Cosmetic improvements and small fractures with composites
Sometimes it is a nightmare to try to stratify in small spaces. Thanks to the good optical properties of some composite materials it is possible to use the single mass approach with an optimal aesthetic result, enough to satisfy most aesthetic expectations. In small restorations the single mass approach is easier and faster compared to stratifying. So we present a cosmetic small shape modification and a little fracture restored with composite.
The Single mass and freehand approach was used, and has some undeniable advantages. We will mention the three main advantages:
1. Easier to stratify. It is almost impossible to stratify 3 masses (enamel, dentin, opalescent mass) in a reduced space like in the one available in the following clinical case.
2. Lets the clinician focus on other essential aspects of the anterior direct restoration (shape and texture)
3. Eliminates the need of wax-up or direct mock-up to build the silicone key.
Big class IV with large bevel are also indicated for a single mass approach (when all the attention has to go to the modelling stage) as you can see in the clinical case of this article http://www.styleitaliano.org/single-shade-anteriors
The styleitaliano suggestions for the single mass restorations are the following ones:
– Small restorations, as a small class IV or a little diastema
– Contained restorations, as class III or class V restorations
– Large-extended lesions as large class IV especially if they have large or infinite bevel
Img. 1 – The patient presents small old enamel fractures on 22 distal, and on 11 and 21 mesial which are difficult to stratify with different color masses because of the lack of space. We can tell that a fracture is old, because the edges are rounded.
Img. 2 – The day the patient came to the clinic we also proposed a small shape modification: for this purpose, we did a fast direct mock-up with composite for an aesthetic improvement. We modified mesial angles of 11 and 21 putting a small quantity of composite without adhesive to give the patient a preview of the changes he would get to his smile, then he accepted to proceed. Teeth 11, 21 and 22 direct composite restorations free-hand and with a single mass (only one color) were planned.
Img. 3 – We are cleaning and polishing the superficial enamel where we want to adhere the composite; since we are following the concept of minimally invasive dentistry, we don't need a preparation. In addition, we are adhering to the enamel, so we don't even think of touching the sound structure and risking exposure of dentinal tubules. We only use a pop-on disk (Soflex from 3M) to smoothen the edges.
Img. 4 – The single mass technique intends to use the so called "body masses" which have an opacity in between the enamels (translucent) and dentins (less translucent). On the far right we can see a sample of dentin (more opaque) and on the far left we see an incisal (the most translucent), the second from the left is an enamel (mild translucency). In the middle, third from the left, we can see Body masses (opacity between enamels and dentins)
Img. 5 – In our experience we found that low scattering composite Body masses (i.e. Filtek, 3M, Asteria, Tokuyama) have the perfect degree of translucency-opacity in the majority of the anterior cases in the young and mid-age patients. We placed a single mass, an A3 Body in only one increment polymerizing 60 seconds each. As the restorations are small, they are done freehand and in only one increment.
Img. 6 – Placing composite is done in a few minutes. Now we can focus our attention on other essential parameters for a clinical and aesthetic successful restoration: surface, texture, shape and function. Composite surface is irregular before polishing steps, even when using brushes to delicately smooth the final layer. Scrubbing articulating paper in the surface, the irregularities are highlighted and also the composite-tooth junction. This step is optional if the clinician is experienced.
Img. 7 – The first thing to do is to smoothen the irregular composite surface. It is done with the low speed diamond bur (Periodontal bur from Komet, found in the Finishing Style Kit burs)
Img. 8 – We are checking again with the articulating paper the integration of the restoration. This time we see the composite is not irregular anymore, without excess on the margins and perfectly integrated.
Img. 9 – The superficial periquimates present in the natural tooth were recreated in the composite with the same bur.
Img. 10 – Now we want to control the transitional angles. Marking with a pencil the transitional angle (where vestibular changes to the proximal wall). As you can see the line on tooth 21 is not straight. It means that we have to modify it changing the shape of the composite. We have to change angulation from where we want the line to be.
Img. 11 – We modify the composite shape and mark it again with the pencil to verify that the transitional angles are in the right place. This time the shape is the right one.
Img. 12 – The restorations need to be reviewed from different angulations in order to check for composite adaptation and flaws in texture. Even if the restoration is small, the shape is crucial for the integration of a restoration. That is why we spend approximately 5 min finishing and polishing even the smallest restorations.
Img. 13 – Result after removing the dental dam.
Img. 14 – 2 weeks control, rehaidration is complete.
Img. 15 – Lateral view
Img. 16 – Lateral view
Img. 17 – Before and after.
Small modifications can dramatically change a smile. Cosmetic modifications with composite for a smile improvement with the free hand technique and single mass approach are the fastest, easiest, cheapest way of treating small fractures or small shape modifications. With the single mass technique we obtain optimal aesthetic results, being able to satisfy most of the patients and their aesthetic demands. In order to get greater aesthetic results when layering, it can sometimes be convenient to use the technique we presented in this article.