curvature. (b) Hard steel (50 µm thick) perforated metal matrices (TORVM). These

matrices are available in 5 sizes. They can be used in combination with a matrix tightener. These

matrix bands have a more pronounced curvature compared to the traditional sectional matrix bands.

The curvature starts more cervically, making this matrix band useful to restore a box with a deeper

cervical cavity margin. (c) Hard steel (50 µm thick) Saddle matrix (TORVM). These matrices are

available in 3 sizes. They can be used in combination with a matrix tightener. The curvature of this

matrix is quite similar to that of the perforated metal matrix. (d) BioFit matrix bands (Bioclear Matrix

Systems) are transparent and available in two thicknesses (BioFit Blue matrix: 50 µm and BioFit HD

matrix:76 µm) and 3 different heights (4.5, 5.5, 6.5 mm). The white transparent BioFit HD matrices

are more rigid which allow them to be placed as metal matrices. The blue transparant BiofFit Blue

matrix is more flexible. These matrices have a more pronounced curvature and larger bucco-lingual

wrap. In addition, the occlusal embrasure is included in the matrix band. These matrix bands are part

of the Bioclear Posterior matrix system (Bioclear Matrix Systems), including separation rings

(Twinring) and Diamond wedges (cfr. Infra).

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Figure 9: Schematic presentation of the maximum curvature of the Sectional matrix (TORVM), the

Saddle matrix (TORVM), the Perforated Contoured matrix (TORVM) and the BioFit HD matrix

(Bioclear Matrix Systems). Matrix bands of 6.5 mm height were used.

Figure 10: (a) A hard steel (50 µm thick) sectional matrix band does not deform permanently during

placement and positioning of the separation clamp compared with (b) a soft stainless steel matrix

band. After burnishing, the matrix band is deformed in the center. This will result in an irregularity in

the proximal composite surface at the level of the contact area). (c) A sectional matrix (red dotted

line) is selected in class-2 cavities where the distance between the cervical cavity margin and the

adjacent tooth is ±0.5 mm (red double arrow).

Figure 11: (a-b) A Saddle matrix (TORVM) or Perforated contoured matrix (TORVM) (pink dotted line)

is selected in class-2 cavities where the distance between the cervical cavity margin and the adjacent

tooth is ±0.7 mm (pink double arrow). (a) This is possible when the teeth are positioned a bit further

from each other, or when the tooth is tilted. (b) The most common situation is when the cavity

margin becomes deeper. This kind of situations requires a more pronounced curvature of the matrix

band. (c) The Saddle matrix (TORVM) is mainly used in medium deep class-2 cavities. (d) A Perforated

contoured matrix band (TORVM) is used to restore a MO cavity with a deep cervical cavity margin.

The matrix band is tightened in between the two molars using a matrix tightener. Teflon tape is

pushed in between the matrix band and rubberdam to adapt the matrix band to the cavity margins.

No wedge is used. The distal surface of the second premolar was damaged by the previous operator.

Figure 12: (a) BioFit matrix (Bioclear Matrix Systems)(green dotted line) is selected in class-2 cavities

where the distance between the cervical cavity margin and the adjacent tooth is ±0.9 mm (green

double arrow). The most common situation is when the cavity margin becomes deeper. (b) The large

distance between the cervical cavity margin of the 1st molar and 2nd premolar requires the use of a

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BioFit matrix (Bioclear Matrix Systems) to restore the mesial side of the molar. (c) The matrix band is

positioned and stabilized with a Diamond Wedge (Bioclear Matrix Systems). Additional stabilization is

obtained with block-out resin placed in between the matrix band and the adjacent tooth. (d-e) After

placing the composite restoration on the 1st molar, the mesial surface shows an adequate contour.

This allows the dentist to obtain a correct contour at the distal side of the 2nd premolar. (d) Occlusal

view, (e). Buccal view.

