Because Classes III and IV Restorations involve only anterior teeth, an esthetic material such as composite is indicated .

Likewise, Class V Restorations on anterior teeth usually require esthetic restorations.

Although esthetic considerations are valid for posterior restorations, many patients are not as concerned with esthetic in posterior teeth as they are in anterior teeth .

However, the use of composite for any restoration provides benefits rather than improved esthetics.

Pertinent Material Qualities and Properties

The specific material qualities or properties that make composite the best material for most Classes III, IV, and V Restorations relate to esthetic.

These include adequate strength and the benefits of being able to bond the composite to tooth structure often resulting in less tooth structure removal during tooth preparation.

Indications

Almost all class III and Class IV restorations are appropriately restored with composite.

Most Class V restorations that are in esthetic prominent areas are also appropriately restored with composite or other toothcolored material.

Contraindications

The contraindications for use of composite for these classes of restorations include:

1- an operating area that cannot be adequately isolated.

2- some class V restorations in areas that are not esthetically critical .

3- some restorations that extend onto the root surface.

Clinical Technique for Direct Class III Composite Restorations

Initial Clinical Procedures

Some information about procedures necessary before beginning restoration:

(1) Anesthesia may be necessary for patient comfort, and if used, will help decrease the salivary flow during the procedures.

(2) Occlusal assessments should be made to help in properly adjusting the restorations function and in determining the tooth design.

(3) The shade must be selected before the tooth dehydrates and experiences concomitant lightening .

(4) The area must be isolated to permit effective bonding.

(5) If the restoration is large (including all of the proximal contact), inserting a wedge in the area will assist in the re-establishment of the proximal contact with composite .

Tooth Preparation

Class III tooth preparations, by definition, are located on the proximal surface of anterior teeth .

Because the bond of composite to enamel and dentin is so strong, most Class III composite restorations are retained only by the micromechanical bond from acid etching and resin bonding, so no additional preparation retention form is usually necessary.

Using diamond stones for the tooth preparation leaves the prepared surfaces rougher, increasing the surface area and the micromechanical retention.

Sometimes a groove or cove may be necessary for Class III restorations that either extend onto the root surface or are very large .

Usually, additional needed retention form can be achieved simply by increasing the surface area with a wider enamel bevel or flare along the margin.

When a proximal surface of an anterior tooth is to be restored and there is a choice between facial or lingual entry into the tooth, the lingual approach is preferable.

The advantages of restoring the proximal lesion from the lingual approach include:

1- The facial enamel is conserved for enhanced esthetics.

2- Some unsupported, but not friable, enamel may be left on the facial wall of Class III or Class IV preparation.

3- Color matching of the composite is not as critical.

4- Discoloration or deterioration of the restoration is less visible.

Indications for a facial approach include the following:

1- The carious lesion is positioned facially such that facial access would significantly conserve tooth structure.

2- The teeth are irregularly aligned, making lingual access undesirable.

3- An extensive carious lesion extends onto the facial surface.

When the facial and lingual surfaces are involved, the approach that provides the best access for instrumentation should be used.

It is expeditious to prepared and restore approximating carious lesions or faulty restorations on adjacent teeth at the same appointment.

Conventional Class III Tooth Preparation

The primary indication for this type of Class III preparation is for the restoration of root surface.

Beveled Conventional Class III Tooth Preparation

The beveled conventional tooth preparation for composite restoration is indicated primarily for replacing an existing defective restoration in the crown portion of the tooth.

The beveled conventional preparation is characterized by external walls that are perpendicular to the enamel surface, with the enamel margin beveled.

The axial line angles may or may not be of uniform pulpal depth, varying as the thickness of the enamel portion of the external walls varies.

Once the outline form and initial axial wall depth have been established, the initial tooth preparation stage is completed and the final stage of tooth preparation begins.

For most Class III restorations using the beveled conventional preparation, the preparation would be complete at this time except for placing an enamel bevel or flare .

Remove all remaining infected dentin using round burs or small spoon excavators or both.

Some undermined enamel can be left in nonstress areas, but very friable enamel at the margins should be removed .

Remaining old restorative material on the axial wall should be removed if any of the conditions presented earlier are present.

Apply a calcium hydroxide liner only if indicated .

If restoration features (grooves or coves) are indicated (and usually they are not), Prepare them along the gingivoaxial line angle and, sometimes, the incisoaxial line angle with a No.1/4 bur .

Occasionally retention may be provided by undercuts left from caries removal.

Particular care must be exercised not to weaken the walls or incisal angles that are subject to masticatory force.

Any necessary incisal retention cove is prepared with the No.1/4 bur at the axioincisal point angle with the bur oriented in similar angle, 0.2mm inside the DEJ, and 0.25mm deep.

It is extended slightly into the facioaxial line angle where it fades out.

The placement of incisal retention is not always as easy in mouth as illustrated because of handpiece size and angulation problems caused by the anatomy of the maxilla and tooth positions.

Modified Class III Tooth Preparation

A modified tooth preparation is the most used type of Class III tooth preparation.

It is indicated for small and moderate lesions or faults and is designed to be as conservative as possible.

The preparation design is dictated by the extent of the fault or defect and is prepared from a lingual approach when possible, with an appropriate size round bur or diamond instrument.

No effort is made to produce preparation walls that have specific shapes or forms other than external angle of 90 degrees or greater.

Weakened, friable enamel is removed while preparing the cavosurface margins in a beveled or flared configuration with the round diamond.

Usually no groove (or cove) retention form is indicated because the retention of the material in the tooth will result from the bond created between the composite material and the etched peripheral enamel.

Begin the preparation from a lingual approach (if possible) by making an opening a round carbide bur or diamond instrument.