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De-mystifying smile designing with direct composite. One material, many solutions

A clinical case by our Community member Dr. Prashant Hatkar

This article and its content are published under the Author’s responsibility as an expression of the Author’s own ideas and practice. Styleitaliano denies any responsibility about the visual and written content of this work.

Direct composite artistry has come a long way from being chosen only as an economically viable restorative option over the indirect restorative modalities as in the past. We have today unearthed the true potential of direct resins, being truly conservative and versatile in many a clinical situations to provide a viable and minimal invasive aesthetic solution. The presented case showcases the use of direct bonding to de-rotate a twisted lateral incisor, close small diastemata and also increase the incisal length all with a no-prep approach.

smile with rotated lateral incisor styleitaliano style italiano

Fig.1
This is the starting point, patient seeks aesthetic transformation but without any orthodontic intervention. The rotated right lateral is her most pressing concern in the smile apart from the mesial diastema on the left lateral incisor.

close-up showing rotated lateral incisor styleitaliano style italiano

Fig.2
Frontal close-up also shows the thinning and mesial wear of the centrals and the notched defect on left central which is planned to be addressed too in the restorative plan.

model with mock-up for shape modification styleitaliano style italiano

Fig.3
A quick chair side mock-up with composite resin on stone model to create the envisioned final result.

color try with vita shade guide styleitaliano style italiano

Fig.4
The Vita Classic shade tabs are a starting point in the shade selection process.

composite button try on central incisor styleitaliano style italiano

Fig.5
Composite Shade Buttons of corresponding body shade composites to confirm shade match.

try in of the silicone index before restoration style italiano styleitaliano

Fig.6
Proper seating of Silicone index done with rubber dam in place, pencil marking for areas of tooth to be prepped before bonding.

floss ligature to improve cervical access on lateral incisor style italiano styleitaliano

Fig.7
The final prep with most of all the enamel yet present as can be seen from the surface gloss.

enamel etching for shape modification styleitaliano style italiano

Fig.8
Use of 32% Phosphoric acid with BAC on the labial and palatal surfaces of the right lateral incisor prior to application of a universal bonding agent.

composite layered in silicone index styleitaliano style italiano

Fig.9
Enamel shade composite loaded on the silicone key in the previously marked area of the planned restoration.

palatal composite shell during shape modification styleitaliano style italiano

Fig.10
A palatal wall created after curing the enamel shade composite.

build up of lateral walls with composite styleitaliano style italiano

Fig.11
The palato-proximal line angles built-up against a pre-contoured metal matrix to create a hollow shell structure prior to multi-layering with different opacities.

layering of dentin shade to hide rotated tooth styleitaliano style italiano

Fig.12
A higher chroma dentin shade placed palatally on mesial half and labially on distal half of the lateral incisor to provide warmth and block-out effect due to the opacity.

layering of the body composite shade styleitaliano style italiano

Fig.13
A lower chroma body shade composite placed over the dentin shade to blend in the shade of the restoration with the natural tooth.

layering of composite resin style italiano styleitaliano

Fig.14
A matrix pull-through technique used to mould and create the mesial proximal enamel wall with an enamel shade composite.

lateral incisor restoration before finishing style italiano styleitaliano

Fig.15
A similar composite moulding technique followed on distal proximal wall to complete the build-up.

enamel etching for shape modification style italiano styleitaliano

Fig.16
Selectively etching the periphery of the left lateral incisor to initiate the planned diastema closure and incisal augmentation.

etched frosty enamel style italiano styleitaliano

Fig.17
The frosty appearance of the enamel following adequate etching, rinsing and drying protocol.

building the palatal wall with a silicone index styleitaliano style italiano

Fig.18
The first layer of the enamel composite created using the silicone key.

lateral incisor modified with composite resin style italiano styleitaliano

Fig.19
The diastema closure completed with a similar technique as used on right lateral incisor but using only one additional body shade composite.

enamel etching for incisal lengthening style ialiano styleitaliano

Fig.20
Selective etching of both central incisors to carry out the planned additive restorations on incisal and mesial surfaces.

incisal build-up style italiano styleitaliano

Fig.21
Incisal composite extensions with enamel shade composite moulded against the silicone key.

layering of mamelons styleitaliano style italiano

Fig.22
Dentin shade composite used to create incisal dentin lobe tips and a high value dentin shade used on the edge to create an halo.

composite restorations on central incisors style italiano styleitaliano

Fig.23
Restoration of incisal and mesial surfaces completed with a body shade composite.

finishing of composite restorations style italiano styleitaliano

Fig.24
Gross composite excess removal and surface refinement with multi-fluted finishing carbide burs.

pencil marks for three dimensional composite finishing style italiano styleitaliano

Fig.25
Pencil markings for creating and retaining the proximal transitional line angles. Graded Sof-lex discs used for shape refinement and pre-polishing.

Polished composite restorations style italiano styleitaliano

Fig.26
Use of diamond-impregnated Sof-lex spiral at 20000 RPM to achieve final highly lustrous surface. A high surface gloss achieved after the final polishing step.

final result after composite restorations styleitaliano style italiano

Fig.27
Intra-oral close-up at 1 week follow-up appointment.

satisfied patient after incisor composite restorations style italiano styleitaliano

Fig.28
The transformed smile after proper composite handling, finishing and polishing protocols, minimalistic yet effective.

Conclusions

Contemporary composites are highly versatile in nature from small additive restorations to extensive build-ups due to superior physical and optical properties.
They are very conservative of the innate tooth structure due to low or no-prep approach.
A rotated tooth can be selectively restored on palatal and labial surfaces with a direct approach to create a visually pleasing, well aligned tooth and with minimal removal of enamel. Its prudent for all restorative dentists to hone their skills in direct composite placement techniques so as to provide responsible esthetics to their patients.

Bibliography

1. Diagnosis and Treatment evaluation in cosmetic dentistry: A Guide to Accreditation Criteria, American Academy of Cosmetic Dentistry.
2. Dietschi D. Layering concepts in anterior composite restoration. J Adhesive Dent 3(1):71-80,2001
3. Scott W Finlay: Accreditation Clinical Case Report -Case Type 5:Six or more Direct Resin Veneers. Journal of Cosmetic Dentistry Vol.24,No.3, Pg.54, Fall 2008
4. LeSage B, Milnar F, Wohlberg J. : Achieving the epitome of Composite art:creating Natural Tooth esthetics, texture and anatomy using appropriate preparation and layering techniques. JCD 2008;132-41(special issue)
5. Howard S. Glazer, DDS: Simplifying Finishing and Polishing Techniques for Direct Composite Restorations. Dentistry Today, November 15, 2009

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