All clinicians encounter challenges when it comes to tissue management. Even with high-quality, predictable tissue management products and techniques out there (such as Astringedent® X or ViscoStat®​ used with the Metal Dento-Infusor® tip​), it helps to know a few tips and tricks for the extraordinary cases that inevitably come about from time to time.

1. In this case, the patient presented with an old, fractured amalgam filling, further exasperated by chewing on the fragments for months, leaving the gingiva inflamed.

2. Start by removing the old amalgam. Keep the caries as a barrier for the time being, in case the pulp is exposed.

3. Next, expose the gingival margin of the restoration before placing a rubber dam. Move to the next step, if necessary, to improve visibility.

4. Achieve profound hemostasis by applying ViscoStat or Astringedent X with the brush end of the Metal Dento-Infusor tip.

5. Place the dental dam, then remove residual caries. Treat exposed pulp if necessary. Etch and bond with Peak® Universal Bond.

6. Do not wedge the matrix band until the first layer of composite has been placed.

See step #7 for correct procedure.

7. First, place the matrix band to create a gingival seal, then place the first layer of composite. (Optional: etch and bond after placing the matrix band, then place the first layer of composite.)

8. Wedge after placing the first layer of composite. Loosen the matrix band and contour for good interproximal contact. Place an initial adaptive layer with PermaFlo® and fill cavity with Amelogen® Plus.