A clinical case by our Community members Dr Rafael Haenggi and Dr Jose Contribunale
This 20 years old female patient came asking to improve her smile. She had a trauma back when she was 10 years old and her central incisors were treated with stainless steel crowns. The patient showed good oral hygiene and healthy gum.
Pulp vitality test was positive and no periodontal or periodical disease was observed on the x-ray.
Note the coronal enamel exposure between the edge of the stainless steel crown and the gingival tissue, an indicator of tooth eruption during the last 10 years, in the maxillary development phase.
Different treatment options were given to the patient, but the less invasive option was chosen in the end, especially because of the very young age of the patient.
The crowns were removed with rotary instruments, using a Jota TM # C18R tungsten carbide bur, being careful not to damage the tooth enamel. The zinc-phosphate cement was removed by cavitation with ultrasonic instruments.
Note the macro and micro texture. Due to the optimal preservation of tooth enamel, we opted for a direct composite resin treatment to preserve dental integrity as much as possible.
Composite shade was chosen doing a preliminary button try. The chroma was taken in the cervical area of the tooth, because it is the portion of the tooth with the least amount of enamel and in the incisal area we determine the value of the enamel and the translucency.
Isolation is carried out to prevent contamination during the procedure.
A direct mock-up was performed before any tissue conditioning. As we didn’t use clamps for the rubber dam, we made the patient occlude before light-curing the direct mock-up.
Making the silicone key with the rubber dam on allows a better fit, since the silicone adapts better.
The mock-up was removed with a sharp instrument, and the surface was sandblasted with 50um aluminium oxide particles.
Selective etching was carried out, followed by dentin conditioning and adhesion.
The palatal composite shell was layered with a translucent mass on the silicone key and sit.
Excess resin is removed with an abrasive strip and a diamond bur.
After excess composite is removed we need to shape the contact point.
So two metal sectional matrices were placed and stabilised with a plastic wedge. To get a tight contact point it’s helpful to pinch the matrices with your fingers, thus getting a straighter proximal wall.
Some flowable resin was used to get a smoother proximal wall.
Note that the shape and amount of mamelons will determine the type of opalescence in your restoration.
We put a last layer of enamel resin A2 and on the proximal edges we change to A1.
We apply glycerin to prevent the formation of the inhibited layer and improve the final glossiness.
Mark the proximal ridges with a pencil. The mesial lines are like an elongated S and the distal lines are shorter. Draw the depressions and elevations on the buccal surf face of both teeth. Always maintain symmetry.
With a conical diamond cutter # 873 JotaTM at low speed, grind the resin, marking the areas of depressions and elevations, also with an inverted cone # 807 JotaTM micro texture can be made.
It is important to wait for the rehydration of the restored teeth to evaluate if the color matching was successful.
Final restorations. Note how the incisal plane matches with the curvature of the lower lip and the correct integration within the labial frame.
Thanks to the evolution of materials and concepts, it is possible to perform this treatment with good results over time. In this case, the most conservative way was taken. Making direct restorations in the aesthetic area is one of the biggest challenges for the dentist. Developing the necessary skills for this type of treatment is a matter of study and practice.
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