2

RESTORTIVE

The New Science of Strong Teeth:

Class II Preps
INTRODUCTION
At some point in their career, most restora-
tive 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 seri-
ously weakening the tooth.
David Clark, Research has now shown that compos-
DDS ite 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 techni-
cally 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 stand-
point; 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 En-
dodontic and Restorative Preparations,”2 we
discussed the formula for crack initiation in
brittle materials (such as dentin and enam-
el). The best formula for determining stress
concentration in the occlusal of a tooth due
to a cavity preparation is (1+2√LR ) , 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 rea-
son. In simple terms, the longer the cut, the
worse the cut. A cylinder-shaped hole (typi-
cal G. V. Black Class I) is worse than a v-
shapeed hole. In the case of a the occlusal of
a molar, several separate shallow fissuroto-
my preps to eliminate stain and caries are
far better than one continuous slot cut with
a square-ended 556 bur.
In this article, we will combine that
strategy along with other pertinent issues,
making recommendations on how to cut a
Class II composite that is consistent with
continued on page xx

Table 1. Steps for the Modern and Opportunistic Class II

STEPS MATERIALS
Step 1. Isolate, prewedge, desiccate, then apply disclosing Orange soft anatomic wooden wedge (Bioclear Matrix), 2-Tone
solution, blast the tooth to remove biofilm (Figures 4 to 7). Disclosing Solution (Young Dental) Bioclear Prophy Plus Blaster
with Aluminum trihydroxide powder (DENTSPLY Professional)
Step 2. Reapply disclosing solution. Abrade the remaining Original Fissurotomy Bur (SS White)
stained/caries with V-shaped Fissurotomy preps taking great
care to not connect theses individual occlusal preps (Figure 8).
Step 3. The interproximal is accessed either through the Original Fissurotomy Bur orange safe-side ContacEZ
marginal ridge (Figure 9) or opportunistically from the side with sander for a single interproximal, or red dual side abrasive
the same Fissurotomy Bur. The contacts are lightly broken ContacEZ sander for back to back interproximals, lightning strips
with an interproximal sander, then reabraded to the line angle (Integra Miltex)
areas with lightening strips. Do not connect the interproximal
to the occlusal fissurotomy areas.
Step 4. For ultraconservative preps it may be difficult to matrix Clear anatomic matrices (Bioclear Matrix) Tetra Ring
and fill back to back simultaneously. Instead, fill the smallest Adaptor/Separator and Soft Wooden Wedge (Bioclear Matrix)
or most difficult to access interproximal first. Then matrix and
fill the second interproximal.
Step 5. Injection molding. For bicuspids and shallow molar Universal Bond, Filtek Supreme Ultra Flowable and Paste
preps, traditional (non bulk-fill) composites can be injection Composites (3M ESPE), Composite Heater (Calset [AdDent] or
molded with a single continuum of bond, flowable composite, Vista Dental Products) Step-Down Tips (Bioclear Matrix)
and paste. Shallow fissurotomy areas can be filled strictly
with flowable composite.
Step 5 (alternative). For deeper preps, a first layer of Filtek Bulk Filtek Bulk Fill Flowable (3M ESPE)
Flowable is placed and cured along the gingival margin.
This will allow for complete curing, then can be quickly injection
molded over the gingival layer as outlined in step 5.

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The New Science of Strong Teeth...

continued from page 00

today’s knowledge and science. Back-

to-back Class II cases will be present-
ed 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 ex-
plain the decisions, materials, and se-
quencing for this case (Figures 2 to 19).
Figure 1. Bonded composite
restoration (right) leaves tooth
just as weakened as an amal-
gam restoration (left). A better
prep, not adhesive dentistry, is
what allows the tooth to survive
over time.
Figure 2. Oblique view of the fea-
tured 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 posi-
tion. The mesial preparation is
separate from the occlusal fis-
surotomy preparations.
Figure 4. Bioclear M406 Matrix
in straight and lateral view. Blue
tint allows better visualization for
posterior teeth and has 99%
light transmission.

