Anatomical proximal reconstruction in the anterior region is one of the most important factor to achieve a protected and healthy-looking proximal papilla, a natural esthetic appearance, and also tooth stability. This is why the proximal area should be reconstructed as close as possible to the original natural aspect of the anterior teeth.
The proximal surface in an apical coronal view has a gingival embrasure, the contact area and also the incisal embrasure. This surface is not flat, it has a 3D architecture.
The anatomical reconstruction of this area can be very challenging for the practitioner. The bigger the surface that needs reconstruction, the more demanding it is for the dentist to restore both color and shape. This article will focus on understanding the design of the natural proximal surface and how it can be restored with composite using sectional matrices from Polydentia.
Fig.1
Initial situation of the case. The patient wanted to improve the esthetic appearance of the proximal reconstructions. We decided to replace the old composite restorations with new ones.
Fig.2
While checking the occlusal contacts, no anterior contacts were recorded, and a retainer, which had to be removed before restoration, was found. I registered the case for a more detailed occlusal analysis.
Fig.3
The case mounted in CR. No contacts in anterior region and and unstable occlusion in the posterior region. I decided to perform a selective grinding to reduce the overbite and to increase the number of occlusal contacts in the posterior region.
Fig.4
After the selective grinding, the overbite was reduced enough to achieve contacts in anterior region using direct restorations. Treatment would proceed as follows:
1. restore the posterior area
2. restore the proximal anterior restorations
3. additive composite on palatal for anterior contacts and dynamic movements
Fig.5
This article focuses on proximal and palatal restorations. After isolating with the rubber dam, the old proximal composites are clearly visible.
Fig.6
From the palatal view we see that we have to restore 11, 21, 22.
Fig.7
Cavity preparation. At this moment focus needs to be on defining cavity margins and on reducing the contact points.
Fig.8
Contact were removed to obtain a more accurate fit of the matrices.
Fig.9
To get the best anatomical fit to the proximal area, the matrix can be modified. I usually cut it to obtain a dropshaped matrix, as you can see in the image. As matrices, QuickMat Flex from Polydentia are a good option, as they are very flexible and thin, and keep their shape during manipulation, which is a mandatory characteristic for any matrix.
Fig.10
The matrix in position that also could be fixed with a wedge.
Fig.11
From this angle we can see the the matrix in its exact position. Its position should be adjusted until appropriate with regards to the proximal ridge of the lateral.
Fig.12
A flowable composite is placed in a thin layer and we press the matrix with the finger on the buccal side before light-curing.
Fig.13
Then, a small amount of enamel composite is placed to restore the proximal wall.
Fig.14
Then the rest of the cavity can be filled. Although, in this case, only an enamel shade was used, a body material can be very useful for this kind of cavities.
Fig.15
Next we go with the centrals. For a good management of the space between the centrals, two matrices are placed at the same time. The position is very important in order to create a restoration as close as possible to the natural shape of the proximal area.
Fig.16
The first central was restored starting with enamel as composite. Also a body material could have worked very nicely.
Fig.17
Both matrices were removed to finish the first restoration. In my opinion, at this stage finishing of the first restoration is better than doing it at the end, because we have a plenty of room and also to manage the proximal shape properly.
Fig.18
The proximal is finished. If the proximal area of the neighboring tooth is well designed, creating the contact point and fitting the matrix will be easier.
Fig.19
Occlusal aspect of the proximal restoration.
Fig.20
The same procedure was used for the other cavity.
Fig.21
Aspect after the primary finishing of the composite.
Fig.22
The result after rubber dam removal.
Fig.23
The proximal and palatal shape.
Fig.24
The proximal ridges were restored for anterior contacts and proper dynamics.
Fig.25
The final aspect with contacts in static and dynamic occlusion.
Fig.26
The final result and also edge to edge positions on centrals and canines.
Fig.27
The final result after finishing and polishing.
Conclusions
1. Understanding the natural aspect of the proximal area in anterior teeth and its relationship with the surrounding tissues is a very import asset for dentists in order to know how to restore it with any chosen technical procedure.
2. A design of the proximal matrix as close as possible to that of the proximal area will help the dentist to restore the specific area as easily as possible, with small final adjustments needed.
Bibliography
1. Martegani P, Silvestri M, Mascarello F, et al. Morphometric study of the interproximal unit in the esthetic region to correlate anatomic variables affecting the aspect of soft tissue embrasure space. J Periodontol 2007;78:2260–2265.
2. Somanathan RV, Simunek A, Bukac J, Brázda T, Kopecká D. Soft tissue esthetics in implant dentistry. Acta Medica (Hradec Kralove) 2007;50:183–186.
3. Chu SJ, Tarnow DP, Tan JH, Stappert CF. Papilla proportions in the maxillary anteri- or dentition. Int J Periodontics Restorative Dent 2009;29:385–393.
