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continuing education

Create Biomimetic Class II

Direct Composite Restorations
Using a Sectional Matrix System
by Dr. Randall G. Cohen
Instructor, Alleman-Deliperi Center for
Biomimetic Dentistry, South Jordan, UT,
Private Practice, Newtown, PA

Dr. David S. Alleman

Director, Alleman-Deliperi Center for
Biomimetic Dentistry, South Jordan, UT

Educational objectives
Upon completion of this course, participants should be
able to achieve the following:
1. Understand the requirements of a matrix for creating
Class II restorations.
Dentaltown is pleased to offer you continuing education.
2. Understand the difference between adhesive prepara-
You can read the following CE article in the magazine, take the tions and amalgam preparations.
3. Understand the appropriate treatment for structural
post-test and claim your CE credits. See instructions on page 72. defects.
4. Understand how different materials replace different
parts of the tooth.

The immediate clinical challenge to a successful posterior

direct composite restoration is recreating the optimal proxi-
mal contour and establishing an ideal contact with the adja-
cent tooth with a restoration that recreates the tooth’s
original physical properties (biomimetic dentistry). While
several different matrix systems have been successfully used
for decades for use with amalgam, they have yielded less pre-
Approved PACE Program Provider dictable results with composite restorations. Matrix systems
FAGD/MAGD Credit
Approval does not imply acceptance for composites, due to the unique requirements for compos-
by a state or provincial board of ite placement, have evolved to today’s products that have
dentistry or AGD endorsement.
12/01/2004 to 12/31/2012 improved design specific to the requirements for composite
placement. In this article the authors will apply biomimetic
concepts to the direct Class II composite resin using an inno-
vative sectional matrix system to create a predictable proxi-
mal contour and contact.

Background
Dentaltown.com, Inc. is an AGD PACE and an ADA CERP Recognized Provider.
Amalgam has been the material of choice for Class II
restorations for more than a century.4 The classic amalgam
This course offers two ADA CERP or AGD PACE Continuing Education Credits. preparation frequently required breaching sound tooth struc-
ture. Restorations, even of minimal proximal lesions, seemed
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to result in the loss of a greater volume of healthy tooth Clinical Procedure for Class II Direct
structure than was originally infected with dental caries. Composite Restorations
Preparations for amalgam restorations required application of
the G.V. Black principle of “extension” of the prep for “preven- 1. Isolate and clean the tooth and pre-etch the enamel
tion” of recurrent caries and a geometric, undercut preparation Once the appropriate case
design for retention of the restorative material. is selected (Fig. 1) the opera- Fig. 1
tive field is isolated in the
While the general approach today in restoring a Class II
usual manner. Proper isola-
lesion with composite can be much more conservative one with
tion greatly aids in retraction
minimal extension beyond the caries, it is still very common to
of oral structures and in min-
treat recurrent decay under failed amalgam restorations. The cli-
imizing salivary contamina-
nician must often contend with large preparations that need to
tion. While the rubber dam
be restored in a way that the physical properties of the tooth are
offers the most effective isola-
replicated by the restorative material.
tion, there are occasions such
Another conspicuous departure from amalgam preparation
as insufficient bulk of tooth structure, limited access, and
design is that there is no need for undercuts to retain the
patient cooperation that preclude its use. Nonetheless, the oper-
restorative material. Classic amalgam design creates a “gingi-
ator should do his/her best to place the rubber dam, especially
val” portion that is wider than the “occlusal” portion to pro-
on lower molars where the tongue and pooled saliva can easily
vide a mechanical means of retention and a design to prevent
contaminate the preparation surface.
dislodgment. Bonded composites, in contrast, are retained by
The authors recommend the use of an antibacterial self-
adhesive bonding to dentin and enamel making undercuts
etch adhesive on the cut enamel and the cut dentin. The chief
unnecessary. Undercuts in indirect restoration preparations can
reasons for using this specific adhesive product are its relative
create a high-stress restoration when used with composite. ease of use, its ability to disinfect the dentin and to create a
Actually, the “undercuts” might in fact interfere with the easy strong, predictable dentin-resin bond. Self-etch adhesives how-
placement of the restorative material and increase the C-Factor ever, do not etch uncut enamel as well as phosphoric acid, and
of the final restoration. so the author utilizes a pre-etch treatment of phosphoric acid
Biomimetic Dentistry onto the tooth prior to beginning the preparation (Fig. 2).
The concept of using dental materials to mimic the natural First, the pellicle layer is removed with either a slurry of coarse
structure of the tooth is the goal of restorative dentistry. The pro- pumice or by air abrasion.
Fig. 2 Also, sodium hypochlorite
cedures necessary to accomplish this have been described at the
Alleman-Deliperi Center for Biomimetic Dentistry* as follows: can be scrubbed into grooves
1. Eliminating infections and cracks in dentin. in order to remove organic
matter. Then, phosphoric
2. Immediately sealing dentin.
acid gel (K-Etchant Gel,
3. Bonding the tooth side to side, front to back and top to
Kuraray) is applied to the
bottom to prevent re-infection and new crack initiation.
uncut enamel, left undis-
4. Lowering stress/strain in the tooth/restoration.
turbed for 15 seconds and
5. Resisting loss of tooth structure from attrition, abrasion,
then rinsed.
erosion and abfraction.
6. Matching the tooth’s functional anatomy. 2. Remove old restorations, cracks and decay without
The procedure as outlined below is based on the protocol for exposing the pulp
composite resin placement known as “Six Lessons” that was Over time and function, old amalgam restorations fail,
developed at the Alleman-Deliperi Center for Biomimetic allowing recurrent decay and cracks to form in the dentin
Dentistry in South Jordan, Utah. substrate. These cracks are structural defects that will con-
The Six Lessons* are as follows: tinue to propagate and cause post-operative pain and poten-
Lesson 1 – Remove decay and disinfect dentin tial failure unless they are carefully removed. So, the first
Lesson 2 – Remove structural defects objective in this protocol is to access the caries with a mini-
Lesson 3 – Dentin bonding mal loss of uninvolved tooth structure. Once the old fillings
Lesson 4 – Control of C-factor are removed, then under magnification of at least 4.5x and by
Lesson 5 – Onlay preparation using transillumination, the clinician must remove all dentin
Lesson 6 – Occlusal balancing cracks completely using a #4 round bur or diamond. When a
*www.allemancenter.com continued on page 68

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crack appears to have propagated into the pulp, the clinician 3. Place the sectional matrix band assembly
should respect the pulp’s integrity and avoid breaching Dental amalgam is often condensed into the proximal cavity
the pulp rather than doing elective endodontics unless prep by using the Tofflemyre Matrix with a metal band to con-
irreversible pulpal symptoms and/or a periapical lesion tain the filling material. With the advent of composite resin
exist. Cracks that undermine cusps must be removed com- materials the Tofflemyre became less useful in creating a proper
pletely, and if only a thin cusp remains, then an onlay restora- proximal contour and a consistent contact with the adjacent
tion needs to be planned. tooth. Further, its design makes it difficult to use on a tooth that
Next, all caries must be thoroughly debrided from the prepa- has been clamped for securing the rubber dam. However, it still
ration, however, establishing the proper endpoint for caries has certain applications in larger, more complex restorations that
removal without pulp exposures is unpredictable if the clinician require buildup of buccal and lingual surfaces.
depends solely on the tactile use of the explorer tip. The function of a matrix band is to replicate the missing
Consequently, the use of a biologic stain to reveal infected and wall of the tooth so that the restorative material can be used
then affected dentin provides a more consistent yardstick toward to create the proper contour and consistent adjacent tooth
effective removal of diseased tooth structure. contact. An effective means of accomplishing this objective
Caries Detector Solution with composite resins is with the use of the sectional matrix.
Fig. 3
(Kuraray) (Fig. 3) is applied The small section of a sectional matrix band is pre-contoured
to cut tooth structure and at the point of manufacture, and sized, then “precurved” and
once rinsed, will reveal caries- placed interproximally using a specialized forceps (Fig. 4). It
infected dentin (stains red) is then wedged to create tooth separation and a tight seal at
and caries-affected dentin the gingival margin (Fig. 5). The plastic wedges (Wedge
(stains pink). Caries debride- Wands Garrison Dental Solutions) represent an advance over
ment is best accomplished by the older wooden wedges because they more accurately con-
first using a flat-ended dia- form to the embrasure and fit more securely with the ring,
mond stone (F-60, Pollard especially with the 3D ring that “straddles” the wedge. A cor-
Dental Products) to create a “bondable ring” that completely rectly sized plastic wedge is selected, then the band is stabi-
eliminates caries from the periphery of the restoration such that lized with the operator’s finger, then inserted into the
there is no red or pink stain 1.5 to 2.0mm inside of the DEJ. embrasure. The “wand” portion of the wedge facilitates easy
Then, using a sharp #2 or #4 round carbide bur on the low placement, then twists off leaving the wedge in its proper
speed handpiece with continuous irrigation to dissipate fric- position. Even if the operator believes that the sectional
tional heat, caries is removed from the dentin surface until the matrix is fitting tightly at the gingival margin, the use of the
red stain is gone. Then the process is repeated until only a “pink wedge is nonetheless mandatory so to avoid overhangs, bond
haze” remains. Further cutting can lead to a pulp exposure, failures, post-operative sensitivity and recurrent caries.
which the operator should carefully avoid.
Fig. 4 Fig. 5
Most Class II preparations utilizing adhesive dentistry are far
more conservative of tooth structure than what is required for
amalgam or cast gold. This is highly desirable since removal of
tooth structure tends to create pulpal changes as well as weaken
remaining tooth structure. The preparation design should be as
minimal as possible with the following additional distinctions
from classic amalgam prep designs:
1. General shape of the preparation should widen slightly
toward the occlusal to facilitate composite resin placement.
2. Cavosurface margin should be beveled to prevent When the ring assembly is seated into position (Composi-
bonding only to the side of an enamel rod column that Tight 3D-Ring Garrison Dental Solutions) the band and wedge
is weaker than bonding across the ends of multiple are securely positioned in preparation to contain the restorative
rod columns. material. Air drying the interproximal as well as seating the ring
3. Any undercuts that remain following caries and crack and rotating it into position as far gingivally as possible will
removal should be modified so that the C-Factor of the improve ring retention. The function of sectional matrix ring is
restoration is minimized. This will give smooth confluent to adapt to and seal the buccal and lingual ends of the matrix
surfaces without sharp angles. band against the tooth and with some models, (Composi-Tight

