dark teeth under rubber dam isolation

Infiltration & direct restoration

Sometimes, in our daily routine, we just can’t relate to the beautiful, youthful, white teeth we see all over the internet. Sometimes patients don’t want us to turn their smile upside down, they just want an even, healthy-looking smile.

So, often for patient-related reasons, we might not be able give a full-mouth, smile makeover.

Yet, some innovative products allow us to be minimally invasive and to improve one’s smile. Because, in the end, the name of the game is to make the artificial look like natural.

old dark decayed teeth

Fig.1

This 52 years old male patient showed enamel defects, caries and bad old restorations in the upper frontal teeth. The old restoration on tooth 12 had secondary decay, teeth 13 and 21 class III caries, tooth 23 an enamel defect on the incisal third, and both central incisors had white and orange spots.

dark decayed teeth with caries

Fig.2

We wanted to manage this case with direct restorations, in order be less aggressive and to contain costs. Covering such big and heavy discolorations is nothing but easy, especially if you don’t want to prepare the teeth thus removing sound structure. So we decided to exploit the infiltration technique to reduce the discolorations prior to restoring, to make composite layering easier.

patient with ugly teeth smiling

Fig.3

The smile of the patient.

blue rubber dam isolation with floss ligatures

Fig.4

Rubber dam isolation is mandatory to perform adhesive procedures.

messia cavity on central incisor

Fig.5

We started removing decay from the centrals.

distal cavity on lateral incisor

Fig.6

The we removed the old restoration on distal 12.

water sandblasting for cavity cleaning

Fig.7

A smooth sand blasting (Aquacare) is very helpful to enhance the infiltration.

icon etch dmg application tip for green gel

Fig.8

The first step of the infiltration protocol with DMG ICON is the etching. Icon Etch is applied for 2 minutes directly onto the discolorations, then thoroughly washed and dried.

alcohol application on etched discoloration

Fig.9

Icon Dry is perfect to pre-visualize the final outcome of the infiltration. If we are not satisfied, we can dry it and repeat the etching process.

icon etch gel on discolorations

Fig.10

A new application of Icon Etch for 2 minutes, followed by rinsing and drying.

alcohol application for infiltration pre-visualization

Fig.11

The second pre-visualization is more satisfying, and we already planned to make a composite direct veneer, so we can remove Icon Dry and proceed to the third step.

icon infiltrant resin application

Fig.12

Icon Infiltrant is a very fluid resin (TEGDMA) which can deeply penetrate to change the appearance of the discoloration. Icon Infiltrant is applied for 3 minutes and then light cured.

fine grain feather edge bur for smoothening enamel

Fig.13

Smoothening and beveling of the enamel.

acid etching gel for bonding adhesion to enamel

Fig.14

Total etch adhesion is performed on teeth that were not treated with Icon.

transparent matrix for palatal composite layering

Fig.15

The silicone key can be a great help to layer composite, but if you don’t have it you can easily make the first palatal layer (DMG Ecosite Elements EM) using a transparent matrix and your finger.

transparent matrix for composite restoration of lateral incisor

Fig.16

The first palatal shell on 12.

layering of composite to restore lateral incisor

Fig.17

It’s very important to get opacity right. A translucent restoration would turn grey, lowering the value. DMG Ecosite Elements A3 is layered to build up the tooth.

third class restoration on central incisor

Fig.18

The small class III cavity on 21 is filled with DMG Ecosite Elements A3, leaving about 0.5 mm for the final enamel layer (DMG Ecosite Elements EM).

opaque composite with fissure instrument for staining

Fig.19

The orange discoloration on the left canine was very intense, so we decided to apply a drop of a very opaque mass (DMG Ecosite Elements OA2), followed by an A3 mass (DMG Ecosite Elements A3).

enamel layering with composite

Fig.20

A thin layer of enamel (DMG Ecosite Elements EM) was applied all over the buccal surfaces in order to make a complete direct veneering.

pencil marks for composite surface texturing

Fig.21

Highlighting the transition lines with a pencil is very helpful to properly plan finishing and polishing procedures.

final result after direct veneering

Fig.22

Right after rubber dam removal.

composite veneers after rehydration

Fig.23

At check-up we could appreciate the good integration of the resin and the natural outcome.

before and after direct veneering with composite

Fig.24

Before & after

Conclusions

In cases like this one, it could be easier to rely on the indirect approach. Handling discolorations, changing shapes, and achieving a natural outcome would seem very easy, but we’d need to be a little bit more aggressive and the treatment would hence become quite expansive. On the other hand, following the direct approach can be tricky, but we can save sound structure and save money too. Having the chance to use infiltration is of great help, in order to reduce the entity of the discolorations and be more effective with a little composite.

Bibliography

1. Manauta J, Salat A, Putignano A, Devoto W, Paolone G, Hardan LS. Stratification in anterior teeth using one dentine shade and a predefined thickness of enamel: A new concept in composite layering – Part II. Odontostomatol Trop 2014; 37(47):5-13
2. Tirlet G, Chabouis HF, Attal JP. Infiltration, a new therapy for masking enamel white spots: a 19-month follow-up case series. Eur J Esthet Dent. 2013 Summer; 8(2):180-90.
3. Meyer-Lueckel H, Chatzidakis A, Naumann M, Dörfer CE, Paris S. Influence of application time on penetration of an infiltrant into natural enamel caries. J Dent. 2011 ; 39(7):465-9.
4. Manauta J, Salat A. Layers, An atlas of composite resin stratification. Chapter 5. Quintessence Books, 2012.