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The New Science of Strong

Teeth: Class II Preps


Category: Restorative Created: Tuesday, 11 June 2013 17:56 Written by David Clark, DDS

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INTRODUCTION
At some point in their career, most restorative dentists have questioned
themselves in regards to the way they prepare Class II restorations. I have
certainly done so as my 57-carbide mowed through mostly healthy tooth
structure, knowing that I was seriously weakening the tooth.
Research has now shown that composite is no better than amalgam for
reducing subsequent tooth fracturing (Figure 1).1 That research was the final
straw for me. At that point, I stepped away and started to design a new cavity
preparation from scratch, based on a rational hierarchy of needs (Figures 2 and
3). That hierarchy is as follows: tooth needs, composite needs, and now modern
engineering needs for brittle materials. (Note: Enamel and dentin are technically
brittle materials.) During my teaching activities, countless dentists have asked
me, Why do we cut such a large hole in a molar to access a tiny spot of dentinal
caries? When I showed the modern Clark-design Class II cavity preps to John
Khademi (an endodontist and coauthor of parts 1 and 2 of this article series), he
replied, Yes, that makes sense. The G. V. Black prep made no sense to me, from
an engineering standpoint; so I refused to cut them in school [24 years ago].
Why Do Teeth Break? Better Yet, Why Do They Not Break?
In our first article, Fracture Resistant Endodontic and Restorative
Preparations,2 we discussed the formula for crack initiation in brittle materials
(such as dentin and enamel). The best formula for determining stress
concentration in the occlusal of a tooth due to a cavity preparation is (1 + 2L/R) ,
where L is length of the cut and R is the radius of the cut. We want L to be as
small as possible. R should be as large as it can be, within reason. In simple
terms, the longer the cut, the worse the cut. A cylinder-shaped hole (typical G. V.
Black Class I) is worse than a v-shaped hole. In the case of a the occlusal of a
molar, several separate shallow fissurotomy preps to eliminate stain and caries
are far better than one continuous slot cut with a square-ended 556 bur.
In this article, I will combine that strategy along with other pertinent
issues, making recommendations on how to cut a Class II composite that is

consistent with todays knowledge and science. Back-to-back Class II cases will be
presented in order to demonstrate and teach several modern principles.
CASE REPORT
Note: The brevity of the article does not allow a full discussion of all Class II
preparations. Instead, I will fully explain the decisions, materials, and sequencing
for this case (Figures 2 to 19).

Clinical Findings
An 18-year-old female presented with interproximal caries on the distal of her
mandibular right first molar (tooth No. 19), and in the mesial of her mandibular
left second molar (tooth No. 18). Unfortunately, despite repeated nutrition
counseling, oral hygiene instruction, office fluoride varnishes, and home fluoride
treatments, the distal of tooth No. 19 continued to worsen on radiographs and a
small cavity was discovered under 16x magnification with a microscope (Global
Surgical).
Images start with a Clark Class II Saucer preparation on the distal of No. 19.

Once the distal of No. 19 was cut away, advanced magnification allowed a unique
opportunistic view of the mesial of tooth No. 18. At that time, a typical crescentshaped decalcification was observed on the mesial of No. 18 with a microscopic
cavitation (not pictured). Because of the patients history of noncompliance, I
opted to prepare opportunistic access2 on No. 18 rather than take a wait-andwatch approach. Tooth No. 18 mesial was cut from the side via the prep on the
distal of No. 19 (Original Fissurotomy Bur [SS White Burs]), and then a calla lilystyle enamel shape with infinity edge margins was cut and sanded (round-ended
course diamond (Piranha 856-018C [SS White Burs]) followed by a thin flameshaped fine diamond (Shofu Dental 848F); followed by coarse ContacEZ and or
lightning strip; followed with blasting with high power air-water abrasive slurry
(Prophy Plus [Bioclear Matrix]) to remove final remnants of biofilm. Again, in this
case, the concept opportunistic access for the preparation of the mesial of tooth
No. 18 was afforded once the distal of tooth No. 19 was opened up with the saucer
preparation. The marginal ridge of No. 18 was spared (Table 1).

Figure 1. Bonded composite


restoration (right) leaves tooth
just as weakened as an
amalgam restoration (left). A
better prep, not adhesive
dentistry, is what allows the
tooth to survive over time.

