Aesthetic and functional restoration with direct composite

Ortho and Kids - Shadeguides - Direct anteriors
3 Aug 2017

The restoration of one or several frontal maxillary teeth is a challenge for every dentist, especially when using a direct approach. The patient’s aesthetic expectations are great and, in many cases, the outcome heavily depends on the protocol and the materials used. However,  in my opinion, the mission of modern dentistry is to break down barriers between conservative and prosthetic. We must do as little invasive work as possible according to the concept of minimally invasive restorative treatmen.t especially in young patients, whereit  is crucial to operate conservatively, restoring the teeth in a functional and aesthetic way, according to the concept of minimally invasive restorative treatment, due to the significant developments of the last 50 years that changed the treatment planning, bonding to enamel and dentin.

Fig. 1

Img. 1 – The patient, male, aged 22, was not happy with the unaestetic appearance of the maxillary central upper incisors, that had been rebuilt many times after the initial trauma at the age of 17. The initial situation shows the multiple fractured composite resin over 1.1 and 2.1

Fig. 2

Img. 2 – Both the central incisors are vital and in excellent periodontal health

Fig. 3

Img. 3 – First of all, in order to simulate the final work, I started checking their centric occlusion

Fig. 4

Img. 4 – And their frontal

Fig. 5

Img. 5

Fig. 6

Img. 6 – and lateral disclusion

Fig. 7

Img. 7 – TIP: After that, without performing any adhesive step, I started doing a functional direct mock up to achieve a better functional and aesthetic outcome

Fig. 8

Img. 8 – In fact, in my personal opinion, it is very important to plan the final shape before starting

Fig. 9

Img. 9 – To better understand the final result and their functional load at the same time

Fig. 10

Img. 10 – In fact, if the direct mock up, simply held by the old composite roughness, doesn't break during the function

Fig. 11

Img. 11 – It means it's correct

Fig. 12

Img. 12 – After that I recorded the palatal and incisal shape using hard lab silicone

Fig. 13

Img. 13 – Remember to chose the correct color mass before putting the dam on, and after having cured it, and on its thickness base, because increasing the thickness increases the saturation as well as the opacity of the color

Fig. 14

Img. 14

Fig. 15

Img. 15 – One of the crucial steps in adhesive dentistry is the field isolation using rubber dam to avoid any contamination and to have full vision of the teeth we are working on

Fig. 16

Img. 16 – The previous old composite was removed with a medium grit diamond disc

Fig. 17

Img. 17 – Vestibular enamel preparation was limited to clean, well finished margins, using a rounded bevel in order to respect the sound enamel and to hide the margin as well

Fig. 18

Img. 18 – 37% ortophosporic acid was used on the vestibular prepared margin and on the whole palatal wall following the initial direct mock up project

Fig. 19

Img. 19 – I strongly recommend using the new bonding generation. Thanks to this technology we can use it as a self-etch system, and as an etch and rinse, but the best option is as a selective etching system on enamel. This is a very big advantage for the dentist, the same bonding agent with a wide field of application

Fig. 20

Img. 20 – Bonding agent was thinned with air and cured for 60 seconds on vestibular and palatal wall

Fig. 21

Img. 21 – The palatal wall was built with a A1/B1 mass pushing the material directly on the silicone key. Brilliant Everglow represents a new generation of composite materials with special fillers. Due to his smart translucency balance, the shades integrate extremely harmoniously into the existing dental arch.This is the best way to control position ad right material amount working outside the patient's mouth

Fig. 22

Img. 22 – After modeling the palatal wall I like to spread a little amount of flowable material on the cervical step to anchor it and to close small undercuts without risk of breaking it

Fig. 23

Img. 23

Fig. 24

Img. 24 – Before removing the silicone matrix

Fig. 25

Img. 25 – In my personal opinion this is the best way to turn a complex shape in a class 1 and to focus on the next step

Fig. 26

Img. 26 – The dentinal body, (I cure for one minute in order to achieve the best possible convertion degree), leaving a little space on the incisal third to mimic the incisal translucency halo and leaving a very little space for the last layer of high value enamel mass

Fig. 27

Img. 27

Fig. 28

Img. 28 – A further 60 sec curing step was made under Ultrasound Gel to isolate from oxigen in order to achieve the best possible conversion degree

Fig. 29

Img. 29 – The same steps were repeated on 1.1

Fig. 30

Img. 30 – After finishing of the surface with a multi-blade bur (Styleitaliano Finishing bur kit), polishing was performed using ShapeGuards, diamond impregnated silicone wheels with easy access to all the areas

 

Conclusions

A modern approach in restorative should consider many aspects, from the function to the aesthetic needs of the patient, with the future possibility to re-enter with small corrections finishing and polishing, accordingly to the concept of minimal invasive treatment, especially in your patients. For these reasons modern composites must represent the primary choice to restore for every dentist.

Bibliography

M.Saracinelli IJED Volume 11 Number 2 Summer
Vichi A. et al. Influence of thickness on color in multi-layering technique. Dent. Mater. 2007 Dec 23 (12);1584-9. Pub 2007 Sep 6
Layers J. Manauta A. Salat An atlas of composite resin stratification
W. Devoto, M.Saracinelli, J. Manauta Composites in every day practice. How to choose the right material and simplify application techniques in the anterior teeth JEAD, Jan. 2010