Smile improvement in a single appointment using direct restorations

A 50-year-old man came to our practice to improve the color of incisor 2.1 and the appearance of his smile. After explaining several treatment plans, the patient opted for direct restoration in a single appointment. Indeed, today clinicians have the opportunity to improve the smile with quick, simple and predictable methods. The direct method for making anterior restorations may be less predictable and less precise than indirect restorations or wax-up, but when accuracy of form is not the patient’s primary concern, or when the patient does not have a very specific idea in mind or is not a perfectionist, the direct method may be the right one.
Therefore, I proposed to the patient to improve his smile in one single. Many dentists would have prepared a wax-up in order to guide the restorations to improve the patient smile. Thanks the StyleItaliano clinical tips like the finger technique or the front wing technique the reliance on a wax-up to guide restorations is minimal. A few tricks and skills can make the difference, as long as we use them to simplify our work throughout each step of the procedure.

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styleitaliano style italiano direct composite restoration DMG Ecosite

Fig.1
Initial situation, the smile showed an unsightly appearance disliked by the patient who requested to improve its aesthethic.

styleitaliano style italiano direct composite restoration DMG Ecosite

Fig.2
The intraoral picture with PhotoMed’s half-cut photo retractors and Smile Line’s black contrastors (Flexipalettes) shows several old and infiltrated restorations and unsuitable tooth shapes and proportions.  Thus, the planned changes to be made during the three-hour appointment were as follows:

  • tooth element 1.2, shape modification and old composite removal
  • tooth element 1.1, proportion improvement, removal of old composite and shape modification
  • tooth element 2.1, removal of old veneer and proportion improvement
  • tooth element 2.2, removal of old composite and shape modification
styleitaliano style italiano direct composite restoration DMG Ecosite

Fig.3
Even if we do not have a wax-up, we need to have in mind a plan of future restorations. One of the views to keep in mind is definitely the occlusal view, which allows us to assess the thicknesses to be added or corrected.
Indeed, occlusal imaging is essential for planification, especially for two considerations:

  1. The pre-existence of old palatal restorations. Their presence and extent affects the duration of treatment, so old restorations must be removed.
  2. Through occlusal appearance the amount and thickness of the final restorations is decided.

Thus, in this case it was necessary to prepare mesial surfaces of 2.2 and 1.2. to align the incisors.

styleitaliano style italiano direct composite restoration DMG Ecosite

Fig.4
Total isolation with dental dam is a requirement for bonding procedures. Two W2A Ivory clamps on the first premolars were used to place the nic tone medium thickness dental dam. Maple wood interdental wedges (Polydentia) were applied to open the interproximal space and to push down the papilla and dental dam before removing old restorations. B4 clamps were used for extra cervical retraction in order to have better access for old composite removal.

styleitaliano style italiano direct composite restoration DMG Ecosite

Fig.5
The low speed bur was used to detect the margin of the old restoration. It’s available in 3 sizes (D3, D4 and D5) in the STYLE DIRETTO Kit, to be used as needed. The kit designed by the StyleItaliano team with Intensiv consists of several diamond and tungsten carbide burs. In addition, two cards are included in the kit showing how and when to use the kit.

styleitaliano style italiano direct composite restoration DMG Ecosite

Fig.6
Final view after the preparation and the removal of old restorations.

styleitaliano style italiano direct composite restoration DMG Ecosite

Fig.7
Following the principles of the Styleitaliano philosophy, attention should be paid firstly to the cavity and the preparation and then to the adhesive procedures. Selective enamel etching was performed for 20 seconds. After that, an universal adhesive (Ecosite Bond, DMG) was applied and cured for 60 seconds for each tooth.

styleitaliano style italiano direct composite restoration DMG Ecosite

Fig.8
Sometimes when it not possible to use the silicon index, the application of finger index technique can be useful to reproduce the palatal wall of the tooth with the composite. Altough the finger index is not the best method and is prefer to used only as a last resort, in some cases, it really is the only way one can proceed. For this reason, some guidelines were established to improve this technique, as described in Layers 2 book (quintessence ed., 2023).
In this case, the technique was used to restore the interproximal structures following the shape of the adjacent teeth. As a final and very important step, abrasive discs, strips, and low-speed burs were used to correctly correct and finalize the shape. After building the palatal walls, pause to see if the perfect emergence profile has been created correctly.  If not, you can modify or correct it. In this case, a simple metal finishing strip was used to modify the emergence profile of 1.1 because it was encroaching on the space of 1.2.

styleitaliano style italiano direct composite restoration DMG Ecosite

Fig.9
EM (Ecosite Elements, DMG) was used to create the palatal wall. Then an opaque mass, OA2 from Ecosite Elements, was applied to unify the color before proceeding with the coating steps.

