Controlled Body Thickness Part 3

The use of personalized shade guides gives the clinician the chance to develop an enormous number of arrangements between enamel and dentin, so that a wider color selection is available.

When using the Controlled Body thickness technique in daily practice, the clinician is able to reproduce any sample developed by the personalized shade guide, and to do so in a very accurate way in the tooth that is going to be restored, stressing out especially the 0.5mm enamel thickness.

Anterior restorations require not only skill, but deep comprehension of color, anatomy and to follow precisely every single step from cavity prep, cleaning, disinfection, bonding procedures, anti-contraction layering, thickness management and last but not least the morphology and texture. Making these steps an every day routine enable us to repeat them with great ease.

A clinical article by Paulo Monteiro and Jordi Manauta from the CBT technique by Walter Devoto and Angelo Putignano

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Fig.1
Incongrous restoration of 11, with wrong shape, unnatural color and marginal over contours.

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Fig.2
From a Wax-up we will obtain a palatal silicon guide. The complete vestibular surface is waxed as well as an exercise.

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Fig.3
Contacts are studied before starting. Closed mouth analysis can reveal very important data not only in function but as well regarding color and shape, as the light conditions and background change dramatically.

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Fig.4
Color is studied immediately, in order to have perfectly hydrated teeth and be able to select the “real” colours of the neighbour teeth. In this case, the VITA shade guide was used and the A1 (the tab in the center) revealed it was not enough white, the tab on the right shows an A0 which was too white. The colour analysis gave as a result an A0,5. Masses were selected from this choice.

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Fig.5
Teeth under isolation, the rubber dam must be perfectly invaginated for many reasons, such as the beauty in documentation, but as well for operative procedures optimisation such as matrix and wedge insertion and moist control factors like the perfect sealing the invagination does.

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Fig.6
Looking at the tooth from other angle and without the moisture, is easy to appreciate the marginal gaps, discrepancies and over contours.

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Fig.7
With a sof-lex disc, we start removing the restoration, these kind of instruments are able to cut very efficiently the composite and do practically nothing to the sound enamel when the pressure applied is very light. In stead, when applying mild-strong pressure, it can wear the sound tissue.

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Fig.8
We can practically remove the whole restoration with the disc.

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Fig.9
As mentioned before, application of mild-strong force to the disc will cause enamel wear. We can use this feature to create a bevel with much control and precision given the fact that compared to a bur the cutting action is very little. Discs can be used as well for polishing the margin using mild pressure.

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Fig.10
The bevel of the restoration when watched from another angle. This preparation shall look smooth and regular. It is a common debate to argue about if the polished enamel bonds better than the rough enamel. Microscopic evidence has shown that the polished enamel has less unsupported prisms and the micro retentions are more and deeper than in rough enamel.

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Fig.11
With the silicone guide in place, we will take a very small and sharp probe (Fissura, LM Arte by Styleitaliano) and we will mark a line following the whole palatal margin.

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Fig.12
This mark is especially useful to layer the enamel composite outside the mouth with much accuracy. This way we can avoid lack of material or excess of material as long as we stay close to the line and then adaptation of the composite to the palatal wall will be a very easy task.

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Fig.13
Silicone index try-in, sometimes the rubber dam can interfere, if it is so, small modification must be done until it fits perfectly.

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Fig.14
Frontal view of the preparation and ready to bond. Disinfection is followed with 2% clorhexidine in aqueous solution for 2 minutes.

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Fig.15
Teflon tape (sterile plumbery tape) is placed in the proximal areas before the adhesive procedures, so that way the etching and bonding will not affect the neighbour teeth.

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Fig.16
Selective etching of the enamel is done, this “etch&dry” technique will allow us to take advantage of the properties of the smear layer in the dentin, do a true dry bonding without fear of over-drying the dentin and to enjoy at the same time the advantages of the etched enamel bonding strength.

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Fig.17
A one step selective enamel etching technique was used (Scotch Bond Universal) rubbing the surface of the dentin for 20 seconds, drying and repeating the mechanical action of the brush. The bonding layer is thinned blowing air gently.

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Fig.18
The palatal wall from the silicon guide is transported to the mouth, adapting very well the composite to the palatal margin. Once polymerised, when done correctly, the wall has enough strength to sustain the following steps.

