Direct anterior composite restorations. Simple acts serving an apparently complex treatment

In restorative dentistry, the constant evolution and progress of materials and equipment (adhesive systems, composite resins, spatulas, brushes, etc.) have made it possible to simplify the daily lives of dental surgeons and to improve the treatments that patients benefit from. Nevertheless, composite resin lamination procedures in the anterior sector are often considered complex and time-consuming by the majority of practitioners. How to obtain an “invisible”, lasting restoration in a reasonable time is a recurring question that many dentists ask themselves.
The objective of this article is to demonstrate that by applying the principle of division of tasks to restorative dentistry, the design of composite resin restorations in the anterior sector is only a sum of simple and reproducible actions to be carried out conscientiously, according to a well-defined timeline leading to a predictable and satisfactory result.

style italiano styleitaliano old unaesthetic composite restorations

Fig.1
A young female patient came to replace composite restorations on her central incisors. On the initial picture, we can see the inappropriate aesthetic adaptation of the two resins on teeth 11 and 21. We decided with the patient to make two new composite restorations.

style italiano styleitaliano button try shade selection for composite restoration

Fig.2
To match the color, we used the button try technique by putting and curing a little amount of composite resin on the tooth. This step has to be quick to avoid the change of color of the teeth caused by dehydration.

style italiano styleitaliano cross polarized picture for color analysis

Fig.3
The analysis of a cross polarized picture helps us in creating a color chart of the sound structure. We can observe blue opalescence, some white spots and characterizations.

style italiano styleitaliano rubber dam isolation

Fig.4
The first step when performing composite resin restorations is rubber dam isolation. The field has to be large enough so the practitioner can see and use the silicone stent.

style italiano styleitaliano class IV cavity preparation

Fig.5
The second step consists in removing the old restorations and prepare the teeth with buccal chamfer and flat design on the proximal and palatal surfaces.

style italiano styleitaliano sandblasting cavity surface

Fig.6
The third step (and 1st step of any bonding procedure) is sandblasting with 50um aluminum oxyde.

style italiano styleitaliano acid etching of enamel

Fig.7
The fourth step is etching with 37% orthophosphoric acid.

style italiano styleitaliano bonding for composite restoration

Fig.8
Fifth step. After rinsing the etching gel and drying the surface, we proceed to the application of the bonding agent. In this case we used a universal adhesive.

style italiano styleitaliano LM arte tool set

Fig.9
Now is time to use our tools, brush and the new LM Arte Dark Diamond instrument set. The handling has been improved, the black color creates a contrast and helps while sculpting composite that does not stick on the instrument.

styleitaliano style italiano LM Arte Dark Diamond instruments
styleitaliano style italiano LM Arte Dark Diamond instruments
style italiano styleitaliano marking the palatal extent of composite restorations

Fig.10
Sixth step. A thin instrument, such as the ErgoSense probe is used to outline the area of the palatal composite. One of the advantages of composite resin stratification is that this procedure, except for the final enamel application, is fully guided.

style italiano styleitaliano palatal composite shells

Fig.11
Seventh step. The palatal walls are layered outside the mouth onto the silicone index and applied to the teeth.

style italiano styleitaliano palatal build up

Fig.12
Once the palatal walls are light cured, the silicone is removed and the composite stays on the teeth.

style italiano styleitaliano blade removing excess material

Fig.13
Excess can be removed at this step with a blade or a disc.

style italiano styleitaliano matrices for proximal buildup

Fig.14
Eighth step. Proximal walls are built with the help of metallic matrices (Polydentia Lumicontrast).

style italiano styleitaliano outline of composite class IV restorations

Fig.15
Proximal walls after removal of the matrices.

style italiano styleitaliano packing dentin composite

Fig.16
Ninth step. The “boxes” created by the palatal and proximal walls are filled with dentin composite resin. The use of the Condensa tool helps by packing the material so that no bubbles are trapped into the layering.

style italiano styleitaliano detailing incisal anatomy

Fig.17
The Fissura is used to shape the dentin on the incisal edges and to let space for the opalescent material.

style italiano styleitaliano details of the incisal characterization with composite masses