styleitaliano style italiano direct composite restoration DMG Ecosite

Fig.10
Four Unica matrices were inserted into place and fixed with plastic wedges (Polydentia).These matrices were placed manually until the proper position and shape was achieved. Although positioning may initially seem time-consuming, it later saves time in recreating the marginal profile.
Once all the matrices were correctly positioned, some undercuts were highlighted between the matrix and the tooth, especially in the triangular teeth; then they were filled in to improve the anatomy and eliminate the black triangles.

styleitaliano style italiano direct composite restoration DMG Ecosite

Fig.11
Universal bonding (Ecosite Bond, DMG) was applied using a brush (Compo-Brush, Smile Line) on the remaining surfaces. The black synthetic fibres of the thin compo-brush tip allowed for extreme precision. Bonding was cured for 60 seconds per tooth. While bonding using DMG for 20 seconds is recommended, curing for 60 seconds ensures adequate curing.

styleitaliano style italiano direct composite restoration DMG Ecosite

Fig.12
After performing the contour restoration, the Unica matrices were removed. A very thin spaghetti-like composite with an opaque mass (pure B1, Ecosite Elements, DMG) was used and placed to create the incisal halo and define the incisal length and shape.

styleitaliano style italiano direct composite restoration DMG Ecosite

Fig.13
For the last enamel layer, a single increment of enamel composite was applied, covering the entire buccal surface. In order to recreate the natural convex contour , the convex side of the LM Arte Solo Anterior spatula was used, and then the cervical contouring was performed by gently applying the rounded tip of the spatula.

styleitaliano style italiano direct composite restoration DMG

Fig.14
View of the final restoration after the placement of enamel composite layer (EM, Ecosite Elements, DMG).

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dmg banner style italiano styleitaliano
styleitaliano style italiano direct composite restoration DMG Ecosite

Fig.15
After rubberd dam removal, using a pencil, the surface anatomy was drawn to characterize the tooth and recreate the surface texture and transition lines using a bur.

styleitaliano style italiano direct composite restoration DMG Ecosite

Fig.16
The picture shows the application of Lucida Gloss Composite System (Diashine, USA). The combination of the DiaShine Lucida™ Paste with Lucida Star Felt with mandrel was used to improve the gloss of the final restoration.

styleitaliano style italiano direct composite restoration DMG Ecosite

Fig.17
The final aspect after finishing and polishing procedures.

styleitaliano style italiano direct composite restoration DMG Ecosite

Fig.18
Final aspect of the patient new smile.

styleitaliano style italiano direct composite restoration DMG Ecosite

Fig.19
Follow-up of 1 week.

styleitaliano style italiano direct composite restoration DMG Ecosite

Fig.20
The new bonding systems allow us to offer smile improvements in an easy way in one appointment (three hours, from 12:00 pm to 15:00 pm). The priority is the management of the shape and anatomy, while the small characterizations can be performed subsequently during the control. Photographs, tools, matrices, and instruments are incredibly helpful in accomplishing this.

Conclusions

When the clinician needs to improve a smile characterised by old restorations, the first step is their modification or removal, the second step is tooth preparation and space management (with or without wax-up) and the third step is the simplification of the restoration using the Unica matrix.
Wax-up is useful but not mandatory. Indeed, thanks to the application of the right tools and materials, sastisfactory results can be achieved even without wax-up.
Nowadays, direct composite restorations represent a feasible and teachable treatment, with a predictable and satisfactory result for everyone.

Bibliography

  1. Monteiro P. The step by step in finishing and polishing: anterior direct composite restorations. 2017, Styleitaliano.org
  2. Devoto W, Saracinelli M, Manauta J. Composite in every day practice: How to choose the right material and simplify techniques in the anterior teeth. Eur J Esthet Dent 2010 Spring;5(1):102-24.
  3. W. Devoto, L. Vanini. Rifinitura e lucidatura dei restauri in composito. Il Dentista Moderno, Dossier, 5-13, 1999.
  4. Manauta J, Salat A, Monterubbianesi R, Tosco V, Devoto W, Orsini G, Putignano A. Advances in diastema closure and tooth shape change using direct composite restorations: the Front Wing Technique. Int J Esthet Dent. 2022 Nov 25;17(4):378-393.
  5. Villares CF. Diastema closure a single shade opacity aesthetic approach. 2019, Styleitaliano.org. Devoto W, Pansecchi D. Composite restorations in the anterior region: clinical and aesthetic performances. PPAD; 19 (8): 465-470, 2007.
  6. Devoto W. Clinical procedures for producing aesthetic stratified composite resin restorations PPAD, vol.14 n.7, 541-544 2002.

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