A clinical case by our Community member Dr. Omar Faez Alany
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Adhesive dentistry has developed notably, revolutionizing many aspects of restorative dentistry. Nowadays, dental adhesion and resin bonding are regarded as the biggest game-changers, not only in restorative dentistry but also in other branches of dentistry (1). This is also due to the versatility of composite materials, especially in the esthetic zone. Composite bonding procedures are considered the most conservative and least invasive to return missing, diseased, and deformed tooth structures to enhanced color, form, and function. Furthermore, the composite can be repaired easily in comparison to indirect restorations (2).
Facing patients unsatisfied with their smiles, or with their old composite restorations in the esthetic zone has become a daily occurrence in the dental practice. Still, sometimes, deciding between replacing and repairing old restorations is difficult, as they (or large portions of them) may clinically and radiographically be considered free of failure. Moreover, complete removal of the restoration inevitably results in a weakening of the tooth, unnecessary removal of intact dental tissues and repeated injuries to the pulp (3) wherever, repairs are suitable to increase the survival of restorations, and the repaired restorations last as long as replacements (4).
This 28-year old female complained about the unesthetic appearance of her anterior composite veneers, made about one year earlier due to multiple caries on both mesial and distal in most incisors teeth. After clinical and radiographic examinations, we found that there was no secondary caries. However, there was a loss of lustre, absence of proportions, unusual morphology, asymmetrical level of the gingiva, and overhanging of the composite. Because there was no secondary caries and the chief complaint of the patient was the esthetic appearance, the treatment plan was minimally invasive and included repairing the old restorations without complete replacement and gingvoplasty.
As a first step, we removed the overhung parts of restorations and did a gingivoplasty by using electrosurgery to correct the gingival levels.
A soft tissue-dedicated bur was used for correction in some areas after electrosurgery, also to bevel the cut margins.
After 2 weeks from gingivoplasty, we started the restorative procedure.
The buccal surfaces were slightly prepared with a coarse diamond bur, then the rubber dam was applied for adhesive procedures (5).
37% phosphoric acid was applied for 15 seconds as a cleansing agent, and at the same time to etch the exposed dental substrates.
Silanization of the margins of old composite by using Monobond Universal primer to increase the bonding strength between aged composite and the fresh composite(6).
Bonding of preparation surfaces by using self-etch 2-step Optibond XTR Universal Adhesive. The primer component is actively applied by rubbing for 20 seconds and air-dried for 30 to 40 seconds to terminate the etching reaction and ensure thorough evaporation of solvents. The adhesive is actively applied to the entire preparation with a micro brush, and a bristle brush is used to absorb excess adhesive, and distribute the adhesive homogeneously on the prepared surfaces.
A previously-fabricated silicone index was used to create the palatal shells. The Clear Enamel shade (Estelite ∑ Quick , Tokuyama) was used.
Sectional matrices were used to build the proximal walls using shade A1 (Estilate ∑ Quick, Tokuyama).
The dentin shade OA2 (Estilate ∑ Quick, Tokuyama) was used for covering the cervical third, while the dentin shade OA1 was applied over the first layer of dentin shade obliquely, towards the incisal margins and to create dental mamelons.
The final layer was both chromatic and achromatic enamel shades. The chromatic A1 used to cover the cervical and middle third, while achromatic enamel clear enamel used to cover the incisal third to show the underlying dentin mamelons.
After a quick finishing, a second session was scheduled two days later. A split dam isolation was used to have better access to the cervical area, while retracting lips for safety.
First, the transition line angles were finished by fine diamond bur, and then the discs, which were also used to correct the curvature of embrasures.
The pointed abrasive-impregnated brush Astrobrush (Ivoclar Vivadent) was used to smooth the interproximal contact areas, as it is intended to reach these areas easily.
After finishing primary and secondary anatomy, the pre-polishing and polishing procedures are done by rubber CLEARFIL Twist DIA polisher (Kuraray).
The final lustre was obtained by using super-snap buff disk (Shufo) with extra-fine polishing paste (1 μm aluminium-oxide paste (Prima-Gloss; Dentsply).
Final result after 1 week.
Before and after direct veneering.
The repairing of direct composite restorations may be a choice when it comes to staying minimally invasive, especially when the patient’s concern is about aesthetics only. Direct composite veneers may be preferable to ceramic veneers in patients with multiple old restorations in the aesthetic zone.
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2. LeSage BP. Aesthetic anterior composite restorations: a guide to direct placement. Dental Clinics of North America. 2007 Apr 1;51(2):359-78.
3. Özcan M, Barbosa SH, Melo RM, Galhano GA, Bottino MA. Effect of surface conditioning methods on the microtensile bond strength of resin composite to composite after aging conditions. Dental Materials. 2007 Oct 1;23(10):1276-82.
4. Kanzow P, Wiegand A. Retrospective analysis on the repair vs. replacement of composite restorations. Dental Materials. 2020 Jan 1;36(1):108-18.
5. Terry DA. An essential component to adhesive dentistry: the rubber dam. Practical procedures & aesthetic dentistry: PPAD. 2005 Mar;17(2):106-8.
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8. Dietschi D, Fahl Jr N. Shading concepts and layering techniques to master direct anterior composite restorations: an update. British dental journal. 2016 Dec; 221(12):765.