Composite meets Ceramics

Combining materials such as ceramics and composite allow getting a perfect shape color and texture of teeth also in aesthetic restorations. In order to do this, we need not just manual skills, but knowledge of the general principles and techniques of restorative therapy. In daily practice, we are often faced with patients who have problems in anterior teeth. It is believed that the anterior teeth are more difficult to restore because we work in the display area. With simple techniques and protocols we are going to learn how to overcome this problems.

I would like to thank Dr. Shemsi Abdulla who was the co-author of this clinical case and article.

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Fig.1
We were contacted by a 25-year-old patient complaining about hypersensitivity in the frontal area of the teeth and she didn’t feel comfortable with her smile. During inspection of the patient, we found two old composite restorations on teeth 11 , 21 and opening portion of the dentin on the cutting edge. On teeth 31 and 41 class 4 defects were detected. In recognition of the patient, she loves to chew sunflower seeds. And that could cause the defects in the lower central incisors, and hypersensitivity can be caused due to defects in cervical areas of the teeth. The patient was advised to do an orthodontic treatment but because of the duration of the treatment she refused. It was decided to restore teeth 11 and 21 with lithium disilicate veneers; composite restorations to the teeth 31, 33, 41, 43, 44, 45.

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Fig.2
First we started with the restoration of the lower incisors. To analyze the internal structure of the teeth, we should use the intra-oral photos. In this case, two photographs were made using conventional and polarizing filter.

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Fig.3
For this we can use the camera with polarizing filters or a mobile phone with the help of Smile Lite.

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Fig.4
For removing sclerotic dentin we can use 27 micron Al2O3 sand with Rondoflex.

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Fig.5
In this case we used 37% etching gel 30 seconds for enamel and 15 seconds for the dentin.

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Fig.6
After rinsing of the etching gel we apply the adhesive. We have to wait minimum 20 seconds for the exposition of the adhesive then 5-10 seconds for air drying. Light curing will be 60 seconds.

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Fig.7
With a silicone key we start to build up palatal walls. First we used enamel layer NE from Asteria.

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Fig.8
For the dentin we used one shade A3 Body from Asteria and we add white and blue tints to the lobes of dentin.

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Fig.9
Here we finished with NE enamel. The thickness of the enamel was 0,5. We can measure it with LM Misura from Style Italiano Kit.

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Fig.10
Air blocking with glycerine and light curing for 1 minute.

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Fig.11
After finishing and polishing.

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Fig.12
The final photo after restoration.

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Fig.13
In order to take such type of photos we used another type of flashes – Softboxes.

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Fig.14
This photo was taken with Polarizer filter before and after rehydration.

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Fig.15
After restoration of the lower incisors we started to restore cervical defects. In the next visit we did 3 cervical restorations.

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Fig.16
After isolation with heavy Nictone dam we used B4 Brinkers for margin opening.

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Fig.17
For preparation we suggest to use 27 micron particle sandblasting. No need for any bur in this stage, just sandblasting with Rondoflex.

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Fig.18
We finished all 3 cervical restorations with one A3 body shade. No need to use many layers for this type of restorations. It always gives a good result in the cervical zone

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Fig.19
The final photo after rehydration. very hard to find any difference between natural tissues and composite restorations.

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Fig.20
After finishing of composite restorations we start a second (prosthodontic) part of the treatment.

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Fig.21
The preparation was finished all in enamel with a light chamfer.

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Fig.22
The provisional crowns made with bis-acryl composite.

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Fig.23
After Isolation with Photodam (we recomended to isolate 8 teeth ) we expose the margins of the preparations with B4 brinkers clamps. Sandblasting of enamel with 27 micron Al2O3.

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Fig.24
After placing a teflon tape on the neighbor teeth, the enamel is etched for 30 seconds with orthophosphoric acid. We recommend to wash generously for about 20 seconds in order to remove all the debris that the acid could left.

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Fig.25
Application of the bonding agent, in this case ScotchBond universal, which can act as a self-etching material or as a total etch. The bonding agent is scrubbed for 20 seconds. Then we bond the veneers.

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Fig.26
Curing should be done properly. Manufacturers recommend generally 20-30 seconds. We suggest to over-polymerize, this will grant us a strong hybrid layer even in areas where the light can not arrive from the intimate contact of the lamp but slightly further. This stage is the final curing after glycerine. We need minimum 1 minute of polymerization for blocking of inhibition layer.

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Fig.26
Curing should be done properly. Manufacturers recommend generally 20-30 seconds. We suggest to over-polymerize, this will grant us a strong hybrid layer even in areas where the light can not arrive from the intimate contact of the lamp but slightly further. This stage is the final curing after glycerine. We need minimum 1 minute of polymerization for blocking of inhibition layer.

style italiano styleitaliano dentistry

Fig.27
The final view of cemented veneers.

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Fig.28
This is right after cementation, cleaning of all excess and rubberdam removing. We need a time for healing of tissues.

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Fig.29
Now we can see how after 1 week the tissues have healed properly.

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Fig.30
Artistic photos taken with Softboxes.

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Fig.31
The final photo after treatment finished.

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Fig.32
Before and after treatment.

Conclusions

Its very practical to combine 2 materials, Composite and Ceramic in everyday treatments. If we manage to do it in the right way we can achieve great results.

Bibliography

1. Devoto W. Direct and indirect restorations in the anterior area: a comparison between the procedures. QDT Yearbook 2003;26:127-138.
2. Devoto W, Saracinelli M, Manauta J. (2010). Composite in everyday practice: how to choose the right material and simplify application techniques in the anterior teeth. Eur J Esthet Dent Spring;5(1):102-24
3. Manauta J, Paolone G, Devoto W. 2013. IN ‘n’ OUT – A New Concept in Composite Stratification. Labline Magazine, 3 (2), pp. 110-127.

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