Class V Restorations

More detail can be found at ClassV. A password is required.

An article by Dr. Walford covering Class V preparations can be found in the
December 2011 issue of Oral Health Journal.
Oral Health Journal, December 2011
This article covers preparation axioms and instrumentation for Incisal
Attrition, Class V, and Cusp tip restorations It can be found at
http://www.oralhealthgroup.com/news/preparations-incomposite-resin-part-i-principles-and-instrumentation-for-class-vcusp-tips-and/1000738881/?type=Print%20Archives

Class Vs on mandibular bicuspids in Gradia X, shade A3.5

The significance of the composite class V in the quest for excellence

The class V restoration is a watershed in the transition to more advanced

composite restorations.Once the practitioner can place a difficult posterior
Class V without violating any principles, amalgam or ionomer materials can
be discarded. These materials are less attractive and generally rougher than
well finished composite.Once simple Class Vs are routinely successful, the
practitioner can advance confidently to large and complex composite
restorations where tissue bleeding might otherwise be an insuperable
obstacle.

For example,
multiple surface restorations with subgingival decay or fracture
multiple surface restorations with almost no coronal structure
patients with poor gingival health, fragile capillaries,(as in the elderly,)
uncontrolled or circumstantial hypertension, high anxiety, or blood thinning
medications. These conditions all promote ready gingival bleeding, which

destroy successful composite placement when not completely managed.

A powerful and reliable method of tissue management eliminates hemorrhage
as a clinical challenge. Successful tissue management in Class V restorations
has spin-off advantages: it advances us into better crown and bridge work,
through better tissue management and isolation during preparations and
impressions.

As well, it builds restorative skills in resin placement on other facial surface,

such as:
freehanding missing cusps from the gumline without a matrix
building composite pontics over wire or cast adhesive frameworks
repairing fractured porcelain on crowns or bridges
layering missing cusps in MODB or larger restorations
placing attractive direct veneers on anterior teeth
Perfect saliva control
Another critical step in Class V excellence is achieving perfect isolation. In
study club we emphasize active saliva and water evacuation in conjunction
with passive absorbent media. When saliva is well controlled, a quadrant of
Class Vs can be placed with hardly a swallow on the patient's part over a long
appointment. Isolation of this caliber not only makes the patient comfortable,
secure, and unlikely to gag, but also provides a stable platform in which the
necessary focus and calm for precision cutting and stress-free placement can
take place, without iatrogenic slips. Nothing faults an appointment more than
a tense, twitching, convulsively swallowing patient due to poor isolation
practices. In the lower arch, the hygoformic saliva ejector is the device of
choice. See Hygoformic Saliva Ejector
Perfect gingival control
While rubber dam is often best practice in treating occlusal and supragingival
surfaces,it is usually an impediment at the cervical. The 212 or other retraction
clamps have limited applicability to posterior Class Vs, and often skew proper
visualization and access.
Our method is to pre-operatively place a fine, tightly-braided retraction cord
impregnated with epinephrine and aluminum sulfate in the sulcus. There are
few cords that are appropriate for this application. Because most cords are
formulated for crown and bridge use, they are designed to expand the sulcus
after placement.In Class V treatment, however, expansion is
counterproductive: cord expansion encroaches into the operative site. Few
cords meet the specification of retraction without becoming bulkier. Twisted
3-strand cord, or self-expanding braids unwind and interfere with
instrumenting the gingival line.
Ferrous salts are the most common astringent product, but they are
contraindicated for composite placement. Stain may develop postoperatively
in the gingival margin of the composite. If you see brown/black stain on the

margins of recently-placed Class Vs, it is probably for this reason.

What does the cord contribute to the process?

Constricts blood flow pre-operatively
Reduces sulcular fluid flow
Visually delineates the gingival margin by increasing contrast ( an ideal cord is
dark-colored)
Retracts gingiva apically by up to a millimeter, and ,in so doing,follows the
architecture of the gingival cuff. This allows placement of the gingival margin
following the intrinsic curvature of the gingival collar. Predictable tissue
rebound will cover the gingival margin of the restoration, thereby preserving
natural aesthetics. Mechanical retraction risks tearing of the attachment
apparatus or distortion the gingival line. If retraction is skewed, a skewed
aesthetic result can be expected. Worse, subsequent recession from the
iatrogenic insult may expose the restored margin to recurrent decay.
Reduces or eliminates hemorrhage during preparation; improves preparation
visibility and reduces preparation time and operator stress
Maintains a hemorrhage-free and sulcular fluid-free field during placement,
ensuring uncontaminated bonding
Displaces plaque, if present, beyond the intended margins, thereby reducing
contamination at placement.
Prevents flowable resin from descending into the sulcus during placement,
i.e., acts as a resin coffer-dam
What if breakthrough bleeding occurs?

