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Post Orthodontic Rejuvenation

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.

The most common problems following orthodontically treated teeth are unusual function, shape, dimension color and caries as a problematic long term maintenance.
So sometimes restorative treatment of anterior teeth is required as the final step of the orthodontic therapy to optimize aesthetics and function. We are aware that during orthodontic treatment the patient is often unable to maintain good oral hygiene, both because of difficulty in brushing properly, but especially because of the impossibility of flossing, resulting in food accumulation which obviously lead to enamel demineralization, discolorations and interproximal caries. In this article, we’ll show how we brought a young patient’s smile to its youth by restoring the biological health and aesthetics using direct composite restorations.

Teeth with gingivitis and multiple caries style italiano styleitaliano

Fig.1
A 17-year-old female came to the dental clinic complaining of gingival inflammation, discolorations and proximal decay after finishing an orthodontic treatment. She wanted to have a beautiful and natural teeth. The treatment plan included patient motivation to improve oral hygiene, and removal of caries and discolorations without any shape or color modifications in a minimally invasive approach.

Rubber dam isolation of anterior teeth style italiano styleitaliano

Fig.2
Rubber dam isolation with floss ligatures is mandatory during work to have a clean environment free from contaminants and a clear vision during the procedure.

Clean cavities under rubber dam isolation style italiano styleitaliano

Fig.3
After removal of proximal and buccal caries, and beveling around large proximal cavities, enamel is sound and clean, and ready to ensure a perfect seal between the restorations and tooth structure.

Acid selective etching style italiano styleitaliano

Fig.4
Etching the entire surfaces proximal and labial with careful selective etching around proximal cavities for 30 seconds, and washing with water for 60 seconds to ensure complete removal of the etching gel residues.

clean and bonded cavities ready for composite restoration style italiano styleitaliano

Fig.5
A universal adhesive is applied on the entire buccal surfaces and inside the cavities. Active rubbing of the adhesive ensures proper penetration of the adhesive. Light curing was then carried out for 60 seconds to ensure complete polymerization of the adhesive layer.

proximal matrices in place for class 3 cavity restoration style italiano styleitaliano

Fig.6
When restoring class III restorations its better to build the proximal walls first to create a box to facilitate adaptation of composite layers.
We used LumiContrast sectional matrices form Polydentia, which allow for good contrast and no light reflection thanks to the matte, blue surface.

sectional matrices used in anterior class III cavity filling style italiano styleitaliano

Fig.7
The high contrast between dark color of the matrices allows for a precise identification of the working area. The stain on the matrices cannot be scratched away and no particles can end up in the filling material or cavity. When restoring the labial surface, the convex side of the matrix is placed towards the labial and concave side towards the palatal.

proximal wall build up to restore class 3 cavities styleitaliano style italiano

Fig.8
After building the proximal walls using SI3 dentine shade WDB from Optident to make the box shape and just ready to be filled with composite.
And I always prefer to use dentine shade in the proximal walls so not to have an issue with the thickness of the material, as might happen when using translucent enamel shades.

dentin composite layered style italiano styleitaliano

Fig.9
After layering all dentine layers SI3 White Dental Beauty in the proximal boxes, the final enamel layer is placed onto the entire labial surface to restore the natural translucency and rejuvenate the labial surfaces. Light curing the dentin shade for at least 40 seconds, and the enamel shade for 20 seconds.

solo anterior spatula to model buccal surfaces style italiano styleitaliano

Fig.10
The LM SOLO Anterior from LM Arte was used for layering the E shade by WDB as a final layer for the entire labial surface.

straight end of solo anterior spatula for incisal modeling style italiano styleitaliano

Fig.11
We can use the straight end of LM SOLO Anterior to model the enamel layer at the incisal edge, controlling the handling and the adaptation of composite very well.

filled cavities before finishing style italiano styleitaliano

Fig.12
For the finishing, we used only one coarse disc, perio bur from the Styleitaliano Finishing Kit (by Komet) to create surface texture.

