Be careful with using wedges with perio patients

I had an issue recently with the use of a wooden wedge during a class II restoration in a perio patient. The issue was that when I inserted the wedge on the buccal, due to the patient's loose gingiva, the tip of he wedge moved apically and penetrataed through the lingual papilla. As a wedge is inserted, it will contact the teeth either side. As the angle of the roots taper away from each other, the further the wedge is inserted, the further apically it is forced. In a healthy periodontium, it will contact the gingiva and be foced back upwards. In this perio patient, the buccal papilla didn't provide much resistance which allowed the wedge to seat more apically into the tissues. Due to the interproimal periodontal pocket, the interdental col was exaggerated and so the tip of the wedge was guided downwards into the pocket. As I wasn't careful with the insertion, the wedge entered the tissues and went straight out the other side.  This caused bleeding and made moisture control more difficult.

In the future, when I am using wedges in these patients I will take a bit more care. It is easy to fit the wedge in initially due to the black triangle but it is more difficult to guide it safely out the other side. Pay close attention to the angulation of the wedge, it should definitely not be pointing apically, it should be horizontal or slightly coronal to avoid impinging on the opposite side papilla. Use light pressure to insert the wedge as it won't tak emuch pressure to penetrate the tissues. If there is any resistance from the tissues, pull back and change the angulation and use jiggling motions to guide it through safely. For whatever reason, I've noticed that no matter how much attention I pay, on posterior teeth the wedge will tend to come out to the side of the papilla rather than above the papilla. This may be because the black triangle between posterior teeth is narrower than anterior teeth due to less tapered roots.