Composite modelling using ultra-thin spatulas
For perfection in aesthetic restorations we need a precise modeling, right color selection and good shapes. In order to model the composite precisely it is suggested to have the right instruments. In the market we can find plenty of suitable instruments for composite stratification. In some of the modelling instruments for composite kits we can find a very thin spatulas. Thin spatula is convenient for modelling precisely the composite. Not all the kits have thin spatula maybe because it is a delicate instrument, but the disadvantages outweigh the advantages in the opinion of most of the experts in composite.
Inside the LM arte kit (LM instruments, Finland) it is possible to find a thin spatula, thinner than many others in the market. In this article we wanted to point out the advantages of modeling with a thin spatula like Applica (the thin spatula from the LM arte kit) whilst presenting anterior free hand restorations for a change of smile of a patient after orthodontics. The instrument has an Italian name (Applica), but the name is internationally understood because it is similar to the english word apply, which is related to its function which is applying composite.
The Styleitaliano group pushes the high quality dentistry with feasible, repeatable protocols, moderate costs for the patient, avoiding over-treatments and controlling the chair time. The free hand single visit smile rehabilitation with a single mass is a good example of that philosophy. In this particular case we demonstrate how choosing the right material, specially choosing the right opacity of the material, with a precise modelling of composite and giving the right shapes, in a single visit and a unique color, the aesthetic results can be more than acceptable for the patient and for us.
THE IMAGES FROM THIS ARTICLE WERE EXTRACTED FROM A 4K VIDEO DONE DURING THE COURSE LAYERS OVER THE SHOULDER WITH LIVE PATIENT IN DENTCOF, TIMISOARA. THANKS TO DR.FLORIN COFAR AND MIHAI SIMONIA FOR THE FILMATION DURING THE CASE PERFORMANCE. I WOULD ALSO LIKE TO THANK WALTER DEVOTO AND ANGELO PUTIGNIANO FOR PUSHING ME USING THE SINGLE APPOINTMENT AND SINGLE SHADE APPROACH AS IT IS IN THE MAJORITY OF SITUATIONS THE PREFERED APPROACH FOR MY PATIENTS. AND THANKS TO LM FROM FINLAND FOR CREATING THE THIN SPATULA BECAUSE I UNDERSTOOD THAT IT WAS A CHALLENGE TO PRODUCE IT BECAUSE IT IS SO THIN THAT IT REQUIRED SPECIAL TECHNOLOGY AND ATTENTION.
Img. 1 – After orthodontic braces removal. With the smile picture we plannified a non-invasive smile rehabilitation with direct composites free-hand and in a single visit. We plannified a shape modification, giving the correct convexity for the proximal walls closing in that way the diastemas.
Img. 2 – Some days after the composite smile rehabilitation. The single appointment approach with composite is the fastest of the existing protocols in dentistry. When spaces are small, when the practitioner is experienced in the field of composite handling and when there is a good knowledge of the anatomy, composites can be done free-hand without the help of the wax-up and silicon matrix. Silicon matrix can be even inconvenient in a case with small diastemas like in this particular case.
Img. 3 – Patient after braces removal. After removing the braces the gingival tissues was irritated and inflamed due to the same procedure of braces removal and because the non optimal oral hygiene during orthodontic treatment. The approach consisted in providing the patient a provisional retention to avoid teeth movements and 1 week treatment with chlorhexidine 0,12% before the composite appointment. The single visit with composites consisted on 3 hours appointment.
Img. 4 – The patient was extremely happy with her new smile which was very encouraging for the dental team.
Img. 5 – As we saw in all the videos patient even change the smile line after the aesthetic rehabilitation. You can see in the “before picture” that commissures of lips were facing downwards because the patient tried to hide teeth whilst smiling. She used the muscles to pull the lip in that position. Meanwhile after the treatment, the smile changed completely as she feels relaxed and the smile now looks natural with the right positive smile curvature.
Img. 6 – A happy and satisfied patient is the ultimate goal of every restorative dentist, this is why simple but well executed techniques are a must.
Img. 7 – Intraoral view of the situation just before the composites.
Img. 8 – Isolating from the midline to distal firstly, one side and after fixing the dental dam with the clamp we proceed with the other side.
Img. 9 – Isolated field from first premolar to first premolar with 2 premolar clamps (W2A) and dental dam (medium opacity Nic Tone). Dental dam correctly invaginated with a thin spatula and air flow from the syringe.
Img. 10 – Cleaning teeth from tartar, debris or adhesive residues before adhesive steps with a sharp instrument Excesso (LM Arte Kit from LM instruments, Finland)
Img. 11 – To provide a good substrate for adhesion we used the extra thin abrasive coarse disc dark orange (Sof-Lex from 3M)
Img. 12 – Placing the matrices for bonding steps
Img. 13 – Matrices in place to separate whilst doing the adhesive steps to avoid touching neighbour teeth. Matrices face `outside´in order to have the best possible free vision.
