old steel crowns on incisors style italiano styleitaliano

Direct mock-up and direct composite on central incisors. Personal Tips!

A clinical cases 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.

x ray of vital central incisors

Fig.1

Pulp vitality test was positive and no periodontal or periodical disease was observed on the x-ray.

steel crowns on central incisors

Fig.2

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.

cement debris on central upper incisors

Fig.3

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.

class 4 cavities on upper teeth style italiano styleitaliano

Fig.4

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 button try for shade selection

Fig.5

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 t prevent contamination

Fig.6

Isolation is carried out to prevent contamination during the procedure.

direct mock-up

Fig.7

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.

silicon key style italiano styleitaliano

Fig.8

Making the silicone key with the rubber dam on allows a better fit, since the silicone adapts better.

sandblasted enamel surface

Fig.9

The mock-up was removed with a sharp instrument, and the surface was sandblasted with 50um aluminium oxide particles.

etching gel on enamel

Fig.10

Selective etching was carried out, followed by dentin conditioning and adhesion.

composite palatal shell

Fig.11

The palatal composite shell was layered with a translucent mass on the silicone key and sit.

composite excess removal with horico strip style italiano styleitaliano

Fig.12

Excess resin is removed with an abrasive strip and a diamond bur.

composite palatal shells style italiano styleitaliano

Fig.13

After excess composite is removed we need to shape the contact point.

sectional matrices for contact point style italiano styleitaliano

Fig.14

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.

flowable resin was used to get a smoother proximal wall

Fig.15

Some flowable resin was used to get a smoother proximal wall.

mamelon layering with composite resin

Fig.16

Note that the shape and amount of mamelons will determine the type of opalescence in your restoration.

enamel resin layer before light curing the composite

Fig.17

We put a last layer of enamel resin A2 and on the proximal edges we change to A1.

glycerin air blocking polymerization

Fig.18

We apply glycerin to prevent the formation of the inhibited layer and improve the final glossiness.

pencil marks to define the angle lines

Fig.19

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.

final composite restorations

Fig.20

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.

glossy natural composite restorations on central incisors

Fig.21

It is important to wait for the rehydration of the restored teeth to evaluate if the color matching was successful.

final smile of restored teeth style italiano styleitaliano

Fig.22

Final restorations. Note how the incisal plane matches with the curvature of the lower lip and the correct integration within the labial frame.

Conclusions

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.

Bibliography

1. Devoto W, Saracinelli M, Manauta J. Composite in Everyday Practice: How to Choose the Right Material and Simplify Application Techniques in the Anterior Teeth. European Journal of Esthetic Dentistry. 2010;5(1):102-124.

2. Devoto V. Direct and Indirect Composite Restorations in the Anterior Area: A Comparison Between the Procedures. Quintessence of Dental Technology (QDT). 2003;26:127-138.

3. Dietschi D, Fahl N, Fahl N Jr. Shading concepts and layering techniques to
master direct anterior composite restorations: an update. British Dental Journal.

4. Dietschi D, Abdelaziz M, Krejci I, Di Bella E, Ardu S. A novel evaluation method for optical integration of Class IV composite restorations. Australian Dental Journal. 2012;57(4):446-452.

5. Ferraris F, Diamantopoulou S, Acunzo R, Alcidi R. Influence of enamel composite thickness on value, chroma and translucency of a high and a nonhigh refractive index resin composite. International Journal of Esthetic Dentistry.

6. Finlay SW. STRATIFICATION: An Essential Principle in Understanding Class IV Composite Restorations. Journal of Cosmetic Dentistry. 2012;28(1):32-34.

7. Magne P. Adhesion, biomaterials, and CAD/CAM. International Dentistry South Africa. 2018;8(6):6-18.

8. Paolone G, Orsini G, Manauta J, Devoto W, Putignano A. Composite shade guides and color matching. International Journal of Esthetic Dentistry. 2014;9(2): 164-182.

9. Salat A, Devoto W, Manauta J. Achieving a Precise Color Chart with Common Computer Software for Excellence in Anterior Composite Restorations. European Journal of Esthetic Dentistry. 2011;6(3):280-296.