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Fig.19
Another view of the cavity up to the palatal wall stage.

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Fig.20
Very often, even taking much precautions during the palatal wall modeling, some composite may stick to the neighbour teeth, making impossible the insertion of the anatomical matrix without harming it. A metallic strip is used to separate very delicately the teeth.

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Fig.21
Doing only one insertion of the metallic strip, we will have free passage for placing other matrices.

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Fig.22
Garrison Varistrip is used for anatomical build up of the proximal walls, as explained in “How to choose a matrix, part 3?.

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Fig.23
Build up of the proximal wall and how it must be thin, anatomical and rounded.

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Fig.24
After curing, matrix and wedge are removed.

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Fig.25
Black back ground control picture in order to appreciate the incisal effects.

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Fig.26
Surface control picture.
CBT is a reliable method, that in my practice has given excellent results since I adopted it. It is not only useful for the expert hands but for the students that initiate in stratification, they already have an advantage.

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Fig.27
Bulk placement of the A1 dentin (Filtek supreme XTE) and before curing, thickness calibration is done with the “Misura” instrument (LM Arte by Styleitaliano).

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Fig.28
Misura instrument is placed the following way: thin part on the sound tissue and thick part on the non-polymerized dentin, this will create a displacement of the excess dentin and a the recreation of the 0,5mm space needed for the enamel layer.

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Fig.29
Dentin is not cured yet, as mentioned in previous articles, after thickness calibration, we can model mammelons, incisal embrasures and other features of the incisal edge.

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Fig.30
CE Enamel (Filtek Supreme XTE) is placed in the incisal edge.

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Fig.31
Enamel is placed worrying only about two things, which are following as much as possible the contour of the neighbor teeth, and achieving a clean and regular surface. The last enamel layer and its thickness is already determined by the calibrated dentinal body and externally by the contour of the neighbor teeth 0.5 mm.

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Fig.32
Frontal view of the last layer already placed and polymerized.

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Fig.33
After polymerizing, glycerin can be applied for a last and extra polymerization.

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Fig.34
This last polymerization will eliminate the inhibited oxygen layer, and it is convenient to do it for extended time (i.e. one minute) not only polymerizing perfectly the surface but the whole restoration and improving its physical properties from the beginning.

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Fig.35
Soflex discs (fine grit) are used to define the outline of the restoration, and the transition angles.

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Fig.36
Vestibular aspect is corrected with the same disc.

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Fig.37
Secondary anatomy is drawn mimicking mirroring the neighbor tooth.

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Fig.38
Step 5 of Finishing Style is used to smoothen the composite and to define the secondary anatomy.

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Fig.39
The secondary anatomy finished seen from above to appreciate the life that such features give to the tooth.

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Fig.40
Sof-lex Spiral medium is used for the first step of polishing.

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Fig.41
Sof-lex Spiral fine is used for high gloss.

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Fig.42
These kind of instruments are ideal to reach proximal areas.

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Fig.43
Morphology final aspect seen from above.

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Fig.44
Restoration finalized prior to the rubber dam removal.

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Fig.45
Control picture, closed mouth to appreciate the over all integration.

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Fig.46
Black back ground control picture in order to appreciate the incisal effects.

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Fig.47
Surface control picture.

Conclusions

CBT is a reliable method, that in my practice has given excellent results since I adopted it. It is not only useful for the expert hands but for the students that initiate in stratification, they already have an advantage.

Bibliography

1. Vanini L (1996). Light and color in anterior composite restorations. Pract Periodont Aesthet Dent 8:673-68
2. Duarte S, Perdigão J, Lopes M (2003). Composite resin restorations – Natural aesthetics and dynamics of light. Pract Proced Aesthet Dent 15:A-H.2. Perdigão J (2010). Dentin/Enamel bonding. J Esthet Restor Dent 22:82-85.
3. 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.
4. Perdigão J, Sezinando A, Monteiro PC. (2012). Laboratory bonding ability of a multi-purpose dentin adhesive. Am J Dent Jun;25(3):153-8.
5. Paolone G, Orsini G, Manauta J, Devoto W, Putignano A. (2014). Composite shade guides and color matching. Int J Esthet Dent Summer;9(2):164-82.

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