From Gourmet to Fast Food Restorations. Indications for different levels of complexity.
A Gourmet restoration is the one that requires an extra effort, and some planification which means extra time. Usually we made them in young patients or when the patient deserves it, in fractures with presence of characterizations: white spots, incisal opalescence, incisal halo, or when the aesthetic demands are high.
The classical polychromatic restoration technique starting the stratification with a palatal enamel shell allows us to perform advanced characterizations in a simpler way as during the stratification it is easier to control the layers thicknesses.(1)
For limited costs and limited time we offer Street Food which for anteriors means single shade restorations or veneers. Quality is not under discussion on any offer to the patient. We offer good quality even in Street Food solution.
The intermediate solution would be the Trattoria dentistry. With only one enamel and one dentin we could offer really good optical quality restorations with incisal translucencies and incisal halos. It is a very good solution when you have some extra time to control thicknesses and you want to fulfill certain aesthetic expectations. There is one best solution for each situation and each patient and the dentist role is to understand which is that best one.
The cases below allow you to see two clinical cases in which we chose different levels of restorations, based on the patient’s needs.
Sofia, 6 years old, came one day to our clinic with her mother, with a simple fracture involving little or no dentin on tooth 11 and an extensive fracture involving considerable dentin on tooth 21. No pulp exposure occurred, so no RCT was needed. As an emergency treatment, disinfected the dentin using 2% pure chlorhexidine for 2 minutes, then polished the sharp enamel with a Soflex disc (3M). Then we sealed the dentin in order to avoid further bacterial filtration by enamel etching with 37% phosphoric acid (Etching gel, DMG) and adhesion with (Ecosite Bond, DMG) and light curing for 60 seconds. We planned another appointment. We proposed some planning in order to perform a Gourmet or High quality restoration.
From the occlusal view we can see that the limit of the fracture is partially subgingival on the palatal of 11, and that the centrals are not completely erupted. Palatal view is very important as it can dramatically change the treatment options available, depending on the limit of the fracture. Luckily for Sofia, the limit was perfectly reachable, so we only needed to place a retraction cord to make the margin accessible.
Our Gourmet planning meant a total time of 30 minutes, and it included three steps.
1. An initial picture from which I created my color map by decreasing brightness and increasing contrast of my initial picture, with a very basic simple software (Keynote, Mac).
This procedure will help you get a better sense of the inside of the tooth, meaning its inner characterizations. (3)
3. Isolation is often an issue with kids, as it’s hardly tolerated, and semi-erupted teeth make it hard to get for the dentist. This special silicone stent allows to overcome the rubber dam issue when working with children.
So we have the lab (DT Daniele Rondoni) wax-up the model, and fabricate a special silicone stent. Even though the lab work represents an additional cost, this is not significant in such cases, and usually parents understand the benefits and agree to the best option for the treatment of their child. Moreover, parents usually understand when they’re explained limitations of dealing with very young patients.
The small windows make the teeth accessible to restore, while the remainder structure allows the kid to comfortably bite the stent (7). In these situations the silicone stent allows to isolate and perform adhesive and layering steps at the same time.
The adhesive procedures were performed through the windows with the silicone in place. Etching of the enamel for 30 seconds with 37% phosphoric acid, and then rinsing thoroughly. Then the a dental adhesive (Ecosite Bond, DMG) was used following the manufacturer’s instructions.
A palatal shell of translucent composite (Ecosite Elements Enamel medium, DMG) was created with the silicone in place after the adhesive steps.
More opaque mass (Ecosite Elements Pure A2, DMG) was used in the place of the natural dentine. The dentin build up stop short of the incisal edge and shaped into lobes, leaving room for the incorporation of the opalescent mass (Ecosite Elements Incisal, DMG) and the more opaque and chromatic incisal halo (Ecosite Elements Pure A2, DMG) placed before the final enamel layer (Enamel Medium, Ecosite Elements, DMG) (2). In this stratification technique the most important thing is to leave the precise 0.5 mm spacing for the enamel layer, as it was the planned thickness. In order to do this we use the LM Arte Misura instrument.
With the Dual stratification technique (one dentin and one enamel) the key to make the final color predictable is thickness. The 0.5 mm enamel thickness plays an important role (4,5,6), and this is why the dual technique takes more time and effort than the other techniques, and mistakes are more frequent, especially in the hands of non experts.
Total treatment time: 2 hours.
– 30 minutes for planning, dentin sealing, impressions, shade guide and initial
– 1 hour for the bonding, layering and the finishing steps.
– 30 minutes for check-up and possible modifications.
This is an immediately post operative picture. Teeth were dehydrated and the aesthetic result could not be evaluated at this moment.
Picture of the check-up appointment, 1 week after treatment. The young patient and her parents were surprised with the result.
This young man Filippo came to the clinic with an enamel fracture on tooth 11, after opening a bottle of beer with his own teeth.
The missing part was small, so there was little or no space to create mamelons, characterizations or complex stratifications. In this kind of case a single mass approach is very indicated, and it’s what we like to call a Fast Food restoration.
With only one medium opacity color (Ecosite Elements Pure A3, DMG) we created a fast restoration (1 hour or less) without wax-up with optimal results.
Finishing and polishing are very important to offer a high quality restoration. Even in Fast Food restorations we always take 10 minutes for this stage to offer the quality. Low speed diamond bur (Perioset bur, Finishing Kit powered by Styleitaliano) allows to create an even surface, macro- and micro-texture.
The final gloss is obtained with fine-grit diamond pastes (Diashine Intra Oral polishing paste) and a felt wheel (Shiny F, Micerium)
The final result, less than one hour after he entered our office.
Very often Fast Food solutions happen to be the most appreciated ones, because they are fast and good-looking.
You can choose either Gourmet or Street food restorations for anteriors, you just need to understand when. You would probably choose a Gourmet Restaurant for a special occasion, for example for your wedding anniversary, or for your first date, or to go with someone you want to impress. In the same way, there is the perfect restoration for each patient. You’d choose a Gourmet restoration to restore your child incisor fracture and you would probably choose a street food restoration for an old patient with very monochromatic tooth that has never paid attention to his own looks.
Regarding the material the good material choice is the one that has the perfect recipe for your case, a color and translucency-opacity degree that matches the natural teeth that you want to copy. For the single shade restorations opacity is very important. In these cases, medium opacity (often named Body masses) which are usually less opaque than dentins, but more opaque than enamels, with certain degree of opalescence, is the perfect type of mass to use.
1) Vanini L. Light and color in anterior composite restoration P.P.A.D. 1996; vol 8, n 7; 673-682
2) Manauta J, Salat A. Layers: An Atlas of Composite Resin Stratification. Quintessence Publishing, 2013.
3) Salat A, Manauta J, Devoto W. Achieving a precise color chart with common computer software for Excellence in Anterior Composite Restorations. European Journal of Esthetic Dentistry, 2011