Minimally invasive old composite replacement

A clinical case by our Community member Dr. Wasan Al Maeeni

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.

In esthetic dentistry, achieving the perfect harmony is always a challenge obtained from the esthetic triad: shape, texture, and color.
For more than 50 years dentists worldwide have been using directly placed resin-bonded composite restorations to restore damaged anterior teeth. While such techniques are invariably more conservative of tooth tissue than indirect procedures, operative techniques using direct composite can be challenging and are considered technique sensitive.
Nowadays, esthetic outcome of the daily dental practice become one of the main demand of the patient. One should understand that the shade and shape are in the same importance for treating teeth in anterior area. In this article, step-by-step of replacing old composite fillings to new ones will be marked in order to make a brighter smile.

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Fig.1
A 26-year-old patient attend the dental clinic to enhance his smile in a simplified approach. He asked about full coverage crowns to end his suffering after many failure due to debonding or non-esthetic outcomes. Patient was complaining from the shape and shade of the restored teeth and the discoloration of the right lateral incisor since the Class III carious lesion.

style italiano styleitaliano Minimally invasive old composite replacement

Fig.2
First, the shade was selected before the dehydration of the tooth. In this case, a button try technique was used, and the choice was medium chroma of dentin and light enamel (GC Essentia).
For this the use of the camera with filters or a mobile phone with the help of Smilelite could be of great importance.
It is crucial to note that the digital shade selection is more useful than the visual shade selection. Further, the accuracy of dental shade matching is increased by using polarization photography. The use of cross-polarizing filter was the most standardized method for both communication and color assessment. The non-polarized tooth color images offered numerous glare designs on the surface of the tooth, which could be affected by the uneven distribution of saliva on tooth surfaces or roughness. Consequently, artifacts in tooth color image analysis will be produced. In juxtapose, a lack of glaring patterns was observed in the cross-polarized tooth color images.

style italiano styleitaliano Minimally invasive old composite replacement

Fig.3
Isolation of the treatment area and removal of the old restoration.
The major cause of grayish was the old metal pin used to increase the mechanical retention.
Nowadays, with the big revolution of the chemical bonding and the isolation, there is no need for any mechanical retention.

style italiano styleitaliano Minimally invasive old composite replacement

Fig.4
From another view there is secondary caries found during old filling removal (it is the second cause responsible for discoloration). Next, the excision of the caries from the right lateral incisor was started.

style italiano styleitaliano Minimally invasive old composite replacement

Fig.5
Other disadvantages of the pin:
– Dentinal micro fractures
– Lower fracture resistance
– Microleakage around the pin
– Perforation of the pulp or the external tooth structure
– Difficulty to achieve proper contour
In this case, there is no corrosion on the pin since it is gold plated.

style italiano styleitaliano Minimally invasive old composite replacement

Fig.6
Etched beveled enamel margin and dentin surface.
Enamel beveling is necessary to blend the color coming from the tooth to the composite.
The preferred method is featheredge bevel blended to the enamel surface; neither butt joint nor chamfer is desirable.

style italiano styleitaliano Minimally invasive old composite replacement

Fig.7
After adding multiple layers of bonding agent to enhance the bond strength, palatal shell is built by using high translucency enamel shade.
Proximal walls are built by using sectional matrices. The most important thing is the very good adaptation of composite on the wall of the band, in an attempt to eliminate the possibility of gap formation.

style italiano styleitaliano Minimally invasive old composite replacement

Fig.8
Starting to put dentin composite part from the bevel area to the incisal area after finishing the contour of the tooth.

style italiano styleitaliano Minimally invasive old composite replacement

Fig.9
Final layer is enamel which should be half the thickness of the natural tooth enamel in order to prevent lowering the final value, and to give the restorations the needed translucency and the opalescence properties.
Basically, finishing and polishing procedure is done by using fine diamond burs, sof-lex discs, enhance finishing system and eve twist polisher sequentially.

style italiano styleitaliano Minimally invasive old composite replacement

Fig.10
To maintain the color of the restoration, the patient should be advised to not brush vigorously but to adopt the correct brushing technique. Vigorous brushing can result in a change in the surface texture, wearing of the material and loss of enamel translucency in the restoration, which can alter the color and the final appearance of the restoration. Professional finishing and polishing at regular intervals and in-dental office and home maintenance are advised.

style italiano styleitaliano Minimally invasive old composite replacement

Fig.11
Before and after restoration.

Conclusions

By following a correct protocol and by having good skills, hard cases will be overcome. Furthermore, clinicians could obtain a very good outcome esthetically and functionally with a durable resin-bonded restoration.
To succeed with the treatment of this case the clinician need to:
1- Simplify the treatment plan by using direct composite restorations as minimally invasive restoration when compared to the indirect restorations.
2- Ensure good adhesion of the composite. In this case, there is no need for the mechanical retention (metal pins) since the big revolution of adhesive systems.
3- Master the finishing and the polishing protocols, in order to have the natural and the anatomical morphology as well as a stable color with time.

Bibliography

1. Manauta, J., & Salat, A. (2012). Layers: An atlas of composite resin stratification. Quintessenza Edizione.
2. Freedman, G. A. (2011). Contemporary esthetic dentistry. Elsevier Health Sciences.
3. Hardan, L., Bourgi, R., Cuevas-Suárez, C. E., Lukomska-Szymanska, M., Monjarás-Ávila, A. J., Zarow, M., … & Haikel, Y. (2022). Novel trends in dental color match using different shade selection methods: a systematic review and meta-analysis. Materials, 15(2), 468.
4. Dietschi, D., & Fahl, N. (2016). Shading concepts and layering techniques to master direct anterior composite restorations: an update. British dental journal, 221(12), 765-771.

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