A simple approach to treat fractured teeth by direct composite restoration

A clinical case by our Community member Dr. Omar Faez Alani

This article and its content are published under the Author’s responsibility as an expression of the Author’s own ideas and practice. Styleitaliano denies any responsibility about the visual and written content of this work.

Dental traumas are estimated an increasing public health problem that affects permanent dentition among children and teenagers. The majority of dental injuries happen in the anterior region, affecting mainly the maxillary central incisors that can have a significantly negative functional, esthetic and psychological influence. Several techniques can be used for restoring fractured teeth, either by indirect or direct restorations, or in some situations by reattachment of the fragment. Direct composite restorations for non-complex crown fractures with missing fragment represents the most minimally invasive method.

broken central incisors style italiano styleitaliano

Fig.1
A 17-year-old male patient presented at our clinic with fractures at both maxillary central incisors resulting from a motorcycle accident that happened two days earlier. He asked for an immediate and aesthetic correction to improve his looks and smile. The clinical and radiographic examinations showed the fracture didn’t involve the pulp. Because the fragment was missing, the decision was to restore the fracture immediately by direct composite resin using a freehand technique as a simple approach.

shade matching with custom shade guide style italiano styleitaliano

Fig.2
Shade matching was done using a custom-made shade guide.

rubber dam isolation of fractured teeth style italiano styleitaliano

Fig.3
Adhesive dentistry requires a clean and dry working field. For this reason, isolation of the operative field by rubber dam should is needed obtain long-lasting restorations.

coarse disc removing chipped enamel style italiano styleitaliano

Fig.4
The irregularities of the fracture, and all unsupported enamel were removed by using coarse and medium discs.

prepared class 4 cavities style italiano styleitaliano

Fig.5
A yellow band football diamond bur was used to create a 1.5 – 2 mm bevel.

etching of the enamel before composite restoration style italiano styleitaliano

Fig.6
Selective etching 2 mm beyond the bevel margins, the lateral incisors were protected by using teflon tape to prevent unwanted demineralization.

finger index palatal shell build up styleitaliano style italiano

Fig.7
After etching, universal bonding was laid twice, then palatal shells were constructed using mylar strip and finger support.

translucent palatal composite shells style italiano styleitaliano

Fig.8
The palatal walls were built using an achromatic enamel shade.

reinforcing palatal composite build-up style italiano styleitaliano

Fig.9
Some flowable opaque composite is used in a thin layer where the palatal wall and the tooth margin meet to improve integration.

dentin shade layering with mamelons style italiano styleitaliano

Fig.10
A dentin shade was applied as one mass and then reshaped by using LM Arte Fissura to create the mamelons of the dentin.

opalescent layer for natural appearance of restorations style italiano styleitaliano

Fig.11
The opalescent composite was applied between and around the mamelons to create nature-mimicking opalescence.

enamel layer before finishing procedures style italiano styleitaliano

Fig.12
The last enamel layer was applied by using LM Arte Solo Anterior.

air-block polymerization of composite restorations styleitaliano style italiano

Fig.13
Before finishing and polishing, the last layer of composite was photopolymerized for 1 additional minute under glycerine air-block; this additional step is important to increase the hardness of the superficial layer as it increases the degree of conversion of composite that prevents the deterioration of the restoration and the interface with the tooth.

pencil marks for anatomical finishing style italiano styleitaliano

Fig.14
A pencil used to mark the transition lines and V-shaped developmental grooves.

pre-polished composite restorations style italiano styleitaliano

Fig.15
Finishing was done using medium-coarse disc and Opti1step polisher, while EVE Dia comp twist was used for pre-polishing and to get initial gloss.

finished and polished incisor restorations style italiano styleitaliano

Fig.16
Immediately after rubber dam removal, the final gloss was obtained by using the Diashine Lucida Paste.

restored central incisors style italiano styleitaliano

Fig.17
At one-week recall and after complete rehydration, the transition between restorations and fracture lines is invisible.

smile with restored teeth after fracture style italiano styleitaliano

Fig.18
Final smile after one week.

Conclusions

Direct composite restorations represent the best immediate solution for the patient with fractured teeth in the aesthetic area, especially when the fractured fragment us missing. Restoration of anterior teeth is regarded as a challenge to most dentists, but following the natural layering concept using one shade of enamel and one shade of dentin with the opalescent composite can be considered the simple approach to obtain lifelike mimicking restorations.

Bibliography

1. Dietschi D, Fahl Jr N. Shading concepts and layering techniques to master direct anterior composite restorations: an update. British dental journal. 2016 Dec;221(12):765.
2. Manauta, Jordi, and Anna Salat. Layers: An atlas of composite resin stratification. Quintessenza Edizionei, 2012.
3. Dietschi, Didier. “Clinical Application of the” Natural Layering Concept”.” Oral Health 97, no. 8 (2007): 69.
4. Boukhris, H. “The challenge of restoring a fractured central incisor: a staged approach.” J Dent Health Oral Disord Ther 9, no. 4 (2018): 290-291.
5. Haddadin, Khattar S., And Maan Al-far. “The Fracture Pattern Of Maxillary Incisors In Children And Adolescence: A New Morphological Classification.” Pakistan Oral & Dental Journal 35, no. 1 (2015).

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