Figure 2. Oblique view of the


featured case with
opportunistic access on No.
18 and saucer/Clark Class II
on distal of tooth No. 19.

Figure 3. Blasted, abraded,


and etched tooth No. 18 with
blue tinted Bioclear Matrix in
position. The mesial
preparation is separate from
the occlusal fissurotomy

Figure 4. Bioclear M406


Matrix in straight and
lateral view. Blue tint
allows better
visualization for
posterior teeth and has

preparations.

99% light transmission.

Figure 5. Application of
disclosing solution is part of
the modern composite
preparation. Even when using
a microscope, the biofilm
(plaque) can be nearly
impossible to see without
using dyes. Phosphoric acid
alone does a poor job of
cleaning.

Figure 6. Blasting of
biofilm with high power airwater abrasive slurry. A cup
and coarse pumice is futile but
remains the current accepted
method to clean teeth before
sealants or composites.

Figure 7. After blasting,


disclosing solution is applied
a second time because the
disclosing solution does not
stain deeply. At this point,
cleaning/abrading of the
fissure will require the use of
a fissurotomy bur.

Figure 8. Low- and highmagnification views of the


Original Fissurotomy Bur (SS
White Burs). The bur will
gently abrade and clean this
defect without significant
weakening of the tooth. In this
application, it would not

require anesthesia.
Filling a Minimally Invasive Preparation Using an Injection Molding
Technique
In reality the bur, prep design, biofilm removal at the margins, adhesive,
composite, and polishing are all interdependent. When you change one element,
it will usually affect all the others. The preparation on tooth No. 18 presents
unique challenges and wonderful conservation. Figures 10 and 11 demonstrate
the constricted access for etching, bonding, and filling; impossible with ordinary
metal matrices and cold paste composite in a normal fat-tipped paste composite
syringe. A new cavity prep design demands new filling instruments. Instead, the
sectional translucent Bioclear matrix allows itself to be temporarily teased away
from the tooth for access for etching. Later the space was injected with bonding
resin, and then chased with a low-stress bulk-fill flowable composite (Filtek
Supreme [3M ESPE]); then chased with heated Filtek paste composite in special
step-down micro-flow tips (Bioclear Matrix). These 3 resins are injected, in
sequence, without curing individually using an injection molding composite
technique. It is similar to using light-body and heavy body impression materials.
At present, it is the optimal method to achieve a monolithic (unibody or
nonlayered) Class II composite. The goal is for at least 80% to 90% of the overall
mass of composite to be paste composite (with less than 20% being flowable
composite).3 An anatomic translucent matrix allows buccal-lingual curing, but
more importantly, it allows the composite and the light to wrap around the tooth
where a metal matrix cannot reach, even with bulk-fill composites. The 0.7-mm
(Figure 17) clearance at the buccal and lingual aspects allows for 5 key properties.
First, the use of a lightning strip (Integra Miltex) abrades away biofilm near the
margins and removes undermined enamel rods. (Tragically, todays composites
are designed to fill pothole preps with a definitive margin and a metal matrix.)
The second advantage is that the long margins allow the composite to wrap
around the tooth to potentially strengthen the tooth; not through adhesion per se,
but from an engineering design perspective. A third advantage of the infinity
edge interproximal margin is better aesthetics from an invisible margin and
resistance to stain. A fourth advantage is better wear resistance than a sharpor
beveledwall margin, which invariably begins to ditch when in function. The
fifth advantage is that the neighboring tooth can be spared from the almost
inevitable iatrogenic gouging; an abrasive strip is used to prep the enamel near
where the teeth touch, not a bur.

The goal is to avoid the over-use of flowable composites or reliance on


grainy, ugly bulk-fill paste composite. Although bulk-fill shows promise, it is no
substitute for cutting a better prep. (Watch videos at dentistrytoday.com.)

Figure 9. Diagram of the


same fissurotomy bur used to
initiate the saucer Class II
preparation (Clark Class II).

Figure 10. Saucer preparation


(Clark Class II) on right,
distal of tooth No. 19.
Opportunistic Class II on left
(mesial of tooth No. 18).
Opportunistic access is
loosely defined as maximally
conservative tooth
preparations based on the
unique situation.

