The daily restorative game: every step count!

Currently our patients are becoming more demanding with dental treatments and the final aesthetic outcome.
The composite resins and the dentin adhesives occupy a very important role in today dentistry, because they are easy to use and have a very acceptable clinical behavior.
In this clinical case I intended to describe a simple and predictable clinical sequence, to ensure the patient expectations with direct composite resins in anterior teeth.

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Fig.1
Initial situation.
A patient came to my clinic to improve the restoration of the tooth 11 and 21 made a few months ago.
As a first option, the patient enjoyed making ceramic veneers, for not believing that direct composite resins can give a natural aesthetic smile.

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Fig.2
Initial situation.
The patient complained mainly with the opacity of the restorations and surface irregularity.
After explaining the advantages and disadvantages of direct composite resin and ceramic veneers, the patient chose to do both teeth in composite resin material.

style italiano styleitaliano dentistry

Fig.3
Shade selection with Vita Classical shade guide.
It is mandatory to select the shade with the teeth hydrated before rubber dam placement.

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Fig.4
Placing the rubber dam.

style italiano styleitaliano dentistry

Fig.5
With a pencil, the area with the old restorations has been marked for a better understanding when removing the old composite.

style italiano styleitaliano dentistry

Fig.6
After removing the old restorations and after making the labial and inter-proximal bevel . The bevel was done with a red Sof-lex disk to a better conservation of the dental tissues and smoothing the surface.

style italiano styleitaliano dentistry

Fig.7
Silicone key testing made from a wax-up.

style italiano styleitaliano dentistry

Fig.8
Bonding procedures.
The selective enamel etching technique was used.

style italiano styleitaliano dentistry

Fig.9
Bonding procedures.
A universal adhesive was used on enamel and dentin (Scotchbond Universal, 3M ESPE). It is important to use more than one adhesive increment and at the end applying lightly air until seeing no movement of the adhesive on the tooth surface. Then light cure.

style italiano styleitaliano dentistry

Fig.10
The palatal enamel was made with a translucent enamel (Filtek Supreme XTE CT effect).

style italiano styleitaliano dentistry

Fig.11
The interproximal enamel was made with Filtek Supreme XTE enamel A3.
A thin convex posterior matrix were used (in vertical position) to give a natural and anatomic surface (Garrison Dental).

style italiano styleitaliano dentistry

Fig.12
For the incisal halo we used Filtek Supreme XTE flow W.

style italiano styleitaliano dentistry

Fig.13
Dentin application (Filtek Supreme XTE dentin A1).
The volume control is essential for the right combination of opacity and a natural outcome.
We use the Misura intrument (LM Arte by Style Italiano) to calibrate the dentin and leaving a 0.5mm space for the buccal enamel.

style italiano styleitaliano dentistry

Fig.14
The dentin incisal anatomy (mamelons) was made with the LM Arte Fissura before light curing.

style italiano styleitaliano dentistry

Fig.15
To increase the translucency at the incisal edge, a small portion of a translucent enamel (Filtek Supreme XTE CT effect) was applied between the dentin and incisal halo.

style italiano styleitaliano dentistry

Fig.16
A suitable light curing device must be used for effective polymerisation of the composite resin (Elipar Deep Cure).

style italiano styleitaliano dentistry

Fig.17
After the composite resin application.
In this case we use the combination of an A1 dentin and A3 enamel, to obtain a final A1 Vita shade guide. It is always necessary the calibration of the vestibular enamel (0,5mm).
This combination has been described previously by studies and work of Style Italiano group.

style italiano styleitaliano dentistry

Fig.18
Shape and texture is a necessary and important step as all the others in the restorative process.
With a pencil, the primary anatomy has been marked (vertical texture) and angle lines.

style italiano styleitaliano dentistry

Fig.19
Finishing procedures with Sof-Lex disc.

style italiano styleitaliano dentistry

Fig.20
Polishing procedures with Sof-Lex Spiral discs.

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Fig.21
Aesthetic appearance after polishing. It stands out the natural shine of the enamel surface.

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Fig.22
Final situation.

style italiano styleitaliano dentistry

Fig.23
Final situation.
Natural integration of the composite resins with the dental tissue, giving to the restorations a very natural look.

Conclusions

The techniques and materials used in this clinical sequence proved to be able to meet the requirements of the patient and restore the natural aesthetics of the anterior teeth.

Bibliography

1. Composites in esthetic reconstruction. Toffenetti F, Vanini L. Dent Cadmos. 1986 Mar.
2. Determination and communication of color using the five color dimensions of teeth. Vanini L1, Mangani FM. Pract Proced Aesthet Dent. 2001 Jan-Feb.
3. Paolone G., Orsini G., Manauta J., Devoto W., Putignano A., Composite Shadeguides and Color Matching. IJED, Vol 9, No. 2, Summer 2014.
4. Manauta J, Salat A, Layers, an Atlas of composite resin stratification, Quintessence 2012.
5. Manauta J, Salat A, Putignano A, Devoto W, Paolone G, Hardan LS. Stratification in anterior teeth using one dentine shade and a predefined thickness of enamel: a new concept in composite layering–Part II. Odontostomatol Trop. 2014 Sep;37(147):5-13.
6. The influence of stratification on color and appearance of resin composites. Betrisey E1, Krejci I, Di Bella E, Ardu S Odontology. 2015 Feb 5. 
7. The effects of finishing and polishing techniques on surface roughness and color stability of nanocomposites. Gönülol N1, Yilmaz F. J Dent. 2012 Dec;40 Suppl 2:e64-70.

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