Shape modification and restoring with medium translucency balanced composite

Composites – though being the most commonly used materials in dentistry – have been changing the approach in aesthetic treatment since they have been introduced and clinicians have a range of materials to choose from, based on their treatment needs. Non-vital anteriors are considered one of the biggest challenges in aesthetic treatment, which is why clinicians often prefer full or partial indirect ceramic restorations. In this article, through the choice of new composite materials, the lecturer points out that direct restorations could lead to successful aesthetic outcomes if correct techniques are applied, step by step.

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Fig.1
56 years old male came to the office to solve the dyschromia on 21, to modify 22 shape and his unaesthetic smile due to primary and secondary caries and inappropriate previous restorations.

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Fig.2
Palatal view showing primary and secondary decay on all the frontal group from canine to canine.

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Fig.3
The Xray shows a peri-apical inflammatory reaction on 21 combined with an overfilling on the coronal side of the root canal and some cavity infiltrations on all the incisor group.

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Fig.4
The new root canal treatment. TIP! Note that the guttapercha level was placed 2 mm below the bone crest to reduce root dyschromia and to perform a bleaching approach.

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Fig.5
We absolutely must prevent the external root resorption, which may be caused by an aggressive and/or incorrect bleaching procedure. This could be a very big problem, as when the process starts, it doesn’t stop until root fracture. External root resorption is caused by passage of the oxygen peroxides into the periodontal space through the dentinal tubules during the bleaching process. In order to prevent it we need to place a glass ionomer cement or a flowable composite at a correct apical-coronal level, in the pulp chamber, on the gutta-percha. To assess the right placement level we first measure the maximum probing depth and then we add it to the height of the crown.

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Fig.6
As you can see in this picture, the flowable material barrier was placed 1 mm coronally.

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Fig.7
A stable temporary restoration is performed before entering with the bleaching product.

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Fig.8
In the same appointment I started preparing all the cavities on 13, 12 and 11

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Fig.9
First of all, I strongly suggest you use a couple of colors using the material shade guide under a 5.500 Kelvin color lamp and to put on the vestibular side the amount of the material you think of using (because increasing its thickness increases the saturation of the color and the opacity), and to cure them, in order not to have mistakes caused by the photoactivator, before putting the dam on.

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Fig.10
So, after that, I chose the most appropriate shade.

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Fig.11
My personal suggestion is to approach all the cavities from the palatal side to save as much sound vestibular enamel as you can. With this method we can achieve a predictable color outcome. If necessary, we can use a drop of elastic flow placed on the internal side of the enamel wall to support it when it’s very thin and fragile.

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Fig.12
After having prepared the cavity with well defined and polished margins, I started with the adhesive steps.

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Fig.13
Using a 37% ortophosphoric acid with an etch and rinse technique on 13 and 12 small cavities, and with a selective enamel etching in the deeper ones on 11 (self etching technique)

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Fig.14
Thanks to the Universal adhesive system we can decide a different approach, using the same product, depending on the clinical situation.

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Fig.15
A single layer was used for all teeth, in this picture a palatal view.

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Fig.16
Buccal view.

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Fig.17
After a couple of weeks, the patient came back to the office to manage the restoration of 21 and the shape modification of 22.

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Fig.18
We suggest you cure all the chosen materials on the buccal side to have a better understanding of the optical behavior.

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Fig.19
In order to match the restoration color.

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Fig.20
Evaluate the color before removing the color try-in with the Eccesso instrument (LM Arte)

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Fig.21
Two body shades and one medium translucent enamel shade were chosen. A diagnostic wax-up was made on an extra hard plaster cast.

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Fig.22
The preparation of the enamel was limited to perfectly clean and finish the enamel margins. A rounded bevel was created on the buccal finishing line. Conversely, never make a bevel on the interproximal and palatal margins, as would be much more difficult to layer and finish.

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Fig.23
On tooth 2.2 we only worked in an additive way, guided by the silicone index and with no preparation at all.

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Fig.24
Palatal view showing the correct color and shape integration with correct contact interdental points.

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Fig.25
Final outcome after rehydration showing a reinforcement of the dental tissues, mandatory aspect in restorative dentistry.

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Fig.26
And the new smile of our patient. The patient was included in a schedule of recalls.

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Fig.27
Final X-ray check: we can appreciate the absence of cavities, the new endodontic seal and the different translucency areas on 2.1 and 2.2 done by the different densities of the composite masses.

Conclusions

The direct anterior restoration has always been a challenge for many dentists. As an opinion leader for many dental companies for the development of composite materials, I had the opportunity to work and to test different composites since 2004, and many times I spent a lot of time to understand their optical properties, with a relevant learning curve to achieve nice restorations.
With this new medium-translucency balanced composite it was “love at first sight”. It’s very easy to match the color and to hide margin preparations, despite the use of a reduced number of shades, and to achieve predictable and high quality results every day both from an aesthetic and a clinical point of view.

Bibliography

M.Saracinelli IJED Volume 11 Number 2 Summer
Vichi A. et al. Influence of thickness on color in multi-layering technique. Dent. Mater. 2007 Dec 23(12);1584-9. Epub 2007 Sep 6
Influence of Different Enamel Shades and Thickness on Chroma and Value of Dentin Vita Shade:
Hajira NS, Metha D, Ashwini P, Meena N, Usha HL.An in Vitro Comparative Assessment Study.
PMID: 26067734
Odontology, 2015 Feb 5. ( Epub ahead of print ) The influence of stratification on color and appearance of resin composites. Betrisey E, Krejci I, Di Bella E, Ardu S.
Layers J.Manauta A.Salat An Atlas of composite resin stratification
W. Devoto: Clinical procedure for producing aesthetic stratified composite resin restorations PPAD 2002, 541-543vol14 n.7
W.Devoto, M. Saracinelli, J. Manauta? Composites in every day practice: How to choose the right material and simplify application techniques in the anterior teeth JEAD, Jan. 2010
Ryan EA, Tam LE, McComb D. Comparative translucency of esthetic composite resin restorative materials. J Can Dent. Assoc. 2010;76:a84
Arimoto A, et al. Translucency, opalescence and light transmission characteristics of light-cured resin composites. Dent Mater. 2010 Nov;26(11):1090-7
Ryan EA, Tam LE, McComb D. Comparative translucency of esthetic composite resin restorative materials. J Can Dent Assoc. 2010;76:a84
Fahl N. Jr. Single-shaded direct anterior composite restorations: A simplified technique for enhanced results. Compend Contin Educ Dent. 2012 Feb;33(2):150-4
Dent Mater. 2014 May;30(5):493-8. doi: 10.1016j.dental 2014.o2.002. Epub 2014 Mar 3. The influence of varying layer thickness on the color predictability of two different composite layering concepts.
Manata 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 1 Pub : Odontostomat Trop. 2014 Jun;37(146):5-16 Part 2 Pub : Odontostomat Trop. 2014 Sep;37(147):5-13

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