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continuing education

3D ring) provide a separating force that in turn requires the Fig. 7 The use of Protect Bond
wedge to be inserted further in order to provide the maximum requires less steps, provides
seal at the gingival margin. antibacterial cavity cleansing,
The ring must properly engage the buccal/lingual tooth sur- while also providing a strong,
faces to avoid excessive extrusion of restorative material through reliable dentin bond.
these unsealed margins that would require extra contouring and Protect Bond self-etch
finishing. The tooth separation from the dual action of the primer is first applied to the
wedge and ring is needed to compensate for the polymerization entire preparation for a 20-
shrinkage of the restorative material as well as for the thickness second period, then dried
of the matrix band itself. thoroughly with filtered air.
The final contour of the sectional matrix involves the use of A drop of bottle #2 (bond) is then applied to the prepara-
an instrument to burnish the band against the adjacent tooth to tion using a brush, and lightly aired to create a uniform thin
assure a tight contact once the band is removed. A specialized layer and eliminate pooling of the resin. Then a standard
multifunctional instrument curing light is used for 20 seconds to polymerize the micro-
(TN0009, Garrison Dental Fig. 6 filled resin.
Solutions) contains two bur-
5. Apply composite to the proximal enamel creating
nishers that are specifically
the proximal wall
designed for this purpose.
The enamel proximal wall is built up using a hybrid com-
Together, the ring, wedge,
posite (Clearfil AP-X) that is applied only to the enamel (the
and contoured band create a
layer will be about 1mm in thickness). 3 This wall is light-cured
predictably tight interproxi-
with a reduced light intensity that facilitates flow, thereby
mal contact that resists food
reducing contraction stresses.6 Clearfil AP-X has been shown
impaction (Fig. 6).
if polymerized by exposing to the light for 20 seconds at
4. Create the bond to the cut enamel and the dentin 200mw/cm2 (from approximately 0.5 inches away), followed
Composite resin restorations require a secure bond to the cut by a 10 second pause, fol-
dentin and enamel. The author recommends the use of an anti- lowed by another 20 seconds Fig. 8
bacterial self-etch adhesive (Clearfil Protect Bond, Kuraray). at 600 mw/cm2 (directly up
Self-etching adhesives maintain the smear layer that forms on against the prep6) the opera-
the cut dentin surface following preparation with burs or dia- tor minimizes contraction
monds, and use it to create a strong, biocompatible hybrid zone stress. The enamel wall is left
without the technique sensitivity of using a phosphoric acid pre- undisturbed for five minutes
treatment. By avoiding the demineralizing effects of phosphoric until the setting composite
acid on cut dentin, the dentinal tubules remain occluded and has reached 90 percent poly-
intratubular fluid movement along with its dentin hypersensi- merization (Fig. 8).
tivity is reduced and many times completely eliminated. 6. Place a liner of flowable composite to the dentin
Self-etch adhesives, in contrast to the total etch systems, floor only
keep the dentin in its mineralized state, and so the protein por- In adhesive restorations, the maturing bond strength to
tion of the dentin, remains upright instead of collapsing down dentin is in competition with the developing shrinkage stress.5
onto the dentin substrate once it is air-dried. Accordingly total Accordingly, success occurs when the operator creates a
etch adhesives require the dentin to remain “moist” but not restoration such that the
“wet” following the rinsing of the phosphoric acid gel, a narrow Fig. 9 bonds are able to withstand
window that makes these kinds of adhesives “technique sensi- the contraction stress of the
tive” in order to develop a strong dentin-resin bond. setting composite. Since
Prior to bonding, the dentin substrate should be disinfected, polymerizing composite
and while the use of antibacterial agents such as chlorhexidine shrinks in the direction of
2% (Consepsis, Ultradent) represent one means to accomplish the stronger bond, not
this as well as de-activating bond destroying matrix metallopro- “towards the light” as had
teinases,8 the adhesive monomer found in Protect Bond been commonly believed,
(MDPB) is itself a highly effective antibacterial agent (Fig. 7). the Alleman-Deliperi proto-
