Management of fractured central incisor with direct composites. Using the right instruments for essential steps

A clinical case by our Community member Dr. Nisha Deshpande

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.

A vast number of techniques and instruments are available today for use with direct composites. So much variety can sometimes be confusing for a clinician who may end up stocking his inventory with items which seldom prove useful.
Many times, clinicians find it daunting to remember which instrument to use for which step while doing direct composites.
Sometimes, less is more. It is far more beneficial to use fewer instruments, as long as in the right sequence, so that the final result is not compromised. This case was done with the objective of using as few instruments as possible to achieve a similar result, as far composite modelling is concerned. This enabled us to achieve a predictable step by step workflow, which is the need of the hour for daily dentistry.

styleitaliano style italiano smile with broken tooth

Fig.1
Pre operative smile shows a fractured right central incisor. The patient would be undergoing orthodontic treatment soon and wished to have the tooth restored before starting with his orthodontic treatment. Tooth 11 had been root canal treated and, considering the patient’s age of 15 years, it was decided to restore the fractured tooth with a direct technique.

styleitaliano style italiano fractured right upper incisor

Fig.2
Pre operative intraoral photograph.

styleitaliano style italiano button try composite shade selection

Fig.3
Shade was selected quickly with the composite button-try technique. A simplified approach for layering was decided with A2 Dentin shade and A1 Enamel shade (Style Italiano Simplified Layering technique and Recipe) Composite material used is Filtek Z350 XT by 3M.

styleitaliano style italiano isolation with floss ligature and teflon tape

Fig.4
Isolation of the tooth to be restored with rubber dam is mandatory for achieving a predictable bond of the restoration to the tooth. Additional retraction was done with the help of floss ties.
A 3 to 4 mm wide bevel was placed at the fracture line to ensure a seamless and well blended final restoration. The bevel was polished with a coarse disc (Shofu Snap on Disc). The adjacent teeth were covered with Teflon tape.

styleitaliano style italiano acid etching of fractured incisor

Fig.5
Etching was done for 20 seconds with 37% orthophosphoric acid and rinsed well with water.

styleitaliano style italiano microbrush applying bonding agent on enamel

Fig.6
A bonding agent (Scotchbond Universal, 3M) was applied in multiple coats, air thinned and photocured.

styleitaliano style italiano LM arte solo anterior spreading composite on mylar strip

Fig.7
To minimize the steps involved, a simplified approach was used to create the palatal shell. A flat and broad spatula, the Solo Anterior (LM Arte kit by Styleitaliano) was used to flatten the enamel mass of composite on a mylar strip against a hard surface like the occlusal mirror. Once the enamel was thin enough, it was carried to the mouth along with the mylar strip and placed against the palatal surface with finger pressure. This method allowed us to get a very even and thin palatal shell aided by the flat and broad shape of the Solo Anterior.

style italiano styleitaliano lm arte solo instruments
style italiano styleitaliano lm arte solo instruments
styleitaliano style italiano finger index for palatal shell construction

Fig.8
The Solo Anterior was further used to model the incisal edge of the palatal shell to mimic the shape oh the adjacent incisor. Once a suitable shape and thinness were achieved, the enamel composite was photocured. The mylar strip was supported by the finger the entire time.

styleitaliano style italiano application of flowable reinforcement to palate shell

Fig.9
As can be seen in this photograph, a thin and well shaped palatal shell was fabricated quickly, without the added step of a putty index and with just one instrument. A thin layer of flowable resin was placed at the junction of the shell and tooth with a thin tipped instrument, the Fissura (LM Arte kit by Styleitaliano) and photocured. This ensured good adaptation and sealing of the interface between composite and tooth.

style italiano styleitaliano lm arte anterior instrument
style italiano styleitaliano lm arte anterior instrument
styleitaliano style italiano palatal composite shell build with finger support

Fig.10
The perfectly sealed and adapted palatal enamel composite shell. The mylar strip can be carefully removed at this stage, but it is preferable to leave it till we adapt and condense the next layer. Light digital pressure can also be maintained palatally for additional support during condensation to ensure that the thin shell does not break.

styleitaliano style italiano misura instrument for excess dentin mass removal

Fig.11
Dentin mass shade A2 according to the previously decided recipe is applied and then calibrated with the help of the Misura instrument (LM Arte by Styleitaliano).
This leaves just the right amount of space for the final enamel layer which is 0.5mm.

styleitaliano style italiano applied composite mass for incisor restoration

Fig.12
The perfectly calibrated dentin mass. It must be thinner towards the incisal edge and ramped up towards the bevel where it will be thickest. This is to mimic the thickness of dentin in a natural tooth.

styleitaliano style italiano brushing composite resin

Fig.13
After calibration, it is now time to blend the dentin seamlessly and make the transition as smooth as possible. This is done with a brush (GC) and modelling resin (3M).

styleitaliano style italiano lm arte solo anterior modeling mamelons

Fig.14
Once again, the Solo Anterior is used to shape the mamelons. The thin and sharp edge and tip of the instrument facilitates this step.

styleitaliano style italiano proximal freehand build-up

Fig.15
The same instrument is then used to create the proximal walls using the Enamel shade composite.

styleitaliano style italiano side view of proximal composite contouring

Fig.16
The versatile Solo Anterior in action.

styleitaliano style italiano composite direct restoration before last enamel layer

Fig.17
After both proximal walls are complete, the final labial enamel layer can now be applied.

styleitaliano style italiano lm arte solo spreading enamel composite

Fig.18
The flat blade of the Solo Anterior along with the brush can be effectively used to blend the enamel composite well.

styleitaliano style italiano composite restoration before finishing

Fig.19
The final enamel layer is polymerized under glycerin gel.

styleitaliano style italiano finished and pre-polished composite direct restoration

Fig.20
Immediate post operative photo. We must always wait for complete rehydration of the tooth before evaluating and assessing the shade match.

styleitaliano style italiano lucida star felt polishing composite restoration

Fig.21
After finishing with rubber polishers (ShapeGuard, Diatech) the polishing was done with Lucida Polishing system (Diashine).

style italiano styleitaliano diashine lucida
style italiano styleitaliano diashine lucida
styleitaliano style italiano finished composite restoration at check-up

Fig.22
After 48 hours, the restoration appears to be well blended. Two shades and minimal steps but with the right armamentarium used effectively.

styleitaliano style italiano smile with restored upper right central incisor

Fig.23
Final smile.

Conclusions

Everyday dentistry must be repeatable and predictable. Only then can we achieve great results within a minimum amount of time. Using the right techniques and instruments goes a long way in ensuring that we have a predictable work flow to depend upon to deliver a consistent outcome.

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. Villarroel M, Fahl N, De Sousa AM, De Oliveira OB Jr. Direct esthetic restorations based on translucency and opacity of composite resins. J Esthet Restor Dent 2011;23(2):73-87.
3. Monteiro P. The step by step in finishing and polishing: anterior direct composite restorations. 2017 Styleitaliano.org
4. Shaalan O. Making class IV restorations predictable. 2020 Styleitaliano.org
5. Manauta J, Salat A. Layers, An atlas of composite resin stratification. Chapter 5. Quintessence Books, 2012.

RELATED CASES

Biologically Guided Simplified Anterior Restoration

A simplified layering technique with only two composite opacities can solve most of our anterior restorations, if we respect the biology and the shape of the restoration.