Managing caries in crowded areas

I will use the example that I encountered recently: a class 2 div 2 case with caries between the central and lateral but this is relevant to caries in any crowded area.

• Caries tends to be more severe in these areas due to the inaccessibility of cleaning and the culturing of anaerobic environments. Overlap of teeth hinder effective access of toothbrushing and allows a protected environment from the cleansing effect of food movement and saliva. Tight contacts hinder the passing through of floss and calculus buildup further prevents this. 
• Caries tends to initiate under the contact point and due to their root torque, class 2 div 2 teeth tends to have a long contact point more apical to the ideal position. Therefore caries tends to be positioned closer to the DEJ and more severe in size. Also, upon caries removal, the distance between the cervical restorative margin will be minimal to none. Once I had caries freed this case, the contact point had not been present because the teeth were in contact till far below the gingival margin. 
• In cases like this, rubber dam is extremely difficult. I attempted to use Rubber dam in this case but a split dam was required in the end. Test prior to any rubber dam placement that floss can be run through the contact without breaking. If it can't then your rubber dam will most likely be caught on a sharp piece of enamel and don't waste your time trying to place the dam before preparation. 
• Placement of restorative matricies is very difficult as the contact hasn't been broken. To remedy this, if only one tooth is carious, you can force the contact open by levering a thin flap plastic between the roots and forcing a matrix down. If this is likely to cause bleeding (on a non recession case) or if both teeth are prepared, you should force a wooden wedge below the contact point subgingivally and use a very skinny bur to separate the contact point. Use this vertically and follow the margin that abuts the two teeth. You are in a sense creating a vertical preparation at this point to separate the two teeth. This will give you room to place a matrix and wedge. Provided the matrix is wedge well against the tooth, an overhang will be difficult to create which is handy because it would be extremely difficult to remove.