Composite resin protocol

This is the composite resin protocol I've been using recently including instruments:

1. LA, Rubber dam, prewedge and cavity prep (Lately I've had difficulty with larger spaces between teeth, the largest wooden wedge hasn't binded and stayed in place. I may try a plastic wedge in the future. It has the benefit of sitting down into the gingival sulcus and inverting the dam)
2. Matrix band and burnish against the next tooth
a) 1-2 walls missing interproximally: Sectional matrix band/s. If the buccal and lingual extensions are too severe and the use of a ring will crush the band then use a wooden wedge to seal the gingival margin. The band can be adapted into the gingival sulcus for adaptation against the tooth but most likely i'll need to trim the excess material post placement
b) 3 walls missing: Tofflemire band and wooden wedges or plastic wedge and separating ring
c) 3.5-4 walls missing: Automatrix and wooden wedges
3. Bonding procedures
4. With the composite resin compules i've found that I haven't needed a flowable base. The Gaenial x flow we have has good scientific properties but i've found it trickier to handle than the other flowables in the past. Maybe I need more practice with it. If you aren't using the compoules then use a carver to slice composite and place it into cavities.
5. Interproximal composite resins wall. ~0.5mm thick manipulated with a round plastic. It should be convex at the marginal ridge to allow floss to slide into the contact. I've found it very tricky to trim the marginal ridge to open the contact so a bit of care here can save some time and damage to the adjacent tooth. If there is no separating ring and I don't think it has enough separation to form a contact then I will form one wall at a time and hold a round plastic against the next tooth for ~ 3 seconds while the curing light is on then remove
6. Buccal and lingual walls. These can be done more simply with an automatrix and a tofflemire that seals the margins. If sectional matrices are used either leave the band on while the whole wall is being formed or take it off before CR is being placed. If you attempt to remove the band while there is unset composite you may knock the composite around. Place the composite just inwards from the margin and tack it down. Push outward with a round or flat plastic then form it to be flush with the margin with a flat plastic. You can cut the excess off with a carver by slicing the tip along the margin
7. Cuspal form. This is more efficient to do 2 cusps at a time. for upper premolars and lower molars with symmetrical cusps this should be the buccal cusps then the lingual cusps or vice versa. For upper molars with asymmetrical cusps, start with the Large ML cusp as the reference then form the oblique ridge with the DB cusp. Then the MB and DL cusp can be formed. Place the CR with a flat plastic or a carver. It is better to shape the composite with a carver as the sharp edge can form fissures and get into tighter corners. Place the composite initially against the cuspal incline and tack it down to the cavosurface margin. Slice off the excess CR with a carver and pat the composite down to the pulpal floor. For the first set of cusps flatten the central fissure area to a vertical wall with a flat plastic or a carver. The next cusp set will then be compressed into this vertical wall and if done gently then the resulting join will form a deeper anatomical fissure.
7. Polishing:
a) Start with a thin tapered diamond. this is thin to get into the embrasure spaces and trim the CR if it is overcontoured. it should be run around the buccal and lingual margins if there is an overhand or excess. If you like you can run the bur over the fissures but this is not necessary
b) Articulating paper
c) Take a rounded football diamond to shape the occlusal surface. Start with the marginal ridge and bring it down immediately to the height of the adjacent ridge. You can use a slightly pointier football diamond at a 45 degree andle to the occlusal plane to open the floss slope into the contact. Use the football to trim high occlusal spots on the cuspal inclines.