enamel etching on central incisor with unica matrix Introduction

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.

poor hygiene and decayed teeth

Fig.1

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.

multiple caries on upper arch

Fig.2

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.

x-ray showing apical radiolucency lesion

Fig.3

An X-ray was taken, which showed an asymptomatical periodical lesion on tooth 11 and caries.

suture after crown lengthening surgery

Fig.4

After crown lengthening surgery.

k-file with apex locator in central incisor after rubber dam isolation

Fig.5

On the same working session, RCT of tooth 11 was performed.

final x.ray of root canal treatment

Fig.6

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.

plaque detector for cavity cleaning from caries

Fig.7

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.

clean cavities under rubber dam isolation and ligatures

Fig.8

Cavities after cleaning.

occlusal view of clean cavities

Fig.9

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.

enamel etching with orthophosphoric acid

Fig.10

Etching of the enamel was carried out with 37% phosphoric acid, following an etch and rinse protocol.

compobrush for layering adhesive

Fig.11

Applying many layers of universal adhesive until a shiny surface is achieved.

lm arte fissura to model composite

Fig.12

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.

Fig.13

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.

opaque stain for natural looking composite restoration

Fig.14

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).

compobrush smileline for anterior composite restoration

Fig.15

A very thin (approx 0.3-0.4 mm) low value enamel composite was laid on the stain using a soft brush.

light curing under ultrasound gel

Fig.16

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.

unica matrix for anterior composite restoration

Fig.17

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.

etching with the protection of unica matrix

Fig.18

The ideal shape of the Unica matrix also helps protect adjacent teeth during the steps of etching and adhesion.

bonding protected by unica incisor matrix and wedges

Fig.19

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.

shape built with composite thanks to unica incisor matrix

Fig.20

Once the cavity is outlined, it is possible to focus on building up the rest of the restoration.

layering of composite masses on central incisor

Fig.21

The Unica matrix was then replaced by a sectional one to have better visibility while layering.

final shade characterization with white stains

Fig.22

Using the same composite masses and stain.

diamond wheel polishing of anterior composite

Fig.23

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.

glossy anterior composite fillings on incisors

Fig.24

The final outcome.

palatal fit of composite restorations

Fig.25

In the end, the polished restorations, had a surface very similar to that of a natural teeth.

final xray for composite seal verification

Fig.26

Similarly, the X-ray shows a very nice root canal and coronal seal.

final aspect of multiple incisor composite restorations

Fig.27

Patient came to the check-up appointment showing a completely different smile.

smile restored with composite

Fig.28

This case was brought to a stable, conservative, healthy state, which could be, in the future, the base for a more complex prosthodontic approach.

smile with restored teeth

Fig.29

The patient’s satisfied smile.

Conclusions

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.

Bibliography

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