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col calls for a “decoupling” of the bond to enamel from the Solutions). The tight contact combined with the affinity of
bond to dentin by waiting at least five minutes following the the bonding agent to the side of the matrix band can make
bond to enamel before connecting it with the dentin (Fig. 9).3 the removal of the small matrix difficult. Besides using the
The first dentin layer in a Class II restoration consists of specially designed forceps, this difficulty can be overcome by
a 0.5mm liner of a highly filled flowable composite (Clearfil treating the restoration side of the band with an emollient
Majesty Flow) applied with a small tipped instrument such (Chapstick) prior to inserting the matrix into the contact.
as a ball burnisher or periodontal probe. In larger prepara-
tions, a small square of a specific woven fiber (Ribbond) is 9. The restoration is contoured and finished
trimmed with the special scissors, covered with the micro- Another advantage of the precise contour of the sectional
filled resin (from bottle #2) and tamped into place using a matrix and the slow build-up of this biomimetic restoration
small endodontic plugger. One effect of the Ribbond is to is the minimal finishing and polishing that is typically
act as a stress breaker that can relieve contraction stresses required. If the restoration includes axial surfaces of the
and improve marginal integrity.1 The Ribbond reinforced tooth, a coarse Soflex disk (3M) is useful in creating a smooth
liner has also been shown to prevent undesirable fractures of enamel/composite interface. Additional rounding of the
tooth substrate.2 proximal aspect of the restoration can be effectively achieved
with the thin finishing burs and polishing cups found in the
7. The bulk of the dentin is now replaced biomimetically G-Block Finishing and Polishing kit (Garrison Dental
The elastic modulus of Clearfil AP-X (16.74 GPa) is equal Solutions). The occlusion is then checked with articulating
to that of dentin (14-18 GPa), and with its stress relief capabil- paper, and adjusted with a shoulder former diamond, keep-
ity,7 is ideal for use as a biomimetic dentin replacement. AP-X ing its end in the grooves so to maintain the occlusal anatomy
is then placed in 1mm horizontal increments using a con- as much as possible.
denser; light-cured using the same slow start protocol until the The final polish can be
Fig. 11
occlusal enamel is reached. Horizontal stacking facilitates attained easily by using the
“decoupling” the dentin bond from the enamel, thereby lower- polishing cups and points
ing the stress on the dentin bond. A denser restoration can be found within the G-Block kit
achieved using a “snowplow” technique between layers where (Fig. 11). Other means of
the flowable composite (Clearfil Majesty Flow) is applied and creating a glossy finish to the
cured simultaneously with the AP-X increment. At this junc- restoration is to re-etch the
ture, a pause allows the dentin bond to improve from 70 per- entire restoration using 40
cent polymerized immediately after the cure, to 90 percent percent phosphoric acid (K-
polymerized after five minutes. Etchant Gel) rinse, dry, and
then apply a fluoride-containing pit and fissure sealant
8. The occlusal enamel is now replaced biomimetically
(Teethmate F-1).
The clinician completes the enamel portion of the
Finally, careful attention is
restoration by applying small increments of a heavily filled Fig. 12 given to the gingival tissues by
composite. Clearfil Majesty Posterior is well suited for this
being sure to remove any flash
purpose, having a high ceramic filler content and a modulus
that might have occurred dur-
of elasticity of 22 GPa, greater than that of dentin and creat-
ing the bonding process. A
ing a gradient in the restoration. Small increments are placed
sharp curette is used to instru-
against facial and lingual walls, using a carving instrument
ment the tooth and subjacent
(shown TN009, Garrison
tissues in order to provide a
Fig. 10 Dental Solutions) to follow
smooth maintainable surface
the cuspal inclines (Fig. 10).
(Fig. 12).
Following the polymeriza-
tion, the operator removes 10. Final check of the restoration
the matrix by using a Often, the anesthetic produces proprioceptive changes
Mosquito hemostat or by whereby the patient is uncertain as to whether the restoration is
using a specialized band appropriately adjusted. The double paper clench test often
remover. (Garrison Band reveals small high spots, and they are easily removed with the
Forceps, Garrison Dental shoulder former diamond and repolished. Where there is doubt,