Img. 14 – The red gel is the etching gel (orthophosphoric acid 37%). Normally, phosphoric acid at a concentration between 30-40% provided retentive enamel surfaces (Silverstone, 1974). Originally, standard treatment time for enamel conditioning was 60 seconds. However, several studies have indicated that a 15-second etching time provides similar surface morphology and bond strength values (Barkmeier et al., 1986). The process involves discrete etching of the enamel in order to provide selective dissolution of prism cores or peripheries, with resultant microporosity into which resin can flow and can be polymerized to form a mechanical bond to the enamel. This procedure practically eliminated microleakage at the tooth/restoration interface (Retief et al., 1982). We etched for 15 seconds the enamel.
Img. 15 – After rinsing and drying the etched surface can be detected as it is whitish and opaque.
Img. 16 – Adhesive layer, we wait the adhesive to penetrate into the etched surface, we blow air gently.
Img. 17 – 60 seconds polymerization. Even if in the adhesive instructions it is recommended to polymerize for 20- 40 seconds depending on the adhesive used we prefer to polymerize longer in order to be sure that the adhesive layer is completely cured as it is the layer that will hold the entire restoration. Generally we do it of 60 seconds.
Img. 18 – First increment. THIN SPATULA ADVANTAGE 1: allows the practitioner to be precise when modelling the proximal wall either in posteriors or in anteriors. Specially in small diastema like the one from the picture, the reduced thickness of the thin spatula allows the practitioner to enter in the interproximal space giving the precise shape to the interproximal wall. So it enables the modeling in narrow spaces and even penetrating them from side to side.
Img. 19 – We can appreciate in the cervical area of tooth 11 the composite does not adapt very well in the cervical area. Natural hair brush helps us to adapt the composite in the vestibular area but in the cervical-interproximal area is convenient to enter with a very thin and small spatula.
Img. 20 – THIN SPATULA ADVANTAGE 2: Adapting the composite in the cervical area is almost impossible to do it right if it is not with a thin and small spatula.
Img. 21 – THIN SPATULA ADVANTAGE 3: Modelling the interincisal angle is also easier with the thin spatula. It is possible to insert the THIN SPATULA in small spaces as you can see in the picture, the same concept that when modelling the interproximal wall.
Img. 22 – THIN SPATULA ADVANTAGE 4: Modelling precisely the incisal edge. Even if there is plenty of space and the incisal edge could be performed with any conventional spatula, thanks that instrument Applica (LM arte kit) is very elastic,it allows the practitioner to be subtle and feel the pressure applied when adapting composite to the tooth.
Img. 23 – Readapting the composite to the tooth with the natural hair brush before polymerizing.
Img. 24 – We polymerize for 20 seconds each increment as the increments are small.
Img. 25 – Mesial interproximal wall and incisal angle already done and polymerized.
Img. 26 – We proceed with the distal interproximal wall. Here we should mention that as the LM-arte Applica is very flexible, when taking the composite directly from the syringe is preferable to use a less elastic instrument to avoid loosing the material. For example the LM-arte Modella. Then is suggested to change to the thin spatula to model the composite.
Img. 27 – THIN SPATULA ADVANTAGE 5: It can be used to gently smooth the composite with more precision as the touch sensation increases.
Img. 28 – We recreated the distal angle with the same thin spatula.
Img. 29 – Brush facilitates the adaptation of the composite to tooth surface.
Img. 30 – 20 seconds polymerization for each layer as the composite is layered gradually. 40 seconds for the final polymerization.
The single visit appointment with composites when changing a smile is convenient and economic compared to ceramic approach. As it is a reversible procedure we can always modify, repair or reshape easily directly in the mouth of the patient and if in a future the patient wants ceramic veneers the composites are not an inconvenient. The single mass approach allows us to perform multiple case restorations with moderate time letting us focus on the modeling and shaping. Modeling composite with the right instruments is important. The THIN SPATULA like the Applica from the LM-Arte kit (from LM, Finland) is mandatory to adapt the composite in narrow spaces like in this case. Once you get used to use a thin and delicate instrument you would probably use it in each situation. Special attention from all the dental team is required for the maintenance of this spatula as it is thin and delicate. A delicate instrument should be treated delicately and we should explain it to our assistents and the personal in charge of cleaning the instumental.
Although more elaborate composite layering techniques exist and may be used in some esthetic scenarios, a simplified approach with a right color and opacity single shade and implementing basic dental anatomy concepts often will deliver highly acceptable esthetic results. You can also find a single shade anterior restorations with esthetic results in the article published by Jordi Manauta in the following link. http://www.styleitaliano.org/single-shade-anteriors