Multidisciplinary approach in anterior multiple restorations
Re-establishing a patient’s lost natural dental esthetics is among the important topics of today’s dentistry, in addition to function and phonetics. color, shape, and structural and position abnormalities of anterior teeth might lead to important esthetic problems for patients. Sometimes aggressive approaches, like single tooth FDPs, are preferred in this situation. On the other hand, financial or time needs might require a direct approach. Luckily composite restorations are today efficient and predictable solution for any practicing clinician, as they can provide long-term function and aesthetics. Many dentists complain that direct anterior and posterior composites can be technique sensitive, difficult, time-consuming, and often financially unrewarding procedures. This may be largely due to the incorrect use of new materials on the market, which require a completely new approach to be part of a successful rehabilitation.
This male patient, 64 years old, came to the office asking for the fastest, less demanding and cheapest treatment. An examination of the gingival tissue revealed marginal gingivitis caused by the patient’s poor hygiene, and a large accumulation of bacterial plaque. Some cavity lesions were subgingival.
After a clinical and radiographic survey, we decided to perform the whole treatment in one single session. The treatment plan involved thorough cavity cleaning after surgical margin exposure, and direct restoration of the cavities, followed by a follow-up treatment schedule and re-evaluation before going for more estensive treatment options.
An X-ray was taken, which showed an asymptomatical periodical lesion on tooth 11 and caries.
After crown lengthening surgery.
On the same working session, RCT of tooth 11 was performed.
The gutta-percha was compacted up to 2 mm below the buccal bone ridge in order to reduce root discoloration, then a sealer was placed above the gutta-percha to achieve a correct immediate seal of the root canal.
After isolating the operative field with a medium weight rubber dam from tooth 14 to 24, cavity cleaning is performed thoroughly, using magnification and a caries detector to selectively remove decay.
Cavities after cleaning.
Margins were finished with a short chamfer on the buccal (to make the transition from composite to natural enamel invisible) and butt-joint preparations in the proximal and palatal.
Finishing of the preparation margins should be done with great care using silicone tips to smoothen the preparation and to remove unsupported enamel prisms. This last step is crucial to prevent these prisms from breaking light curing contraction, which would lead to a higher risk of infiltration.
Etching of the enamel was carried out with 37% phosphoric acid, following an etch and rinse protocol.
Applying many layers of universal adhesive until a shiny surface is achieved.
A 0.5 flowable composite layer was used on the bottom and the walls of the cavities to have a better adhesion conversion degree to act as an elastic liner on the cavity floor.
95% of the restorations on teeth 12 and 21 was made with a single shade composite mass, freehand using a spatula and brushes (LM Arte Modella, SmileLine CompoBrush, by Styleitaliano). The shade was chosen before putting the dam on, before teeth dehydration.
To achieve a better aesthetic integration and to imitate the neighbouring teeth, an opaque white stain was used and spread with a sharp instrument (LM Arte Fissura).
A very thin (approx 0.3-0.4 mm) low value enamel composite was laid on the stain using a soft brush.
A final 60 seconds light curing is performed under Ultrasound Gel, which isolates the surface from the outer oxygen. This helps the composite’s complete polymerization thus improving the surface wear resistance of the material.
To restore 11 we used the Unica matrix (by Polydentia), which is the best to perfectly fit the cervical and proximal margins at once. This matrix makes the shape of this kind of restoration predictable, less time- and energy-consuming.
The ideal shape of the Unica matrix also helps protect adjacent teeth during the steps of etching and adhesion.
The combined application of a stable stent and double sectional matrix allows the clinician to simply and intuitively manage even the most complex dental forms in a single step, thus optimizing both operative time and final results.
Once the cavity is outlined, it is possible to focus on building up the rest of the restoration.
The Unica matrix was then replaced by a sectional one to have better visibility while layering.
Using the same composite masses and stain.
Final polishing is mandatory to the estethic success of the restorations, as a shiny smooth surface dramatically reduces plaque accumulation. The polishing stage is performed with diamond spiral wheels and low speed under water irrigation.
The final outcome.
In the end, the polished restorations, had a surface very similar to that of a natural teeth.
Similarly, the X-ray shows a very nice root canal and coronal seal.
Patient came to the check-up appointment showing a completely different smile.
This case was brought to a stable, conservative, healthy state, which could be, in the future, the base for a more complex prosthodontic approach.
The patient’s satisfied smile.
The evolution of restorative materials has brought to us new composite masses capable of masking margins and mimicking, without the need for complex shade composition.
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