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the patient should be directed to return to the office after anes- Bibliography
thesia has worn off in order to evaluate occlusion and remove 1. Belli S, Donmez N, Eskitascioglu G: The Effect of C-Factor
any prematurities that might still be present. and Flowable Resin on Fiber Use at the Interface on
Microtensile Bond Strength to Dentin JAdhes Dent 2006;
Conclusion
8:247-253.
Creating successful proximal direct composite restorations
2. Fennis WMM, Tezvergil A, Kuijs RH, Lassila LVJ, Kreulen
requires the clinician to increase his or her understanding
CM, Creugers NHJ, Vallittu PK. In vitro fracture resistance
beyond “Basic Adhesive Dentistry” into the more sophisticated
of fiber reinforced cusp-replacing composite restorations Dent
handling of composites, bonding agents, and matrix systems.
Mater 2005, 21: 565-572.
These advanced techniques enable the clinician to create not
3. Deliperi S Bardwell DN, An alternative method to reduce
only well-contoured, highly aesthetic restorations, but also com-
polymerization shrinkage in direct posterior composite
posites that are characterized by the preservation of tooth struc-
restorations. JADA 2002, 133:1387-1398.
ture, the establishment of a secure bond and the use of particular
4. Lavelle CL, A cross-sectional survey into the durability of
restorative materials that mimic the physical properties of the
amalgam restorations J Dent 1976; 4(3): 139-143.
natural tooth.
5. Feilzer AJ, DeGee AJ, Davidson CL, Setting Stress in
The goal of restorative dentistry is to bring the diseased tooth
Composite Resin in Relation to Configuration of the
back to a state of health. An important aspect of this treatment
Restoration, J Dent Res, 1987, 66 (11):1636-1639.
is the proper placement of the restoration so that an effective
6. Uno S, Tanaka T, Natsuizaka A, Abo T, Effect of slow-curing
gingival seal and a proper proximal contour are developed, pre-
on cavity wall adaptation using a new intensity-changeable
venting food impaction and recurrent caries. The use of a sec-
light source. Dent Mater 2003, 19:147-152.
tional matrix will offer the clinician a simplified and predictable
7. Christophe, Charton, et al: Shrinkage Stress in light-cured
means to replace the missing proximal tooth structure. Together
composite resins: Influence of material and photoactivation
with the proper handling of
mode, Dent Mater 2007, 23:911-920.
materials that are similar in
8. Pashley DH, Tay, FR et al, Collagen degradation by Host-
physical properties to natural
derived Enzymes during Aging, J Dent Res 2004, 83(3):
tooth structure, the clinician
216-221.
can create restorations that
truly mimic the biologic and
mechanical properties of
teeth, and deliver highly
functional and highly aes-
thetic restorations. ■

