Review of an old blog post

Today I had the opportunity to review a previous case:

http://dental-tidbits.blogspot.com/2018/08/getting-good-contact-with-large-gics.html
http://dental-tidbits.blogspot.com/2019/05/review-of-alternative-technique-for-gics.html

The entire GIC debonded a couple of weeks ago about a 11 months after placement when the patient was biting on a mintie. It's not a bad result but still needs management. The idea of the initial GIC placement was as a temporary to monitor the pulp status and the tooth has been otherwise asymptomatic. One might question if it's asymptoamtic due to a receeded pulp or a necrotic pulp. The failure was adhesive with the entire GIC lost save for the vitrebond liner so this was placed back when I was doing more indirect pulp caps.

As enough time had passed for pulp review I replaced the restoration in composite. I'm a lot less worried these days about causing pain with wedges. The patient consented to treatment without LA and understands there will be risk of discomfort. The discomfort from wedges is well tolerated as there is stretch in the PDL to accommodate for this. Even our largest wedge wasn't big enough for the space so I loosened the tofflemire and held the contact with a ball burnisher during curing.

Things I have learned since the initial placement:

• GIC is a good temporary material, don't expect for it to last forever, when it shows signs of breakdown (and it will in a harsh mouth) consider overlaying in composite resin or replacing in GIC over and over in a very unfavourable environment. Ideally  you will modulate the patients habits but in a non compliant patient they have to accept that you will need to replace restorations more often. I would rather have restoration breakdown and replacement than reucrrent caries that can go unchecked.
• This case would ideally be done indirect. The only remaining tooth structure is the buccal cusps. The mesial, distal and lingual margins are equigingival. Considerations include the ferrule effect which would be best managed with a lingual gingivectomy or a vertiprep crown. Unfortunately I don't have the option of indirect restorations in my current job. A compromise but one that would protect the buccal cusps would be to cap them with 2mm of composite or even consider  a David Clark type prep with the cusps cut back to the tips to preserve the pericervical dentine. In this case if the buccal cusps fracture the tooth has a very poor prognosis restoratively.
• The best matrix to use in this situation with the large interdental space would be a bioclear matrix as it is much more concave. I would use a bioclear matrix with a large wooden wedge only If I was redoing the restoration with my current material set I would use a sectional matrix, a wooden wedge and a separating ring for the best contact. Use of a ball burnisher to hold the contact always ends up with a rough interproximal surface
• Don't be afraid of giving LA. In this case I was happy to work without LA as the patient was as well but LA is an important step in providing adequate care. I would ideally have run a slow speed bur over the tooth surface to clear any recurrent caries and biofilm or if I could then sandblast the tooth to clear plaque. This ideally requires LA so just because we can do a case without LA doesn't mean that we should.
• Tension is what destroys teeth and dental materials. The mintie adhered to the surface of the GIC and put tension on the bond to tooth.The same will happen to any material if the patient is not careful. Lateral interferences on the lingual cusps will torque the whole restoration lingually and either crack the restoration or debond the composite early