Fig.18
Several increments of dentin material can be added until the right shape and volume are achieved.

style italiano styleitaliano composite excess removal

Fig.19
At each step, burs and discs can be used (no water, slow speed). Here, a disc was used to create a lobule on the incisal edge. After this, the surface must be cleaned and bonding agent applied but not light cured.

style italiano styleitaliano staining incisal edges

Fig.20
Some tint can be added to create the characterizations of the incisal edge.

style italiano styleitaliano packing enamel composite

Fig.21
Tenth step. The Modella tool is used to apply enamel composite buccally. This is the only non-guided step. The practitioner has to be careful and has to respect the final shape and volume of the teeth.

style italiano styleitaliano glycerine air block for final curing

Fig.22
Final light curing is done under glycerine gel to avoid the polymerization of last layer of composite to be inhibited by the oxygen.

style italiano styleitaliano pop on disc in finishing restorations

Fig.23
Eleventh step. The finishing procedure is done at slow speed without water with discs and burs.

style italiano styleitaliano multiblade bur finishing restorations

Fig.24
Finishing with burs.

style italiano styleitaliano proximal excess material removal

Fig.25
The Eccesso instrument helps remove excess material in the proximal area. A blade can be used as well.

style italiano styleitaliano polishing composite restorations

Fig.26
Twelfth step. Polishing by using Lucida composite gloss system.

style italiano styleitaliano diashine lucida
style italiano styleitaliano diashine lucida
style italiano styleitaliano finished and polished composite class IV restorations

Fig.27
The final result shows a highly glossy surface and very natural shape and volume.

style italiano styleitaliano composite restorations after rubber dam removal

Fig.28
Final smile after rubber dam removal.

style italiano styleitaliano before and after composite restoration

Fig.29
Before and after comparison.

style italiano styleitaliano composite restorations 3 months after procedure

Fig.30
Before after comparison, 3 months post operative.

Conclusions

Taken one by one, the steps required to design a composite resin laminate restoration in the anterior sector are simple and reproducible. This principle of division of the clinical act must bring confidence and serenity to practitioners carrying out this type of treatment and must lead to satisfactory results both for the dental surgeon but also for the patient.

Bibliography

  1. Adam Smith, Recherches sur la nature et les causes de la richesse des nations, 1776.
  2. Faucher AJ, Ortet S, Camaleonte G, Weisrock G, Etienne o, Paris JC. Réussir les composites antérieurs au quotidien. Quintessence Publishing 2017.
  3. Camaleonte G, Ortet S, Weisrock G, Salehi A, Faucher AJ. Comment aborder les restaurations antérieures en composite, décomplexé et sûr de sa technique ? Réalités Cliniques 2018. Vol. 29, n°4 : pp. 244-251.
  4. Vanini L, Mangani FM. Determination and communication of color using the five color dimensions of teeth. Tract Procède Aesth Dent 2001;13(1):19-26.
  5. Ceinos R, Lasserre JF. La couleur des dents naturelles : bases fondamentales. L’Information Dentaire n°41 – 25 novembre 2020 (pages 22-32).
  6. Weisrock G, Brouillet JL. Le champ opératoire évidemment. Information Dentaire 2009;91(42):2525-9.
  7. Salehi A, Toledano C, Camaleonte G. Comment choisir la bonne couleur en dentisterie restauratrice. Biomatériaux cliniques 2018;3(1):86-9.
  8. Manauta J, Salat A. Layers : an atlas of composite resin stratification. Quintessence;2021, 448p.
  9. Ceinos R, Bernard C, Camaleonte G. Restaurations antérieures directes en résine composite : mise en oeuvre. EMC – Médecine buccale 2019;14(6):1-16 [28-612-A-10].
  10. Manauta J, Salat A, Devoto W, Putignano A. Layers 2, Direct Composites : The Styleitaliano Clinical secrets. Quintessence Publishing 2023.
  11. Camaleonte G. Stratification antérieure des résines composites : une somme d’actes simples au service d’un traitement en apparence complexe. L’INFORMATION DENTAIRE n° 32 – 27 septembre 2023
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