A clinical case by our Community member Dr. Shiraz Khan
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It is not often that a patient will present with a high smile line, a fractured central incisor, and a job interview in 2 days time. However in these circumstances it is critical to be able to understand the principles of layering and thickness control to be able to provide the patient with an immediate, satisfactory result.
Ordinarily, the workflow that I follow is to take an initial scan, have a wax up made, along with a silicone stent to help build the palatal shell. Without doubt, this is the most predictable method for restoring anterior teeth, irrespective of the number of layers that are likely to be used (1). However emergency situations, with time limitations sometimes require a more efficient, but equally effective approach.
The patient was provisionalised with a composite restoration on the upper right central incisor, whitening of all of the teeth and then returned for an ‘updated’ UR1 restoration, along with lengthening of the lateral incisors and canine riser restorations.
This case demonstrates a freehand palatal shell utilising clear strips to create the scaffold for which we choose to layer, and the use of a combination of materials to achieve the desired outcome.
The emergency situation. High lipline, mild incisal translucency and the patient does not like the lateral incisal shape. The patient had come in before this appointment for a consultation, but had the interim emergency of the old composite fracturing.
Immediate composite button try-in.
Isolation with rubber dam.
Isolation and etching with 35% phosphoric acid.
Bonding using Kerr Optibond FL (2-bottle primer and adhesive).
Freehand palatal shell using shade A1 (Venus; Kulzer) and opaquer (OLC; Venus, Kulzer) in the mid third, using a clear acetate strip and finger pressure to support the matrix. The challenge is ensuring the incisal edge position mirrors the adjacent tooth.
Provisional restoration with a subsequent single shade A1 (Venus, Kulzer). Now this was a provisional restoration which appeared mildly short incisally, which was taken into account for the definitive restoration.
Demonstrating the incisal edge position was kept relatively consistent with the adjacent tooth.
Provisional restoration in situ after 2 weeks of whitening and 2 weeks of having stopped whitening. The next visit was 4 weeks later in total. The. Restorations appears to integrate reasonably, but the patients value has increased.
Composite button try in with suspected shades to be used.
Re-isolated with rubber dam.
As we were happy with the palatal contour from the provisional restoration, I was happy to re-use this as the scaffold for our new layered composite restoration. This was air abraded along with etching the laterals and canines.
Teeth re-bonded with Optibond FL (Kerr).
Opaquer replaced (OLC; Venus, Kulzer) followed by B1 (Venus, Kulzer) to create a feint halo effect on the incisal edge. Furthermore the was used to lengthen the tooth.
The Optrasculpt (Ivoclar Vivadent).
The lateral incisors were lengthened to improve the smile profile, with canine riser restorations placed to ensure canine guidance in lateral excursions, protecting the anterior and posterior dentition.
Immediate post-op with some refinement required.
Final post-operative polished situation.
Final post-operative polished smile.
Although a wax up could have been created, the provisional restoration was undertaken with care trying to respect thickness control. This then worked as the perfect restoration to allow the patient to whitening before the definitive restoration. An appropriate treatment strategy was made, however the emergency situation changed our strategy for management in this case. In many ways it was opportunity to treat the emergency that allowed me to assess and plan the final restorations (post-whitening). The provisional composite was my diagnostic wax up.
Above all, respecting anatomy, the thickness of the materials, and combining different opacities of materials lead to a suitable aesthetic resultant importantly a happy patient.
1. