Amsterdam is a great city. With its beautiful houses along the canals. And with a lot of cyclists. This patient came to our practice after visiting the emergency room. She was unfortunately involved in a bike accident and had undergone trauma. She got two crown fractures of the two central incisors without pulp involvement. Both teeth were slightly moving compared than the neighboring teeth. The exposed dentin was sealed with a glass-ionomer cement and x-rays were taken. Tooth #11 displayed a pulp shining through giving the dentin a dash of pink color. The two involved incisors were slightly more sensitive but not limiting the patient in her daily life. The patient wanted the two incisors to be restored: invisibly and naturally. The treatment of choice was a direct layering composite. In cases like these – involving relatively young patient trauma – we may encounter two extra challenges besides trying to create exact replicas of the fractured teeth. Because of the widespread use of an orthodontic fixed retainer on the palatal the possibility to correctly place a rubber dam is limited as well as the access for treatment. So usually removal of the retainer is indicated. Replacement is necessary to prevent any unwanted tooth movements after restoring. This means fabricating a new fixed retainer because of distortion occurring while removing it. Second is the issue of time after trauma. The patient often demands direct restoration. But for a long term satisfying result the use of a silicone index based on a wax-up increases your chances of achieving that long term goal. That means taking impressions for models, photography and referring to the lab for a wax-up. Delay of direct treatment is unavoidable. This case shows how we handled the challenges on the road and how the final outcome destination was reached within the estimated time of arrival
Initial situation: both tooth #11 as #21 suffered crown fractures without pulp involvement. The left lateral had one small part of enamel chipped off distally.
Initial situation: the exposed dentin is sealed with glass-ionomer
Initial situation: bruising of the accident is noticeable above the upper lip.
Close-up of the fractured teeth shows cracks in the remaining enamel.
Close-up: cracks in the enamel can be noticed cervically of teeth #12, #11 and #21
Close-up: a crack as well distally on the incisal third of tooth #21. No enamel will be sacrificed to mask or visibly remove the cracks. It is like being appreciative of the cracks in grandmothers teacups: in most cases they do not spoil the beauty of the cups.
The fixed retainer in situ.
Retracted frontal view initial situation. The patient was informed about the difference between an immediate treatment or a delayed treatment with the use of a wax-up to guide the layering and shaping process of the restoration. The last approach was chosen.
Retracted left view, initial situation. A clear halo can be observed on the left lateral incisor and canine. The first clue on how the restorations should be built up to reproduce the characteristics of the dentition.
Retracted right view, initial situation. In this first visit information was collected: impressions for study models were taken, photographs to communicate with the lab.
The patient was temporarily provided with a further glass-ionomer build-up for obvious esthetic reasons. To overlap time until the definite procedure. No composite was used in order to avoid an etching procedure. In this way the definitive composite restoration can be placed on virgin enamel without the need of accurate removal of the composite placed in emergency. Removing composite, besides being a time consuming step, always bears the unwanted risk of removing sound enamel tissue.
Although now immediate restorations were made in the first visit; the case is treated with emergency. The lab is asked to proceed with the wax-up with priority and the appointment book is slightly rescheduled to create extra time for the treatment.
The silicone index is made on the wax-up.
The rubber dam in place. Because of the use of glass-ionomer the removal of the material was very easy. The fixed retainer was removed temporarily from both central incisors to ease access, but kept in place on both laterals and cuspids. After restoring the teeth the part of the retainer was too distorted to be repositioned for the longterm. So it was decided to make an impression for a new one.
The pulp shining through gives a pink hue. A 2,0 mm bevel was applied and the teeth were sandblasted taking good care not to linger on the thin dentin area covering the pulp.
Placement of the index with the rubber dam in situ. The seating of the index can best be checked on the uninvolved laterals. Any interfering with the rubber dam can be solved by cutting away some of the silicone material until proper seating is achieved. The fracture line was recorded onto the silicone index with the LM Arte Fissura instrument. When applying the composite in the index for the first palatal shell layer of the restoration the line gives the indication where to place the material. Too little material will give voids in the back. Too much material will give unwanted excess that needs time consuming correction later.
Based on a color mock-up from the first visit the index was filled extra-orally with a very thin layer of white enamel composite. Then the index was transferred to its intra-oral position. Before light curing a small brush ensures perfect adaptation on the palatal avoiding voids.
A2 Vita based dentin composite was applied in a mamelon shape.
A sectional matrix served as a guide to make the approximal walls.
The composite needs further modification before light-curing. Brushes and Fissura are the instruments used.
Both mesial and distal approximal walls are built. The next step is to apply a body enamel.
On the incisal small spots of diluted white stain are applied.
Same step on the other incisor. In between the mamelons a very translucent composite is carefully placed. The translucency of the material is in beautiful contrast with the opacity of the mamelons and the white incisal edge. The final layer is one of enamel composite.
Excess of the final layer can be reduced with total control using the index. A repeatedly applied pencil line will guide the steps.
Final polishing with Sof-Lex Spirals. Starting with the beige on a wet surface.
The beige is followed by the pink spiral.
Finally a felt coated disk combined with aluminum oxide paste is used without water. The new fixed retainer can be placed.
The final result in close-up. There is no transition from restoration to tooth structure observable. Both left and right central look a like despite having differently shaped fractures. The goal desired by the patient, a natural and invisible restoration, is achieved.
Final result. Display of the incisors with the lips at rest. There is a beautiful soft contact with the vermillion border of the lower lip.
Final result. The patient’s beautiful smile is fully recovered. The incisal edges, shape and color are in harmony with the rest of the dentition. What do you think about restoring the enamel chipped off on tooth #22 in the future?
Cases that involve anterior teeth fractures compromise the patients appearance in a massive way. The first emotion is to make restorations instantly to help the patient. And that is as well what the patient asks you urgently do. But underneath that question is the actual demand: restore my teeth back to what they were before they were fractured. To achieve that goal mostly more time is required in preparation. In color and shape analysis, lab work for the models and wax-up and adjusting the schedule book to offer your patient your full attention. Good communication with the patient is of great importance; explaining that waiting a few days can prevent re-treatments in the future because of aesthetic failure.
Manauta J, Salat A. Layers, An atlas of composite resin stratification. Quintessence Books, 2012
Dietschi D. Layering concepts in anterior composite restorations. J Adhes Dent 2001;3:71–80.
Fahl N Jr. A polychromatic composite layering approach for solviing a complex Class IV/direct veneer-diastema combination: part I. Pract Proced Aesthet Dent. 2006;18(10):641-5.
Villarroel M, Fahl N, De Sousa AM, De Oliveira OB Jr. Direct esthetic restorations based on translucency and opacity of composite resins.J Esthet Restor Dent. 2011 Apr;23(2):73-87.