A clinical case by our Community member Dr. Agne Malisauskiene
Single tooth composite restoration is arguably the most difficult one in the anterior region. Composite resin offers a clinician reliable aesthetics and longevity [1-2, 4]. Shape, shade and texture are the cornerstones in aesthetic dentistry if the function is right. Once the shape and surface texture mimic natural dentition shade does not play a big role anymore. Light is reflected from the micro relief increasing value of the restoration . If surface texture in two central incisors looks alike, the “music of light” composes both natural tooth and restoration into one symphony.
Initial situation. Male patient was referred by his dentist to change old composite restoration. He is an anxious patient who has had some bad experience in the dental office in the past. Patient has had trauma and upper right central incisor was fractured. Tooth remained vital and composite restoration was placed 5 years ago. Now the patient would like to improve the aesthetics of his composite restoration.
The initial consultation was carried out, and records were collected. Vitality of tooth #11 checked. A decay on tooth #12 was detected. Patient was presented with treatment options including orthodontic treatment. However, patient refused orthodontics for now. He wants to change the composite on tooth #11 and treat the decay on tooth #12. In order to ﬁx canted midline little ameloplasty on #11 was carefully suggested. Even though ameloplasty is highly conservative and may lead to exceptional aesthetic results the patient refused because of his anxiety in the dental oﬃce . Written consent form for treatment and photography was signed and treatment was booked.
When patient presented for treatment photographs were taken the same day before, during and after the treatment. Firstly, shade analysis done with Rite-Lite 2 (Addent) by placing and curing composite buttons on the teeth.
As long as functional analysis was favorable, a silicone impression of upper anterior region was taken with silicone in order to use it as a stent for palatal shell. Some topical anaesthetic applied and a dose of 4% articaine administered to upper right anterior region. Initial isolation achieved by placing Optragate (Ivoclar).
In order to preserve the tooth structure and remove only composite without removing additional enamel or dentine the majority of old composite from tooth #11 was removed with burs, but the ﬁnal removal achieved with polishing discs, decay on #12 cleaned. Rubber dam placed from #15 to #25 with ﬂoss ties on #12-21 to achieve dry working ﬁeld.
Silicone index was cut with scalpel at the gum line in order to achieve perfect placement. #11 and #12 were etched and rinsed according to manufacturers instructions, “Prime and Bond Active” adhesive (Dentsply Sirona) rubbed into the tooth structure for 20 seconds, air-dried and light-cured. Class III on #12 restored with single shade Spectra A2 (Dentsply Sirona). Silicone key was used as a stent of #11 and Renamel Microhybrid shade MI (Cosmedent) was used for palatal shell, because of it’s translucency .
Spectra shades A3, A2 and A1 (Dentsply Sirona) were used as body shade and placed as artiﬁcial dentine to restore class IV defect on #11 and chromatic enamel Renamel Microﬁll shades A3, A1 (Cosmedent) carefully moulded as ﬁnal enamel layers and light-cured. Also #11 and #12 lightcured under oxygen block Oxygone (Cosmedent) .
Restorations were pre-polished and rubber dam removed to check occlusion. Once occlusion was adjusted it was a time for ﬁnal touches.
The most important part in this restoration was surface texture. Surface texture was copied from tooth #21 and carved with burs and polished using Enhance and PoGo (Dentsply Sirona) and Flexidiscs, Flexipoints, Flexibuﬀs and Enamelize paste (Cosmedent).
Due to the dehydration and soft tissue changes patient was booked for a recall in two weeks. Pictures were taken.
The final situation.
Composite resin technology oﬀers excellent aesthetic potential.
The key to success in the single tooth restoration lies in ﬁnalising the treatment. Carving composite to mimic natural tooth surface is essential. Replicating nature is dentist’s ultimate objective.
1. Ardu S, Braut V, Gutemberg D, Krejci I, Dietschi D,
Feilzer AJ. A long-term laboratory test on staining susceptibility of esthetic composite resin materials. Quintessence Int 2010 Sep;41(8):695-702.
2. Dietschi D, Ardu S, Krejci I. A new shading concept based on natural tooth color applied to direct composite restorations. Quintessence Int 2006; 37: 91-102.
3. Dietschi, Didier. Post-orthodontic restorative approach for young patients with missing anterior teeth: no-prep and ultraconservative techniques. In: Italian Journal of Dental Medicine, 2016, vol. 1, n° 1, p. 13-17.
4. Peumans M, Van Meerbeek B, Lambrechts P, Vanherle G. The 5-year clinical performance of direct composite additions to correct tooth form and position. I. Esthetic qualities. Clin Oral Investig. 1997;1:12-8.
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.