In Enamel We Trust
One of todays biggest confusions is the term adhesive dentistry. When I see
symposiums on adhesive dentistry, I scratch my head. Thats a term that should
be discarded or clarified. Composite/enamel adhesion is essentially unrelated to
dentin bonding in real practice. We have 20-year outcome studies showing that
porcelain veneers will stay bonded to enamel, but they may just fall off the dentin
after a few years. Ninety-nine percent of the dentists I talk to refuse to risk
themselves and their patients by relying on dentin bonding for certain restorative

tasks, and for good reason. When outcome studies show long-term retention of
bonding to dentin substrates in the everyday practices, we can talk. Until then,
dentin bonding is something we do to avoid sensitivity, and to avoid significant
microleakge and stain. No one wants to hang their hat on just dentin bonding.
Let someone else deal with dentistry that falls off at 3 to 5 years. Not me!
Todays careful clinician will maximize enamel engagement, and carefully
seal dentin but not rely on dentins slowly weakening bond to retain the
restoration. Table 2 features an overview of current Class II cavity preparation
styles and relevance.

Figure 11. HighFigure 12. Higher


magnification view (4x) of the magnification view (8x) of the
opportunistic access (left,
occlusal access of the
mesial tooth No. 18) with
Opportunistic prep
Bioclear Matrix in position. (highlighted in green). The
matrix can be teased open for
insertion of the etch tips,
dispensing resin flowable and
then paste composites. Then
the matrix is teased back into
position.

Figure 13. The 27% blue


phosphoric acid etchant was
placed. Note how the Bioclear
Matrix allows an interesting
aquarium view of the
procedure. This allows the
operator to evaluate the
completeness of etching and
delivery of resins to the
cavity.

Figure 14. Clear matrix


allows direct light penetration
from curing light from many
angles. In this case, no
layering is needed even with
conventional (nonbulk-fill)
composites.

Figure 15. Once the smaller


prep is filled (left), another
clear molar matrix is placed,
soft wooden edge replaced,
and Bioclear Tetra ring is
placed. Note how the 4 patent
pending independently
hinging engagers of the clear
ring apply pressure to fully
adapt the matrix, eliminating

Figure 16. Highmagnification view of the


Tetra rings 4 independent
suspension engagers on teeth
Nos. 18 and 19.

overhangs.

Figure 17. Green arrows


Figure 18. Heating of paste
show optimal clearance of
composite allows Step
0.75 mm, which strikes a
Down Tips that are selfperfect balance, allowing for 5 threading and are screwed
key properties.
onto traditional Filtek
Supreme (3M ESPE)
compules. Regular (top), 2x
(middle), and 4x (bottom)
Step- Down Tips (Bioclear
Matrix) are shown.

Figure 19. HighFigure 20. Illustration of the


magnification immediate
evolution of the modern Class
postoperative view of
II: Clark Class II (left), slot
contacts. Note the invisible
prep (middle), and traditional
infinity edge margins,
G. V. Black preparation
mirror smooth finish, broad (right).
contacts, and lack of white
lines. The tooth, composite,
and marginal ridges should
deliver decades of excellent
service to the patient without
retreatments.
Here We Go Again! Partial and No Dentinal Caries Removal
G. V. Black mandated that all dentinal caries must be removed. That rule is
contradicted by modern science, yet remains the standard. As dental schools
slowly but surely change, the cavity preparations will go through another painful,
chaotic, and exciting transformation as the rulemakers decide how much and
where we will practice strategic selective dentinal caries removal. As I prepare

our textbook on modern cavity preparations, these changes will make a profound
effect on cavity design, materials and the approach to the
pulp/predentin/dentin/enamel/restoration continuum (Figure 20).
IN SUMMARY
Our most common restorative procedures, Class I and Class II restorations, are in
a state of chaos as the manufacturers design adhesives and composites for a
cavity prep that is 120 years old (Table 2). Many of the current preparations are
tweener preps, somewhere in between a G. V. Black and a slot prep, neither of
which are well suited for composite. What the schools teach is even more
curious. We also see a resurgence of direct pulp-capping materials, when the
research tells us to never expose the pulp. Instead, in teeth with an intact pulp,
we should leave a clean margin and 1.0 mm of carious dentin over the pulp! As
mentioned above, the tunnel prep was designed to preserve enamel while
accessing the dentinal caries, but we are currently questioning the need to
remove carious dentin. Can we all begin to appreciate how cataclysmic these
changes will be?
It is my hope that the principles advanced in this article will aid clinicians in their
journey toward ideal conservative restorative dentistry.