Authors’ Bios

Dr. Randall G. Cohen is in private practice of general, cosmetic and restorative dentistry in Bucks County, Pennsylvania, since his grad-
uation from Temple University School of Dentistry in 1982. He has published papers in several journals and has lectured nationally on
adhesive dentistry.

Dr. David S. Alleman graduated from the University of the Pacific School of Dentistry in 1978. He spent three years in the U.S. Navy dental corps
and 28 years in private practice in the Salt Lake City, Utah area. Dr. Alleman has studied with Dr. Ray Bertolotti since 1995 and has been teach-
ing hands on biomimetic dental courses since 2003. He also partnered with Dr. Simone Deliperi to teach minimally invasive dentistry in 2007.

Disclosure: Dr. Cohen declares having received an honorarium from Garrison Dental and Kuraray America for this course.

This CE activity is supported by an unrestricted grant from Garrison Dental and Kuraray America.

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Post-test

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1. Following diagnosis, treatment plan- the operator should respect the b. Has a modulus of elasticity in the
ning, and anesthesia, the first step integrity of the pulp. center of the range for human
toward a successful Class II restora- c. The crack must be removed fully, and dentin.
tion is: if it has reached the pulp, then c. Should be stacked horizontally to
a. Selecting the best bonding agent. endodontics must be planned. facilitate enamel/dentin decoupling.
b. Isolating and cleaning the tooth. d. The crack must be removed unless it d. All of the above.
c. Correct placement of the matrix. undermines a cusp.
d. None of the above. 8. After placement of the sectional matrix
5. Dentin caries ring, the plastic wedge should be:
2. The difficulty with the Tofflemyre a. Is best detected tactilely using an a. Left untouched.
matrix is: explorer: b. Removed prior to restoration placement.
a. The contour that is developed does b. Can remain in the restored tooth c. Seated further.
not match the original proximal since the restorations effectively iso- d. Replaced with a smaller one.
anatomy. late residual bacteria from their
b. The increased frequency of an open nutrient source. 9. One way to facilitate the removal of
contact when used with composite. c. Should be removed until Caries. the sectional matrix band from the
c. Using it on the rubber dam-clamped Detector Solution stains with a contact without compromising the
tooth. “pink haze.” restoration is:
d. All of the above. d. Does not affect the bond strength a. Coating the entire preparation with
to dentin. lubricant.
3. Using a wedge to seal the gingival mar- b. Avoiding use of the wedge to prevent
gin of the matrix band: 6. The undercut design for indirect restora- excessive proximal contact.
a. Creates an open contact. tion preparations: c. Grasping the sectional matrix band
b. Should always be used. a. Can create a high stress restoration with specialized forceps.
c. Is not needed with a sectional matrix. when used with composite. d. None of the above.
d. None of the above. b. Is counter-productive when used
with composite. 10. A tight gingival seal between the sec-
4. When an old restoration in an asympto- c. Is required to retain amalgam tional matrix and the tooth is necessary:
matic tooth is removed revealing cracks restorations. a. To prevent post operative sensitivity.
into the dentin: d. All of the above. b. To prevent bond failure.
a. The cracks can be bonded over with- c. To prevent overhanging restorations.
out concern. 7. Clearfil AP-X: d. All of the above.
b. The crack needs to be removed but a. Has a “built in” stress relief property.

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Create Biomimetic Class II Direct Composite Restorations Using

a Sectional Matrix System by Drs. Randall G. Cohen & David S. Alleman

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8. a b c d
9. a b c d For any questions, please contact Rita Zakher, DMD, MBA, director of continuing
10. a b c d education at [email protected]

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