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 repeat-
ed nutrition counseling, oral hygiene
instruction, office fluoride varnishes
and home fluoride treatments, the dis-
tal 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 crescent-shaped
decalcification was observed on the
mesial of No. 18 with a microscopic
cavitation (not pictured). Because of
the patient’s history of noncompli-
ance, I opted to prepare opportunistic
access2 on No. 18 rather than take a
wait-and-watch approach. Tooth No.
continued on page xx
Figure 5. Application of disclos-
ing solution is part of the mod-
ern 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 9. Diagram of the same
fissurotomy bur used to initiate
the saucer Class II preparation
(Clark Class II).
Figure 6. “Blasting” of biofilm
with high power air water
abrasive slurry. A cup and
coarse pumice is futile but
remains the current accepted
method to clean teeth before
sealants or composites.
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.
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 high-magnifi-
cation views of the Original
Fissurotomy Bur (SS White
Burs). The bur will gently abrade
and clean this defect without sig-
nificant weakening of the tooth.
In this application, it would not
require anesthesia.
Figure 11. High magnification
view (4x) of the opportunistic
access (left, mesial tooth No. 18)
with Bioclear Matrix in position.

Table 2. Overview of Current Class II Cavity Preparation Styles and Relevance

Preparation Name Joint type Relies on Adhesion? Current Relevance Estimated Popularity
Enamel or dentin for Composite in the US
Classic G. V. Black Class II Mostly compressive: No Completely irrelevant (but 40%
(mortise and tenon plus remains perfect for amalgam)
dovetail/jigsaw)?
Tunnel Class II Compressive No Relevance undecided. 2%
Poor C-factor, unfavorable
occlusal margin/composite
interface
Slot Prep Class II Half tension, half Undecided. Dentin bonding Needs to be discarded. It 40%
compressive of high importance, enamel is retains some of the worst
underutilized and margins leak parts of the G. V. Black prep
Clark Class II Saucer Tension with some Yes, mostly enamel Relevant 17%
compressive
Infusion No Prep for None Enamel “infusion” only, Relevant only for 1%
Decalcified Non-Cavitated dentin and dentin caries are decalcification lesions
Lesion(ICON System) left undisturbed

