Re-establishing a patient’s natural dental esthetics is one of the most requested and important topics of today’s dentistry. Many patients with a diastema complain it affects the aesthetics of their smile. In addition to function and phonation, color, shape, and structural and position abnormalities of anterior teeth might lead to important esthetic problems for patients. In order to solve such problems, the most frequently preferred solution is full coverage by means of dental crowns, which requires a very aggressive approach. In this case report the Authors, according to the philosophy of the Styleitaliano group, want to drive all the colleagues through a simplified approach system directly to the final outcome, with an appropriate working time.
Direct composite restorations are today feasible and teachable, and being efficient and predictable are a must for any practicing clinician. Additionally, direct composites provide functional, long lasting, and esthetically pleasing results in the most conservative fashion. New materials on the market require a completely new approach if want to be successful with them.
Fig.1
A female patient, 55 years old, came to the office complaining about her smile and the big black triangle. She asked to get a fast and easy solution to improve her smile. After clinical evaluation, we decided to perform a no prep shape modification on mesial 21, and mesial and distal 11, with a direct veneering of tooth 12.
Fig.2
Field isolation, inverting the rubber dam to improve access to the cervical areas of the teeth, and to better manage the emergence profiles.
Fig.3
The old composite third class restoration on tooth 12 was removed by just sandblasting the surface with 53µm Aluminium Oxide (AquaCare). No anesthesia was needed.
Fig.4
After cavity preparation the new Unica Mini Deep matrix was used to restore tooth 12. This matrix perfectly hugs the cervical and interproximal margins, especially of smaller teeth. This is a significant help as it makes final shape predictable, allowing for time management and limiting chair time. We can exploit a complete contour in just one step.
Fig.5
It’s mandatory to check the matrix fit from the occlusal.
Fig.6
The Unica Mini Deep matrix was kept in place during the whole adhesive procedure, starting with etching of the enamel surface with 37% H3PO4 (Coltene Etchant Gel), for 20 seconds.
Fig.7
The the surface was bonded using a universal adhesive (Coltene One Coat 7 Universal). Keeping the matrix in place helps to avoid accidental contamination of the adjacent teeth during the adhesive procedure.
Fig.8
95% of the restoration on teeth 12 was made using a single shade (A3/D3, Brilliant Everglow, Coltene) using a spatula and brushes (Styleitaliano LM Modella & Styleitaliano CompoBrush). The color was chosen in the preliminary investigative phase, before putting the dam on, before teeth dehydration.
Fig.9
The new LM Arte Modella Dark Diamond non-stick edition which offers the great sensitivity and flexibility of stainless steel with a non-stick coating to improve composite handling.
Fig.10
A very thin high-value enamel composite layer (0.3-0.4 mm approximately), was spread over the A3/D3 mass to increase the depth and the brightness of the restoration.
Fig.11
Using a very soft brush to follow the already designed anatomy and contour.
Fig.12
The enamel mass was cured for 40 seconds with an high power multi-led lamp (Spec 3, Coltene).
Fig.13
Once the restoration was complete, a 60-second final curing under glycerine was carried out. This step prevents oxygen from inhibiting the outer layer of composite from completely being cured.
Fig.14
Air abrasion of teeth 11 and 21 using Aquacare (29µm aluminium oxide particles) was carried out. The purpose of this step is cleaning and improving the bond strength.
Fig.15
Enamel etching using 37% H3PO4 for 30 seconds, followed by a 60 second rinse. This is very important to ensure that all the etchant is washed off the tooth surface.
Fig.16
The etched area should be a little larger than the working area, to get the best bond strength quality, and the transition between composite and tooth surface.
Fig.17
Bonding with One Coat 7 Universal (Coltene). Multiple adhesive layers were applied until surface was shiny. Then the adhesive was air-blown until no movement was detectable on the surface.
Fig.18
Light curing for 40 seconds.
Fig.19
The same composite mass used on tooth 12 was applied by using the new coated LM Arte Modella (LM Arte™ Dark Diamond non-stick edition, powered by StyleItaliano) to build the proximal walls, free-hand.
Fig.20
The buccal wings of both 11 and 21 were first modeled.
Fig.21
I work with composite until symmetry between the two incisors is satisfactory.
Fig.22
Two pre-contoured sectional metal matrices (Quickmat FLEX, Polydentia) were inserted vertically and stabilized by a plastic wedge to achieve a tight contact point.
Fig.23
Palatal view.
Fig.24
The cavities were then filled from the palatal by placing a drop of flowable composite (A2/B2 Coltene Brilliant Everglow) first, which was left uncured, near the proximal margin.
Fig.25
Then the palatal cavity was filled with packable composite.
Fig.26
As a last step, to improve symmetry, some packable composite was added on the distal buccal side of tooth 11.
Fig.27
Finishing started by refining the cervical margin using the StyleItaliano New finishing burs kit (Intensiv).
Fig.28
Then, macro and micro-texture were reproduced using the perio coarse grain bur (Styleitaliano New Finishing kit, Intensiv), at low speed, without any water, in order to obtain more light-reflecting areas and to enhance the final value.
Fig.29
Final polishing is mandatory to the esthetic success of the restorations, as a shiny smooth surface reduces plaque accumulation, and prevents the teeth from discoloring. The polishing is performed with a disposable felt charged with diamond paste (Lucida).
Fig.30
Final result after finishing and polishing, before removing the rubber dam.
Fig.31
Aspect from the palatal side.
Fig.32
Immediate post-op smile. The slight discoloration cause by dehydration will improve soon.
Fig.33
At check-up, two weeks later.
Fig.34
Two months recall. We can appreciate that the composite has integrated very well with the natural dentition and the papilla has filled the small gap.
Fig.35
Aspect from the palatal side.
Fig.36
X-ray aspect of the restorations.
Conclusions
The evolution of restorative materials, pushed by dental practitioners themselves, has led dental companies to the manufacturing of new composite masses with a balanced degree in terms of translucency that, based on the thickness applied, make it possible to appropriately masque both the preparation limit and the restoration itself, without resorting to complex stratification techniques and providing a good esthetic result with a limited number of shades at the same time.
The use of the Front Wing Technique can represent a useful solution for closing diastemas in a few steps. With non-invasive, purely additive, we can radically change patient smile.
Bibliography
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