Keep it direct each time you can!

This young girl come to the office because of an ugly restoration on her upper left central incisor. She was not satisfied by the aesthetics of the old composite since the very beginning, but she was afraid because the previous dentist told her the only solution would have been to prepare the tooth for a complete crown. So she was trying to postpone the treatment, both for biological and financial reasons.
She finally took heart to face the problem, and came to us. First the root canal tretment was retreated, then an impression was taken in order to ask to the lab for a wax-up. A couple of days later, the old restoration partially broke, so she suddenly came to the office. Luckily we were able to set some free time in the agenda, to immediately treat her in a definitive way.

styleitaliano style italiano detail of old broken composite restoration

Fig.1
In this picture we can appreciate the old broken composite restoration on tooth 21, very matte and unmatched color. We can also see part of the temporary material used to close the endodontic access. On tooth 11 we can see a white spot. We tell her about the possibility of infiltrating it to erase it, without removing sound tissue, and she was enthusiastic about the idea.

rubber dam isolation before old composite removal styleitaliano style italiano

Fig.2
The use of the rubber dam is mandatory when we want to perfectly control the operative field during adhesive procedures.

cavity on central incisor after old composite removal styleitaliano style italiano

Fig.3
The old restoration and the temporary one are removed using a diamond bur.

post space ready to receive post restoration styleitaliano style italiano

Fig.4
The post space is prepared by removing the gutta-percha and sealant. No sound dental tissue is removed during this step.

cementation of fiber post styleitaliano style italiano

Fig.5
A large fiber post (DMG LuxaPost 1.5 mm) is tried in and then luted in the canal with a dual-cure resin cement (DMG PermaCem Universal) after using a dual-cure universal adhesive (DMG LuxaBond Universal).

palatal restoration after endodontic post cementation styleitaliano style italiano

Fig.6
The rest of the endodontic access is filled with composite (DMG Ecosite Elements Pure A2)

composite palatal shell styleitaliano style italiano

Fig.7
Since the original appointment had been scheduled in a couple of weeks, but the patient came as an emergency, we hadn’t gotten the wax-up from the lab. So the palatal shell was layered free-hand using a translucent composite (DMG Ecosite Elements Layer EL).

layering of dentin shade for direct composite restoration styleitaliano style italiano

Fig.8
The dentinal body is restored, leaving space for characterizations in the incisal third (DMG Ecosite Elements Pure A2).

working of raw composite to get internal dental anatomical features styleitaliano style italiano

Fig.9
A very translucent material (DMG Ecosite Elements Highlight INC) is applied in between the mamelons, to enhance the different opacities. Then an opaque mass (DMG Ecosite Elements Highlight OA2) is used for the incisal halo, and a white one (DMG Ecosite Elements Highlight W) to create some little imperfections, in order to give a more natural appearance to the restoration.

finished direct restoration of upper left central incisor styleitaliano style italiano

Fig.10
A final enamel layer (DMG Ecosite Elements Layer EL) is applied on the buccal surface.

etching white spot before resin infiltration styleitaliano style italiano

Fig.11
To treat the white spot on tooth 11, a completely non-invasive approach was selected. The key is DMG Icon Smooth Surface, an incredibly effective and unique kit to treat this kind of problems.

white spot disappeared after infiltration treatment styleitaliano style italiano

Fig.12
Contouring and finishing are performed over the 21 restoration, using diamond burs and discs. Then silicon tips are used for the first part of the polishing procedure on both the central incisors.

polishing with lucida gloss system paste styleitaliano style italiano

Fig.13
Final polishing is done with a diamond paste (LucidaTM Diashine)

glossy composite restoration styleitaliano style italiano

Fig.14
After final polishing.

composite restoration after rubber dam removal styleitaliano style italiano

Fig.15
The situation after rubber dam removal.

integration of composite direct class IV restoration styleitaliano style italiano

Fig.16
After 2 weeks the restoration appears very well integrated. The white spot on 11 has completely disappeared. The patient is completely satisfied and happy for saving sound structure.

before and after direct composite restoration styleitaliano style italiano

Fig.17
Before and after picture.

before and after dental restorative treatment styleitaliano style italiano

Fig.18
The smile before and after.

Conclusions

Maybe it’s because I really love making direct restorations in anterior areas, but I strongly believe that we should always try the direct way, whenever we have the chance. Of course sometimes indirect solutions are mandatory, or simply easier to perform, but especially in young patient always worth a try.
In this particular case, a complete crown preparation would have required quite an aggressive removal of sound structure. We should always think to the future: our restorations will not be all life long lasting, so we should preserve healthy tissue for the future replacement. Quoting Opdam et al. “Crowns have limited indications […], in most cases less invasive procedures options should be preferred”, and: “the operator’s skill in direct techniques is an important factor. Training in large direct composite should be part of the dental training program”.
So we should focus more and more on direct solutions, trying to master new technologies and new techniques, and training ourselves to improve our skills with direct restorations.

Bibliography

1- Manauta J, Salat A. Layers, An atlas of composite resin stratification. Chapter 5. Quintessence Books, 2012.
2-Devoto W, Saracinelli M, Manauta J. Composite in everyday practice: how to choose the right material and simplify application techniques in the anterior teeth. Eur J Esthet Dent. 2010 Spring;5(1):102-24.4.
3- Vichi A, Fraioli A, Davidson CL, Ferrari M. Influence of thickness on color in multi- layering technique. Dent Mater 2007;23:15841589
4- 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
5- Njm Opdam, R Frankenberger, P Magne. From ‘Direct Versus Indirect’ Toward an Integrated Restorative Concept in the Posterior Dentition. Oper Dent. 2016 Sep;41(S7):S27-S34.

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