If breakthrough hemorrhage occurs, we use a method we call "Hemostatic

Etching" See Hemostatic Etching To quickly summarize the method, at the
very end of the etching process (after 10 seconds), our etchant, liquid 37%
phosphoric acid, is titrated with a pledglet containing a saturated solution of
aluminum chloride. As aluminum chloride is an acid salt, it admixes well.
Aluminum chloride exhibits high surface tension, revealed when placed on a
hard surface as it "beads-up" like water on a freshly waxed automobile. The
liquid phosphoric acid reduces this surface tension and increases penetration
into the field.
Clinically, this method confers nearly absolute success without resorting to
more heavy-handed methods, such as electrosurgury or laser cautery, and
without the loss of time entailed with these resective methods, nor with the
potential damage to the attachment or architecture of the gingival collar.
When Hemostatic Etching fails,which it occasionally may in Class V
restorations, it indicates that the tissue is deeply inflamed and/or there is a
fragility in the patient's clotting system. It is best to re-think the situation at
such a time, temporize with a zinc oxide material such as IRM, and adopt a
tissue-recovery program involving better hygiene and chlorhexedine rinsing. A
definitive final restoration can be placed several weeks later when tissue
healing and re-epithelialization has taken place. In the author's experience
this is a very rare occurrence: Hemostatic Etching has proven extremely

effective over a period of decades of use without post-operative sequelae.

Preparation design for composite as compared to gold foil or
amalgam

Our prototypical class V preparation borrows from classic gold foil principles:
*occlusal margin perpendicular to the long axis of the tooth, rising to the
proximal line angles in a "smiley" outline form.
The gingival margin is placed one-half millimeter subgingivally, in the "cariesprotective zone", by the simple expedient of placing the gingival margin to the
cord-retracted level of the gingival tissue.
Axial depth is cut to a consistent plane,to provide aesthetic control, balance
contraction effects, and develop definitive finish lines near the line angles.
However, in contrast to gold foil or amalgam,
External line angles are radiused, not sharp.
Internal line angles are the radiused, from the use of the 330 bur
Explicit internal retention features are absent; all walls are divergent.
Oclusal Margin in enamel

The occlusal margin is lightly beveled, with a Conservative Composite

Bevel(CCB) See Conservative Composite Bevel. This minimally divergent
bevel (6 degrees), exposes rod ends for optimal etching and bonding, and
sacrifices no more tooth structure than absolutely necessary.
Conventional wisdom, in contrast, advocates a 45 degree bevel on the occlusal
margin of a Class V. In my opinion, this extension is grossly unnecessary and
condemns the patient to a lifetime of overly-prominent facial restorations. The
CCB, in contrast, produces a virtually invisible, stable, stain resistant occlusal
margin that is decay-proof if mated to a resin with suitable shade and opacity,
incremented properly, and finished judiciously,
See the examples below,prepared with CCB occlusal margins, and restored
using a a number of different resins. The photos illustrate the esthetic
potential and consistently controlled results obtainable. This method
produces restorations that are 100% retained over time and completely stable
clinically.

Instrumentation Sequence
1.

2.

The initial preparation preparation is cut with a sharp 330 FG bur, following
the retracted tissue line and preparing the occlusal line into sound enamel.
The bur is 90 degrees to the surface of the tooth. This will produce an outline
form that is slightly undercut by the divergence of the bur throughout the
preparation.
Once cut to depth and outline, a 12-fluted 7406 finishing bur is used to refine
all margins, including the gingival and proximal margins. This will
produce a slight divergence to all cavosurface margins.
Why the 7406 or 7404 burs?

These large diameter burs smooth out irregularities generated by the small
radius of the 330 bur. In some cases a 7404 FG carbide, the next step smaller
in the series, is more suitable for gingival and proximal refinement. These
large-diameter, unaggressive finishing burs clean up the margin and
simultaneously establish a minimally-beveled enamel cavosurface, where the
preparation is in enamel, that is rod-end bonded not rod-side bonded. Such a
margin is also easy to adapt resin to during placement, and finishes readily
and polishes with clarity. The less-aggressive cut of a finishing bur is effective
for this step, rather than an operative bur of equivalent diameter, such as a

703. The rake angle and greater depth of the blades of a 703, for example,
easily leads to overcutting in both depth and outline form enlargement.
Prep-less Preparations?

Our recommended Class V preparation is similar whether the etiology is

abfraction, abrasion, or caries-induced lesions. This author rejects the
"prepless" cervical restoration, as inferior in lifespan, and aesthetics, due to
uncontrolled prep depth = uncontrolled aesthetics
uncontrolled margin exit angle = indefinite finish lines
uncontrolled depth = uncontrolled contraction effects
uncut tooth structure = sclerotic and uncut enamel that resist etching and
produces lower adhesion values, early leakage, and premature loss
uncut gingival margins = uncontrolled margin placement with respect to the
gingival tissues = caries recurrence
uncut occlusal margin = uncontrolled and unartistic occlusal margin
inclination
un-instrumented proximo-occlusal and proximo-gingival radii = uncontrolled
radii placement or depth = thin, unstable and unpredictable margin
placement and tendency to produce both undercontour and root damage in
finishing
no gingival retraction = likely contamination with crevicular fluid,dental
plaque or pellicle at the margins during placement.
In summary, the prepless restoration is inferior with respect to almost every
important clinical variable.
Restoration Quality
The patient expects a restoration for their hard-earned treatment dollar, not a
procedure. A procedure is not a restoration. We shortchange the patient and
the profession when we abdicate controlling the variables that impart beauty,
longevity and clinical intelligence to the Class V restoration.
Specifics on preferred resins, matrixes, placement methods, curing,
instruments, finishing and polishing methodology are omitted in this brief
overview. More detail can be found at ClassV