Large Class IV Restorations

A clinical case by our Community member Dr. Muhammed Bahadeen

This article and its content are published under the Author’s responsibility as an expression of the Author’s own ideas and practice. Styleitaliano denies any responsibility about the visual and written content of this work.

This patient presented to the clinic with a class IV fracture of both central incisors, and chipping of tooth 22, asking for a non-invasive esthetic treatment. A direct restorative approach was chosen and an impression was taken to get a wax up.

styleitaliano style italiano plate model of broken teeth

Fig.1
Impression was taken for creating a cast and perform the wax up.

styleitaliano style italiano silicone index of waxed up model

Fig.2
The silicone index was then fabricated on the waxed-up model to build a composite palatal shell.

styleitaliano style italiano composite color selection

Fig.3
Shade selection should be done within 3 minutes to avoid color mismatch due to tooth dehydration.

styleitaliano style italiano acid etching of enamel

Fig.4
Enamel is etched for 20 seconds.

styleitaliano style italiano try in of silicone index

Fig.5
Our silicone index is cut and we are ready to create the palatal shell.

styleitaliano style italiano bonding application on etched enamel

Fig.6
A 7th generation bonding agent was used for our restoration.

styleitaliano style italiano cleansing of spatula

Fig.7
The LM Arte Applica instrument by Styleitaliano was used for our layering. I like to clean the instrument with ethanol before starting, and between the layering steps to remove debris, and to prevent it from getting into the composite.

style italiano styleitaliano lm arte anterior instrument
style italiano styleitaliano lm arte anterior instrument
styleitaliano style italiano modeling liquid for composite modeling instrument

Fig.8
If the composite sticks to the instrument use a very little amount of composite modeling liquid. Too much liquid will create bubbles in the composite and during the finishing stage will appear.

styleitaliano style italiano palatal composite shells

Fig.9
The palatal shell is created using OBN from Enamel Plus HRi (Micerium), about 0.5mm to be rigid enough to resist breakage during the subsequent layering.

styleitaliano style italiano thin palatal composite build up

Fig.10
Lateral view shows there’s plenty of space for layering.

styleitaliano style italiano composite outline of class IV restorations

Fig.11
Mesial and distal walls are created using A2 Estelite Asteria (Tokuyama).

styleitaliano style italiano mamelon layering with composite

Fig.12
Dentin layer is applied and mamelons are recreated to give a natural translucency to the final restorations.

styleitaliano style italiano checking for buccal layer spacing

Fig.13
Occlusal check for the enamel spacing. An A2 enamel shade will be used.

styleitaliano style italiano translucent composite paste

Fig.14
The Applica instrument is used to place some translucent enamel composite on the incisal edges.

styleitaliano style italiano layered composite class IV restorations

Fig.15
Final work after placing the A2 enamel layer. Tooth 22 was restored before removing the rubber dam.

styleitaliano style italiano finishing of class IV composite restorations

Fig.16
Polishing strips (GC) were used to polish the mesial and distal walls.

styleitaliano style italiano pencil marks and bur for surface composite texture

Fig.17
Red coded rounded-end fissure bur was used to create surface texture, at slow speed to have a better control.

styleitaliano style italiano composite polishing paste and star felt

Fig.18
The Lucida polishing system was used to polish the restorations.

style italiano styleitaliano diashine lucida
style italiano styleitaliano diashine lucida
styleitaliano style italiano finished class IV composite restorations

Fig.19
Final result.

styleitaliano style italiano class IV polished composite restorations

Fig.20
One-week follow-up.

Conclusions

The restoration was done in two visits one visit for taking an impression and wax up, and the next visit for the restoration to provide accurate measurement for the restoration with proper shape and texture. Not every case can be done in a single visit some cases require more than a visit to provide the patient with the proper result.

References

Manauta J, Salat A. Layers: An atlas of composite resin stratification. Quintessence Pub, 2012.
Magne P, Belser UC. Biomimetic Restorative Dentistry. Quintessence Pub, 2021.

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