management of angle line finishing for symmetry of incisor group style italiano styleitaliano

Fig.13
The transitional lines or light lines can be drawn using a pencil. A caliper can also be used to measure the width on each tooth to create symmetrical proportions between the right and left side. The transitional lines can be easily finished using a small disc, because its flexible and can easily adapted in the proximal yellow areas to produce smooth continuous lines. I personally advise against using burs in this phase, as they sometimes produce too much force during finishing, thus reating irregularities if not controlled well.

highlighting surface anatomical features of dental restorations style italiano styleitaliano

Fig.14
We can use the Perio bur from the StyleItaliano Finishing Kit at low speed to make secondary and tertiary anatomy.

finished composite restorations before polishing style italiano styleitaliano

Fig.15
For pre-polishing, we used the beige spiral wheel from 3M. This tip has flexible ends which can adapt to all surfaces, including proximal and labial. Moreover, it can easily smoothen and pre-polish the surface texture without removing the surface details.

composite polishing paste and star felt style italiano styleitaliano

Fig.16
As a last step, the Lucida™ Composite Gloss System by Styleitaliano was used. The disposable Lucida Star Felt is mounted on the autoclavable latch mandrel to buff
the DiaShine Lucida Paste (completely water soluble).

glossy composite surface after polishing style italiano styleitaliano

Fig.17
Immediately after the final polishing with Lucida. Note the symmetry of the transitional, light lines and the high surface gloss.

teeth restored with direct composite restorations style italiano styleitaliano

Fig.18
One week follow-up.

smile restored with composite resin style italiano styleitaliano

Fig.19
6 months follow-up.

Conclusions

The aim of a post-orthodontic restorative treatment is to optimize the integration between biological health, function and aesthetics, be it by direct composite restorations, dental re-contouring or bleaching. Direct composite is an affordable, minimally invasive option which can often be only additive, thus being the ideal solution for our patients.

Bibliography

1. Morley J, Eubank J. Macroesthetic elements of smile design. J Am Dent Assoc 2001; 132: 39–45.
2. Blitz N. Criteria for success in creating beautiful smiles. Oral Health 1997; 87: 38–42
3. Devoto W, Saracinelli M, Manauta J. Composite in everyday practice: how to choose the right material and simplify application techniques in the anterior teeth.
4. Manauta J, Salat A. Layers, An atlas of composite resin stratification., Quintessence Books, 2012.
5. Villarroel M, Fahl N, De Sousa AM, De Oliveira OB Jr.Direct esthetic restorations based on translucency and opacity of composite resins. J Esthet Restor Dent 2011;23(2):73-87.
6. Manauta J, Salat A, Putignano A, Devoto W, Paolone G, Hardan LS. Stratification in anterior teeth using one dentine shade and a predefined thickness of enamel: A new concept in composite layering – Part II. Odontostomatol Trop 2014; 37(47): 5-13
7. Blitz N. Criteria for success in creating beautiful smiles. Oral Health 1997; 87: 38–42
8. Hosaka K, Tichy A, Motoyama Y, Mizutani K, Lai WJ, Kanno Z, Tagami J, Nakajima M. Post-orthodontic recontouring of anterior teeth using composite injection technique with a digital workflow
9. Nordquist GG, McNeill RW. Orthodontic vs. restorative treatment of the congenitally absent lateral incisor-long term periodontal and occlusal evaluation. J Periodontol 1975;46:139-143.
10. Villarroel M, Fahl N, De Sousa AM, De Oliveira OB Jr. Direct esthetic restorations based on translucency and opacity of composite resins. J Esthet Restor Dent 2011;23(2):73-87.
11. Heintze SD, Rousson V, Hickel R. Clinical effectiveness of direct anterior restorations-a meta-analysis. Dent Mater 2015;31(5):481-95.

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