Difficult restorative appointment

 Today I had a difficult and very frustrating restorative appointment. it was restoring a back to back interproximal cavity on an upper canine and premolar. The premolar was rotated to the distal so the cavity was on the palatal surface and there was moderate recession and severe wear with 100% overbite and a vertical parafunction pattern with a horizontal platform worn into the canine and premolar where the opposing teeth occluded. 

Difficulties of this appointment was:

-The caries was equigingival on teeth with recession. The further down the tooth the lesion is, the more difficult the access, matrixing, wedging and application of restorative materials. Pretty much every aspect of the procedure is more difficult.

-When there are well defined wear facets, the occlusion has to be spot on post restoration as the teeth fit together perfectly and any failure to conform will lead to a high spot on a patient with heavy occlusion. 

-The rotated premolar put the caries on the palatal root surface, this means that the lesion was at a point where the tooth surface is extremely close to the pulp. It also makes radiographic interpretation of the lesion more difficult as it is different to the "traditional" interproximal caries.

-The caries on the root surface meant that the interproximal crown convexity hindered seating of the matrix band as the root curved in more severely than the contour of the matrix band. 

-The more severe recession interproximally meant that the buccal and palatal gingiva was in the way of the matrix band seating. If I tried to put a clear strip or sectional matrix in, the elasticity of the gingiva would push it out. Therefore I opted for a tofflemire which by tightening would naturally force its way downwards. The rotation of the premolar and the narrowness of the palatal contours compared to the buccal meant that there was a natural gap on the palatal side. In the future I would be careful to position the retainer at the most buccal convexity of the tooth rather than just on the buccal aspect of the arch. Imagine the "relaxed" position of a tofflemire sitting on the bench. The curvature of the band is perpendicular to the retainer and the widest part of the band is on the palatal aspect. Make sure the retainer is sitting on the mid buccal aspect of the tooth and seat the lingual aspect of the band before you tighten the band. As vision was difficult, I tightened the band when I thought it was seated and ended up cutting into the palatal gingiva quite a few times. When the root surface is involved, the benefit of a tofflemire sliding down the corvature of the crown from occlusal to cervical disappears as the root surface is comparably more vertical. 

-Wedging was difficult as the buccal papilla was in the way of the wedge passing all the way through.

-When there is recession and the restoration is quite far down the tooth on the palatal surface, it is difficult or not possible to get a polishing disc down there as the head of the handpiece will hit the adjacent teeth. Instead use polishing cups or points

-These restorations are mostly dentine bonded and as the contact point is strange or non existant there is often food packing, gingival inflammation and bleeding as in this case

In the end I produced a restoration that I was not happy with that didn't adapt well against the tooth, probably was overhanging and had an open contact. In hindsight I would have restored the more difficult premolar freehand giving me the access to remove any overhangs and polish the filling before moving onto the easier canine which could be matrixed using a tofflemire. If the food packing is an issue, my plan to proceed would be to cut a traditional box prep on the premolar leaving the margin untouched using my current restoration as a marginal elevation. I should then more easily be able to get a contact and seal the cervical margin as a wedge would be possible to insert tightly.