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The New Science of Strong Teeth...
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18 mesial was cut from the side via the
prep on the distal of No. 9 (Original
Fissurotomy Bur [SS White Burs]), and
then a calla lily-style enamel shape
with infinity edge margins was cut
and sanded (round-ended course dia-
mond (Piranha 856-018C [SS White
Burs]) followed by a thin flame-
shaped 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 con-
cept opportunistic access for the prepa-
ration 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).
Filling a Minimally Invasive
Preparation Using an Injection
Molding Technique
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; impossi-
ble 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 individual-
ly using an injection molding com-
posite technique. It is similar to using
light body and heavy body impression
materials. At present, it is the optimal
method to achieve a monolithic (uni-
body or nonlayered) Class II compos-
ite. 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
DENTISTRYTODAY.COM • JUNE 2013
Figure 12. Higher magnification Figure 13. The 27% blue phosphoric Figure 14. Clear matrix Figure 15. Once the smaller prep
view (8x) of the occlusal access acid etchant was placed. Note how the allows direct light pene- is filled (left), another clear molar
of the Opportunistic prep (high- Bioclear Matrix allows an interesting tration from curing light matrix is placed, soft wooden edge
lighted in green). The matrix can “aquarium” view of the procedure. This from many angles. In replaced, and Bioclear Tetra ring is
be teased open for insertion of allows the operator to evaluate the this case, no layering is placed. Note how the 4 patent
the etch tips, dispensing resin completeness of etching and delivery of needed even with con- pending independently hinging
flowable and then paste compos- resins to the cavity. ventional (nonbulk-fill) engagers of the clear ring apply
ites. Then the matrix is teased composites. pressure to fully adapt the matrix,
back into position. eliminating overhangs.
Figure 16. High magnification Figure 17. Green arrows show opti- Figure 18. Heating of paste Figure 19. High magnification
view of the Tetra ring’s 4 inde- mal clearance of .75 mm, which composite allows “step down” immediate postoperative view of
pendent suspension engagers strikes a perfect balance, allowing tips that are self-threading and contacts. Note the invisible “infinity
on teeth Nos. 18 and 19. for 5 key properties. are screwed onto traditional edge” margins, mirror smooth fin-
Filtek Supreme (3M ESPE) ish, broad contacts, and lack of
compules. Regular (top), 2x white lines. The tooth, composite,
(middle), and 4x (bottom) Step- and marginal ridges should deliver
Down Tips (Bioclear Matrix) are decades of excellent service to
shown. the patient without retreatments.
ably begins to ditch when in function. we can talk. Until then, dentin bond-
The fifth advantage is that the neigh- ing is something we do to avoid sensi-
boring tooth can be spared from the tivity, and to avoid significant
almost inevitable iatrogenic gouging; microleakge and stain. No one wants
an abrasive strip is used to prep the to “hang their hat” on just dentin
enamel near where the teeth touch, bonding. Let someone else deal with
not a bur. dentistry that falls off at 3 to 5 years.
The goal is to avoid the over-use of Not me!
Figure 20. Illustration of the evolution of the
flowable composites or reliance on Today’s careful clinician will max-
modern Class II: Clark Class II (left), slot grainy, ugly bulk-fill paste composite. imize enamel engagement, and care-
prep (middle), and traditional G. V. Black Although bulk-fill shows promise, it fully seal dentin but not rely on
preparation (right).
is no substitute for cutting a better dentin’s slowly weakening bond to
prep. (Watch the videos at dentistryto- retain the restoration. Table 2 features
reach, even with bulk-fill composites. day.com) an overview of current Class II cavity
The 0.7-mm (Figure 17) clearance at preparation styles and relevance.
the buccal and lingual aspects allows In Enamel We Trust
for 5 key properties. First, the use of a One of today’s biggest confusions is Here We Go Again! Partial and No
lightning strip (Integra Miltex) the term adhesive dentistry. When I see Dentinal Caries Removal
abrades away biofilm near the mar- symposiums on adhesive dentistry, I G. V. Black mandated that all dentinal
gins and removes undermined enam- scratch my head. That’s a term that caries must be removed. That “rule” is
el rods. (Tragically, today’s composites should be discarded or clarified. contradicted by modern science, yet
are designed to fill “pothole preps” Composite/Enamel adhesion is essen- remains the standard. As dental
with a definitive margin and a metal tially unrelated to dentin bonding in schools slowly but surely change, the
matrix.) The second advantage is that real practice. We have 20-year out- cavity preparations will go through
the long margins allow the composite come studies showing that porcelain another painful, chaotic, and exciting
to wrap around the tooth to potential- veneers will stay bonded to enamel, transformation as the rulemakers
ly strengthen the tooth; not through but they may just fall off the dentin decide how much and where we will
adhesion per se, but from an engineer- after a few years. Ninety-nine percent practice strategic selective dentinal
ing design perspective. A third advan- of the dentists I talk to refuse to risk caries removal. As I prepare our text-
tage of the infinity edge interproxi- themselves and their patients by rely- book on modern cavity preparations,
mal margin is better aesthetics from ing on dentin bonding for certain these changes will make a profound
an invisible margin and resistance to restorative tasks, and for good reason. effect on cavity design, materials and
stain. A fourth advantage is better When outcome studies show long- the approach to the pulp/preden-
wear resistance than a sharp-or term retention of bonding to dentin tin/dentin/enamel/restoration contin-
beveled-wall margin, which invari- substrates in the everyday practices, continued on page xx
 6 RESTORATIVE

The New Science of Strong Teeth...

continued from page 00

uum (Figure 20).

IN SUMMARY
Our most common restorative proce-
dures, Class I and Class II restorations,
are in a state of chaos as the manufac-
turers design adhesives and compos-
ites for a cavity prep that is 120 years
old (Table 2). Many of the current
preparations are tweener preps, some-
where 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 cata-
clysmic these changes will be?
It is my hope that the principles
advanced in this article will aid clini-
cians in their journey toward ideal
conservative restorative dentistry.!

References
1. Wahl MJ, Schmitt MM, Overton DA, et al.
Prevalence of cusp fractures in teeth restored
with amalgam and with resin-based composite. J
Am Dent Assoc. 2004;135:1127-1132.
2. Clark DJ, Khademi J, Herbransen E. Fracture
Resistant Endodontic and Restoratve Prep-
arations. Dent Today. February 2013;32:118-
123.
3. Clark DJ. The injection-molded technique for
strong, esthetic class II restorations. Inside
Dentistry. 2010;6:68-76.

Dr. Clark founded the Academy of Microscope

Enhanced Dentistry, which is an international
academy formed in 2002 to advance the art
and science of microdentistry, microendodon-
tics, microperiodontics, and dental micro-
surgery. He has also developed the Bioclear
Matrix System, a comprehensive, tooth specif-
ic, clear anatomic matrix and interproximal
restorative system. He can be reached at
drclark@microscopedentistry.com.

Disclosure: Dr. Clark is the owner of Bioclear

Matrix Systems, and is a consultant for SS
White Burs.

continued on page xx

DENTISTRYTODAY.COM • JUNE 2013