old composite restorations

Esthetic direct veneering in vital and endodontically treated anterior teeth

More than 50% of restorative procedures are direct composite resin restorations. Sound dental tissue preservation, fast workflows and repairability are only a few of the advantages offered by composite resins. Many materials of different optical and physical properties are today available, which might make the outcome very unpredictable if you don’t have deep knowledge of their usage. For example, the thickness of one of several masses may dramatically change the final outcome. That’s why many clinicians consider non-vital anterior teeth a very big challenge and they often prefer to cover them with all-ceramic restorations. This said, most patients are simply asking for a “a white smile”, because white means healthy and beautiful, as displayed in magazines, ads, and so on.

In this case report, I want to show how a direct approach could lead to a successful esthetic outcome if correct materials and techniques are used, in order to make up for the differences between vital and non-vital teeth.

old broken composite restorations

Fig.1

Initial photos show inappropriate composite restorations for teeth 11, 21 and 22. The central incisors are also dyschromic. The patient complains of discoloration and shape of her central incisors, which, as you can see, are too short and don’t follow the lower lip-line.

xray showing apical lesion on 11

Fig.2

The x-ray shows a pariapical lesion on tooth 11, with a poor root canal obturation.

shade selection for composite restoration

Fig.3

Before isolating with the rubber dam, the correct shade was selected thanks to a customized CompoSite shade guide made with the My ShadeGuide kit (SmileLine, powered by StyleItaliano), under a light source of 5500° K.

intra op and after root canal treatment

Fig.4

The root canal of 11 was retreated, and filled up to 2 mm below the bone ridge, in order to allow space for a flowable composite filling to improve the esthetic outcome.

isolation with rubber dam

Fig.5

In the same operative session, after having re-isolated with the dental dam (Vision Clamps by ASA Dental, powered by StyleItaliano ) from tooth 14 to 24.

removal of old composite

Fig.6

The old composite restorations were carefully removed using a cylindrical medium-grain bur (Direct Style bur kit, by Styleitaliano, Komet), because every sound enamel prism and dentin tubule is crucial to a durable restoration.

prepared teeth under rubber dam isolation

Fig.7

All the margins were cleaned and smoothened. A chamfer design was used to define the buccal finishing line, using a fine-grain round bur ( Finishing Style bur kit by Styleitaliano, Komet).

filling the root canal

Fig.8

The cavities are now ready for the adhesive procedures.

professional composite system white dental beauty shade composite veneers

Fig.9

A high opacity, high value and fluorescent flowable composite was selected to fill the first part of the root cana (Masque flowable CompoSite by White Dental beauty).

opaque flowable composite professional composite system white dental beauty

Fig.10

This flowable was also spread on the buccal walls to balance dentin fluorescence loss, and to mask the dark color.

professional composite system by white dental beauty for direct composite veneers

Fig.11

The whole dentinal body was built using the previously chosen CompoSite Si 2 shade.

palatal fillings on incisors

Fig.12

The palatal shape was built using a silicone key.

layering of composite on central incisors

Fig.13

A narrow proximal space was left in order to easily accomodate the matrices.

unica matrices for incisor reshaping with direct composite veneers restoration

Fig.14

To create a natural and beautiful buccal shape and contour for teeth 11 and 21, the Unica matrix system (Polydentia) was used.

fit of unica matrices from occlusal view

Fig.15

These matrices perfectly hug the cervical and interproximal margins. They easily provide a natural emergence profile and optimize the position and fit of the contact points. This is of significant help, as it makes the final shape predictable, allowing for better time management.

enamel composite layering with white dental beauty professional composite system and unica matrices

Fig.16

The buccal anatomy was layered using the CompoSite Enamel mass, which has a a refractive index very close to that of natural enamel.

brush to model composite layer

Fig.17

CompoBrush (SmileLine) is great to help the clinician to spread and shape the composite up to the margins.

composite restorations before polishing

Fig.18

The final light curing is 60 seconds long, and is better performed using an air-blocking system (e.g. ultrasound gel). This procedure will provide the composite resins’s complete polymerization, improving surface resistance and giving better polishing performances.

occlusal view of unica matrices on lateral incisors

Fig.19

After having defined the buccal contour and thickness of the central incisors, a couple of Unica matrices were applied on 12 and 22.

my custom resin for proximal matrix adaptation

Fig.20

To optimize the stability of the matrices while avoiding crashing them, a drop of flowable resin (My Custom Resin, Polydentia) was injected in the cervical embrasures.

etching of lateral incisor

Fig.21

No surface preparation was needed, as we are directly veneering the laterals. Enamel-specific adhesive procedures were carried out.

professional composite system shades by white dental beauty

Fig.22

Buccal layering was done with the same CompoSite masses used for the centrals, up to achieving the same thickness and good contour harmony.

finishing of composite restoration on lateral incisor

Fig.23

Surface texturing was made using different kinds of burs.

perio bur from finishing kit by styleitaliano

Fig.24

The perio bur from the StyleItaliano Finishing Style kit (Komet) is ideal when used at low speed and no irrigation, in order to obtain better light refraction and reflection to enhance the value.

polishing diamond rubber wheel

Fig.25

Final polishing is mandatory to get esthetic success of these restorations. Furthermore, a glossy surface reduces plaque accumulation and prevents the teeth from undergoing discoloration. The polishing is performed with diamond-charged spiral wheels (Diacomp plus, EVE), and low speed under water irrigation.

polished composite veneers restorations

Fig.26

Restorations completed before removing the rubber dam.

finished composite veneers

Fig.27

And after complete rehydration.

final xray after RCT

Fig.28

The x-ray shows very nice root canal and coronal fillings.

final aspect of composite veneers

Fig.29

The final outcome.

Conclusions

Modern composite resins allow us to make restorations while staying minimally invasive. They also allow us to provide affordable solutions for our patients.

Bibliography

1. Mackenzie L, Parmar D, Shortall A, Burke T. Direct Anterior Composites: A Practical Guide. Dental Update 2013;40(4):297-317.

2. Devoto W, Saracinelli M, Manauta J. Composite in every day practice: How to choose the right material and simplify techniques in the anterior teeth. Eur J Esthet Dent 2010;5(1):102-24.

3. Devoto W, Pansecchi D. Composite restorations in the anterior region: clinical and aesthetic performances. PPAD 2007;19(8):465-470.

4. Devoto W. Clinical procedures for producing aesthetic stratified composite resin restorations. PPAD 2002;14(7):541-544.