Rationale in Direct Anteriors

Everyone of us who faced a class four restoration, knows well that without a clear vision of the issue in performing direct anteriors, quite often the outcome is not as good as we desire.
Here is our way to reach an excellent result, just using one dentin and one enamel, applying an easy protocol with few tools.

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Fig.1
Pre-operative: The patient, female, 48 years old, required an esthetic improvement of her smile. She asked for the replacement of the old and incongruous restoration on 1.1

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Fig.2
Details of the preoperative situation: In the same session we chose the colors of the restoration checking those of the adjacent teeth, using 5500° Kelvin lights (Smilelite – Smile Line) and drawing a chromatic map of the tooth we have to copy.

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Fig.3
After the creation of a silicon index, which will be used to build the palatal wall, according to Lorenzo Vanini technique, we put in place the rubber dam, before the removal of the old filling and of the secondary decay under it. Ligatures can help in isolation.

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Fig.4
We have to protect the adjacent tooth with a matrix

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Fig.5
With a multiblade ball shaped bur the old restoration is removed, and the decay too. Then a ball shaped fine grained diamond bur is used to perform a short chamfer and to refine the prep on the enamel. Then with a Soflex disc (orange, medium grained) the enamel is smoothened cervically.

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Fig.6
We can use this silicone index in order to check the thickness of the enamel, it must be 0.5 mm. To simplify this procedure we have developed the Misura Instrument.

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Fig.7
A total etching procedure is performed for 15-20 seconds. The etchant is rinsed for the same amount of time, and the dentin is gently dried and not dehydrated.

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Fig.8
A primer is applied for 20 seconds, and bonding for 20 seconds too. It is gently dried and light cured for 40 seconds.

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Fig.9
With a translucent enamel we do the palatal wall with just one amount of material. Be careful to use a little bit of it just to have a thin wall. By the way you can do corrections if it becomes too thick with a bur and then use again the bonding before going on.

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Fig.10
The mesial surface can be done with an opaque material (the same dentin of the central build up) in order to underline the contrast between this frame and the translucency of the halo.

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Fig.11
The palatal wall and the mesial wall are done. You can see the thickness and the translucency of the palatal shell.

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Fig.12
The inner build up and the mamelons are done with an A4 dentin, due to the high chromaticity of the natural dentin of the median part of the two central incisors. A little space is left between the mamelons and the mesial surface done before, to apply the enamel mass which will give the contrast between the mamelons.

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Fig.13
A little amount of the same enamel used for the palatal wall is placed between the mamelons and the mesial surface and light cured for 40 seconds. This with a little of white stains put in place on the incisal edge in order to recreate the incisal halo.

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Fig.14
All will be covered with 0.5 mm of the same Translucent Enamel.

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Fig.15
Details after the finishing and polishing procedures done under the dam.

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Fig.16
Immediately post op. After the removal of the dam you can clearly see how dehydration distorts the color perception.

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Fig.17
After one week, the shade matches correctly and it does not need any correction.

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Fig.18
Details of the restoration on 11 one week post op.

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Fig.19
One year follow-up.

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Fig.20
One year follow up, details. It does not need any re-polishing.

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Fig.21
Two years follow up.

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Fig.22
Two years follow up, details.

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Fig.23
Three years follow-up.

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Fig.24
Three years follow up details. It requires a little polishing of the mesial-vestibular surface.

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Fig.25
Before and after the new finishing and polishing procedures.

Conclusions

This case that seems one of the hardest challenge in direct restorations, can be done quite easily just by following simple rules and application of few steps. This can lead us to reach feasible and repeatable results, that will last in time. Achieving this kind of results as in this clinical case, in one time without corrections, is a little more difficult. But the beauty of composites is that they can be modified, corrected and repaired in time. We can reach perfect result in a second session, changing colors and shapes if they do not satisfy us.

Bibliography

1. Paolone G., Orsini G., Manauta J., Devoto W., Putignano A., Composite Shadeguides and Color Matching. IJED, Vol 9, No. 2, Summer 2014
2. Manauta J, Salat A, Layers, an Atlas of composite resin stratification, Quintessence 2012
3. Vanini L, Mangani FM. Determination and communication of color using the five color dimensions of teeth. Pract Proced Aesthet Dent. 2001 Jan-Feb.
4. 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 Sep;37(147):5-13.
5. Betrisey E, Krejci I, Di Bella E. The influence of stratification on color and appearance of resin composites. Ardu S Odontology. 2015 Feb 5.

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