Figure 13: The distance between the cervical cavity margin and the adjacent tooth largely determines

the selection of the matrix band. When the space is ±0.5 mm a sectional matrix band (TORVM) is

selected. When the space is around ±0.7 mm a Saddle matrix (TORVM) or a Perforated matrix

(TORVM) is selected. These 3 types of hard steel metal matrix bands can be used in 90% of the class-

2 restorations. A BioFit matrix (Bioclear Matrix Systems) is selected when the interdental distance is

about ±0.9 mm.

Figure 14: (a) Initial situation: caries lesions are present at the distal side of the 1st molar and the

mesial side of 2nd molar. (b) After opening the distal marginal ridge of the 1st molar a deep caries

lesion, extending below the cemento-enamel junction, is observed. Electrosurgery of the interdental

papil takes place to visualize the cervical cavity margin and facilitate rubberdam isolation (c) The

teeth are isolated under rubberdam and the cavity preparations on both molars are finished. A BioFit

Blue matrix (Bioclear Matrix Systems) is selected to restore the deep Class-2 cavity on the 46. The

matrix band is positioned. A Sabre Wedge (predecessor of the Diamond wedge, BioClear Matrix

Systems) is used to stabilize the matrix band and to obtain a good adaptation to the deep cervical

cavity margin. Additional stabilization of the matrix band towards the buccal and lingual surface is

realized with block-out resin. (d) After placement of the composite restorations on both molars, the

restored proximal surfaces show an adequate emergence profile and contact area. (e). X-ray of the

initial situation showing the deep caries lesion on the 46, (f) X-ray after placement of the composite

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restorations. One can notice a good adaptation of the composite to the deep cervical cavity margin

on the 1st molar.

Figure 15: Selection of the matrix band with the correct height. The matrix band should be

positioned ±0.5 mm above the marginal ridge of the adjacent tooth. This is necessary to give the

proximal surface a correct contour in a cervico-occlusal direction.

Figure 16: (a) A BioFit Blue Matrix is placed interproximally and fixed with a Diamond wedge

(Bioclear Matrix systems). Occlusal view: The Diamond wedge adapt the matrix band well to the

cavity margins. (b). Buccal view: one can easily control the height of the matrix band as the occlusal

embrasure is included in the matrix band. A well-positioned contact area (white circle) is noticed. (c

and d) Placement of the separation ring of the Bioclear matrix system (Twinring; Bioclear Matrix

Systems) is required to compensate for the thickness of the matrix band. The adaptation of the ring

prongs towards the matrix band is not optimal in the occlusal part. This can be improved by pushing

teflon tape in between clamp and matrix band (white arrows). (e) A sectional metal matrix band is

centered bucco-lingually, so that the contact area is in a correct position.

Figure 17: Different wedges available on the dental market including plastic V-shaped wedges, hard

and soft anatomical wooden wedges, silicone wedges and hard plastic wedges.

Figure 18: (a) When a tall wooden wedge is required for fixation and adaptation of the matrix band,

the wedge often comes higher than the cervical cavity margin. The wedge pushes the matrix band

into the cavity (white arrow). This results in the formation of a large interdental area with increased

food impaction. (b) After corrective trimming of the wooden wedge (=customization of the

wedge)(yellow arrow), the matrix band can keep its normal contour.

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Figure 19: (a) Diamond wedges belonging to the Bioclear matrix system (Bioclear Matrix Systems),

available in different sizes (S, M, L, XL). (b). Diamond cut-out (yellow arrow) allows for the tip of the

wedge to collapse during placement, facilitating insertion of the wedge. Once placed, the tips burst

open to create a gingival seal. The wedges show a low profile. The largest wedge (Green color), the

so-called deep caries wedge, has a furcal flare (white arrow) which allows the wedge to adapt better

to deep caries and root furcations. (c) A large distance between the cervical cavity margin and the

premolar requires the use of a BioFit matrix (Bioclear Matrix Systems) with a pronounced curvature.

(d) The Green Diamond wedge is positioned interproximally and stabilizes the matrix band. By

pushing the wedge interproximally a tight adaptation between matrix band and cavity margins can

be obtained. (e) Proximal view after positioning of the matrix band. The contact area is in a correct

position. (f) After placing the composite restoration, the teeth show anatomically contoured

proximal surfaces and a well-positioned contact area. (g) Occlusal view of the restored molar and

premolar. A tight contact area is obtained. The form of the buccal and lingual embrasure has been

respected.

