Biologically Guided Simplified Anterior Restoration

A clinical case by our Community member Dr. Gilbert Jorquera

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.

One of the main challenges in daily clinical practice is the replacement of old restorations, either due to caries or poor aesthetics. To do it in a simple and efficient way, we first need to know the anatomy of the tooth to be treated, meaning not only the macro- and micro-morphology, but also its internal structure, to imitate it perfectly with different opacities and thickness of composite resin. In this case, the biological foundations to use a certain thickness and shape of dentin, the step by step and some tips to achieve a simple anterior restoration with two opacities will be described.

styleitaliano style italiano 3d anatomical model of incisor

Fig.1
Before reviewing the clinical case, it is important to look inside an upper incisor and understand its internal composition, not only conceptually but also physically, to try to imitate it with restorative materials. For this purpose, analysis with dental micro CT equipment is very useful, which allows us to separate the tooth by different densities thus obtaining a graphic representation of the enamel, dentin and pulp chamber.

styleitaliano style italiano 3d anatomical incisor model without enamel

Fig.2
If we look closely, we can see that human dentin is very irregular and usually ends in the shape of a knife edge, determining an individual dentin pattern for each patient.

styleitaliano style italiano incisor with and without enamel

Fig.3
Image after removing the enamel using 5% formic acid to check the shape of dentin.

styleitaliano style italiano incisor with old composite restoration

Fig.4
Once the biological bases have been presented, changing the restoration on a central incisor with the concept of simple stratification of two opacities, to reach a final A3 shade will be presented. Once the patient’s occlusion has been checked, the first step will be the preparation of a guide by silicone putty.

style italiano styleitaliano 3m
style italiano styleitaliano 3m
styleitaliano style italiano isolation with rubber dam before removal of old composite

Fig.5
Good isolation before removing the old restoration. It is very important to make the color selection before the isolation. In this case where the shade was A3, the Styleitaliano Custom Shade A3 Dentin + A3 Enamel for simplified layering technique was used.

styleitaliano style italiano checking the fit of silicone key

Fig.6
Check that the isolation doesn’t interfere with the silicone guide, and that it reaches the correct position.

styleitaliano style italiano class IV prepared cavity

Fig.7
Complete removal of the old restoration.

styleitaliano style italiano highlight of long bevel preparation

Fig.8
The preparation should be done in a way not to see the limit between the future restoration and the tooth. The bevel must be wide and the proximal area should have a clear limit to give a space for the new proximal wall.

styleitaliano style italiano marking the limit of the restoration

Fig.9
Delimitation for the enamel layer on the silicone guide, using LM Arte Fissura instrument.

style italiano styleitaliano lm arte anterior instrument
style italiano styleitaliano lm arte anterior instrument
styleitaliano style italiano etching enamel surface

Fig.10
Always protect neighboring teeth during acid etching.

styleitaliano style italiano bonding incisor with a micro brush

Fig.11
Application of a universal adhesive (3M Scotchbond Universal).

styleitaliano style italiano layering of composite inside silicone key

Fig.12
Once the adhesive is light-cured, a layer of enamel is placed on the silicone key, according to the delimited area, and then positioned in the mouth.

styleitaliano style italiano built palatal shell for class IV composite restoration

Fig.13
After creating the palatal layer (Enamel A3 z350 XT 3M) with the help of the silicone key, LumiContrast matrix (Polydentia) was positioned and secured with a wooden wedge.

polydentia banner style italiano
polydentia banner style italiano
styleitaliano style italiano proximal build up with sectional matrix

Fig.14
Proximal wall reconstruction (Enamel A3 z350 XT 3M).

styleitaliano style italiano palatal and proximal restoration of incisor

Fig.15
Matrix and wedge removal to check the contact point.

styleitaliano style italiano calibrating composite shade thickness with dedicated instrument

Fig.16
Placement of a dentin increment (Dentin A3 z350 XT 3M) and thickness calibration with the help of LM Arte Misura instrument to keep 0.5 mm for the enamel layer.

styleitaliano style italiano modeling internal anatomy with composite

Fig.17
Once the thickness of the dentin has been calibrated, match the dentin pattern according to the biological concept (knife-edge ending towards the incisal edge) and define the mamelons.

styleitaliano style italiano dental restoration ready to receive final enamel layer

Fig.18
Check the space for the enamel layer once the increment was light-cured with the multi-wave Curing Pen device (Eighteeth).

curing pen light style italiano styleitaliano eighteeth
curing pen light style italiano styleitaliano eighteeth
styleitaliano style italiano spatula adapting enamel composite shade

Fig.19
The final enamel layer was added (Enamel A3 z350 XT 3M) to finish the restoration.

styleitaliano style italiano perio diamond finishing bur

Fig.20
Finishing of the restoration, by respecting the macro and micro anatomy of the neighboring incisor, performed with a low speed bur from the Styleitaliano Finishing Kit by Intensiv.

styleitaliano style italiano polishing composite with spiral wheel

Fig.21
For polishing, spiral soflex (3M) was used.

style italiano styleitaliano 3m sof lex discs and diamond spirals polishing
style italiano styleitaliano 3m sof lex discs and diamond spirals polishing
styleitaliano style italiano polishing composite restoration with felt

Fig.22
And for the final finish, diamond polishing paste (Premier) and felt disc.

styleitaliano style italiano final aspect of incisor composite restoration

Fig.23
Restoration finished.

styleitaliano style italiano mobile dental polarized photograph of composite restoration

Fig.24
Photograph with cross-polarization filter to check the color integration of the finished restoration. Picture was taken with a smartphone and Smile Lite MDP (Smile Line, Switzerland)

style italiano styleitaliano smileline mdp dental photography
style italiano styleitaliano smileline mdp dental photography
styleitaliano style italiano before and after restoration of central incisor

Fig.25
Perfect integration of shape and color of the new restoration.

styleitaliano style italiano seamless restored central incisor

Fig.26

Conclusions

A simplified layering technique with only two composite opacities can solve most of our anterior restorations, if we respect the biology and the shape of the restoration. To achieve good aesthetic results, and to do a fast and efficient job, smart materials, products and instruments should be used to facilitate our daily work.

Bibliography

1. Walter Devoto, Monaldo Siracinelli, Jordi Manauta. Composite in every day practice: how to choose the right material and simplify application techniques in the anterior teeth. Eur J Esthet Dent. 2010 Spring;5(1):102-24.
2. Jordi Manauta, Ana Salat. Layers: An Atlas of Composite Resin Stratification. 2012.1st edition.
3. Gaetano Paolone, Giovanna Orsini, Jordi Manauta, Walter Devoto, Angelo Putignano. Composite shade guides and color matching. Int J Esthet Dent. 2014 Summer;9(2):164-82.
4. Pablo Atria, João Barbosa, Camila Sampaio, Gilbert Jorquera, Ronaldo Hirata, Gustavo Mahn. Comparison of a non-destructive technique using three-dimensional imaging and histoanatomical chemical dissolution for dental morphology analysis. Int J Esthet Dent 2019;14(1):76-85.
5. Louis Hardan et al. Novel Trends in Dental Color Match Using Different Shade Selection Methods: A Systematic Review and Meta-Analysis. Materials (Basel). 2022 Jan 8;15(2):468.

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