Single shade anteriors
Solving a broken tooth emergency can be a nightmare. We tend to complicate things too much. How could we achieve a fast, easy and high quality result? When getting to know certain rules, the choice is easy: in many cases, we can operate differently from the classic procedures in order to simplify workflow.
When light curing composites first appeared, there were not many shades to select. Even worse, generally speaking, there was only one opacity to choose from, and if a wider range was available, it was to only a very few privileged people. Those masses are the `body´ shades that we know today, a medium opacity composite which is designed to match the overall opacity of a tooth. In the mid 90s, many aesthetic composite kits appeared: for the first time, many clinicians around the globe started doing stratified composites which matched natural teeth in an amazing way, including color, opacity, texture and characterizations. This tendency relegated the single mass approach to a level of non-refined dentistry.
Acknowledging that the stratification is, and has been the state of the art during all these years, there are certain indications where the single mass approach is more convenient. These are very easy indications, suggested from the Styleitaliano group and are the following.
Indications for single mass restorations:
– Small restorations, as a small class IV or a little diastema
– Contained restorations, as class III or class V restorations
– Large-extended as large class IV especially if they have large or infinite bevel
Img. 1 – Patient came to our attention with an emergency of a broken restoration. The fractured old composite restoration on tooth 2.1, and the badly integrated restorations on 1.1 and 2.2, supposedly performed in the same procedure, made us think about a more comprehensive treatment which included the replacement of every old restoration.
As many of these emergencies require a quick fix of the broken tooth and sealing of the dentin, instead of sealing the dentin and programming a wax-up, silicon guide, etc… many times we opt to build-up the whole structure with a single shade. Corrections and enhancements can eventually be done in the surface layer to make them look `prettier´, but only if necessary.
Img. 2 – Color matching can be done with the Vita Shade Guide Classical, only if we have first checked that our body material matches the color of the VITA shade guide. Note that it is not common for this to happen.
Color matching is done before teeth are dehydrated and the focus of our attention is the healthy tissue and not the overall color of the tooth which has still much old composite that gives the appearance of a dark tooth.
Img. 3 – The isolated field. Rubber dam must be clean and perfectly inverted, not only to work in a pleasant field but to facilitate matrix and wedge placement and avoid infiltration.
Img. 4 – Composite removal is probably one of the most demanding stages, not only because of the time needed but of the concentration required to perform the stage without removing sound tooth structure as well. In this case we worked with abrasive discs and multi blade burs. For the final stage a medium-long bevel was performed and the preparation was polished.
Img. 5 – Old composite removal corroborated the presence of an enamel birth defect which was the reason for the previous restorations to be done.
Img. 7 – A universal bonding agent was used to perform the bonding stages with an etch and dry technique.
Img. 8 – Extended polymerization of the treated teeth was done.
Img. 9 – Note that the restorations are single mass, but multilayered. In this particular construction technique the build-up is of outmost importance rather than the color. While developing layers with a single shade technique, there is no need to develop very thin or precise layers, but we can focus on sealing and shape.
In this particular tooth, proximal walls were built taking advantage of the already existing enamel structure. For the tooth 2.1 we will develop a similar strategy.
Img. 10 – The vestibular wall is built independently and modeled with care, in order to leave the surface as flat and smooth as possible. Immediately, a quick finishing of the proximal walls is done, this way, it is easier to create the perfect space and shape of the proximal walls.
Img. 11 – This image of the palatal and proximal walls would be unacceptable for a multi color layering technique, as the walls are thick and imprecise. But dealing with one single mass this is not an issue.
The walls were performed using a slight amount of composite placed on the finger and using it as a palatal wall. Note that the operator has to tilt the tip of the finger in order to imitate the angulation of the tooth. After polymerizing the palatal wall, which is way too thick compared to the walls of the classical layering technique, we create the proximal walls with the use of posterior sectional matrices (Garrison Slick Bands). The remaining step consists in constructing the vestibular wall with the same color.
Img. 12 – Look how inaccurate the restorations are. We knew from the beginning that the finishing stage would be a little longer than usual.
Img. 13 – The finishing stage, as for the most part of our direct composites is carried out with a low speed diamond bur (Finishing Style Kit by Komet). Low speed allows us to have full control of the movements we make, and even if the grit is not fine, the surface remains very regular and smooth. Good lustre and polishing will come off if a precise finishing stage was done, though it is impossible to do perfect polishing without a proper `rough stage´.
Img. 14 – Pre polishing with brown spiral wheels (3M) and polishing paste (Premier Diamond Twist SCL).
Img. 15 – Polishing is performed with the second spiral wheel.
Img. 16 – Extra gloss is achieved with a buff wheel.
Img. 17 – Immediate outcome after rubber dam removal. No success or failure is granted at this stage. Checking is mandatory after rehydration. What might look good now could be terrible some days later.
Img. 18 – Surface texture and polishing.
Img. 19 – One month check-up.
Img. 20 – One month check up and picture taken without diffusers to appreciate the high gloss of the restorations.
Img. 21 – I would like to thank Dr. Walter Devoto, Prof. Angelo Putignano and Prof. Simone Grandini for the inspiration taken in cases like this image that made me strongly believe in this kind of approach.
Strategies like the Single Shade restorations can be the perfect solution in many situations. If we follow the right indications this could be a smart move in our clinical approach.
Should the patient require a better outcome, this same `single shade´ restorations can be corrected with a cut back and the addition of hyperchromatic masses, translucent effects and opaque colors in order to create heavy incisal effects. But most of the times neither the clinician nor the patient wish to do so, because the outcome is already perfect.