Figure 20: A variety of separation clamps is available on the dental market.

Figure 21: (a) Placement of a sectional matrix band fixed with a wedge. The matrix band is in a

correct position and shows an ideal curvature. (b) After placement of the separation clamp, the

matrix band straightens in the occlusal third (white circle). This will result in the formation of a closed

occlusal embrasure and a less contoured marginal ridge. Chipping will occur more easily during

occlusal loading. The marginal ridge and occlusal embrasure can be contoured after placement of the

restoration with a Soflex disc (3M Oral Care). However, this requires additional time for the operator.

(c) A sectional metal matrix band is positioned interproximally. (d) After placement of a wedge and

separation clamp the matrix opens slightly in the cervical area. This gap can be closed by pushing

teflon tape in between wedge and matrix band.

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Figure 22: (a) Several class-2 cavities need to be restored. It is best to start with the cavities at the

mesial side of the 1st molar and distal side of the 1st premolar. Because the distance between the

cervical cavity margins is small, a sectional hard steel matrix (TORVM) is used. (b). The matrix band is

fixed with a wedge. The matrix band adapts well at the cervical cavity margin, but is a slightly open at

the occlusal part of the 1st premolar. (c) The matrix bands are relocated by putting teflon tape in the

proximal cavity of the adjacent tooth. Additional stabilization of the matrix bands is obtained by

placing flowable between matrix band and adjacent tooth. (d) After restoring the cavities and

removal of the matrix band, an adequate proximal contour is obtained. No additional contouring is

required.

Figure 23: (a) Initial situation. Proximal caries lesions were present on the 1st (distal side) and 2nd

premolar (mesial and distal side). (b) Rubberdam isolation and final class-2 cavity preparations with

interproximal clearance. (c) The large distance between the distal cervical cavity margin of the 2nd

premolar and 1st molar requires the use of a more curved matrix band. (d) A BioFit HD matrix band

(Bioclear Matrix Systems) was selected and positioned. (e). Buccal view of the cavity preparations. (f)

After positioning of the matrix band, one can notice that the contact area and the marginal ridge are

in the correct position. (g) Palatal view after placement of the matrix band. (h) Positioning of the

separation clamp (Twinring) and placement of a Diamond wedge (Bioclear Matrix Systems). At the

mesial side a sectional matrix band (TORVM) was positioned and fixed with a wooded wedge. The

matrix band was relocated with teflon tape in the mesial cavity of the 1st premolar. A separation

clamp is not needed at the mesial side. (i) The composite restoration on the 2nd premolar was placed

and the matrix bands were removed- occlusal view. (j) Buccal view- both proximal surfaces show an

adequate proximal contour. A well-positioned contact area can be noticed between 1st molar and 2nd

premolar. (k) After restoring both premolars an adequate interdental anatomy is observed- occlusal

view. (l) Buccal view.

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Figure 24: (a) Cavity preparation. (b) Placement of the sectional matrix band fixed with a hard

wooden wedge (also used for pre-wedging). A contact area between matrix band and adjacent tooth

can be noticed. In this situation, a separation clamp is not required. (c) Final restoration after

removal of rubberdam, showing a tight and well-contoured proximal surface and marginal ridge.

Figure 25: (a) Layering of the box starts with application of the adhesive system. (b) Followed by

placement of a 1.5-2 mm layer of highly filled flowable composite in the cervical part of the box, in

order to improve the internal and marginal adaptation in this critical area of the box (31)

(c) Further build-up of the proximal enamel wall with a conventional small particle hybrid composite,

in order to have the best physico-mechanical properties in the area of the marginal ridge. (d) In the

occlusal cavity the dentin part is replaced with a highly filled flowable composite. Enamel

replacement is performed with a small particle hybrid composite following the successive cusp build-

up technique (31). (e). After contouring and finishing the interdental anatomy is restored.

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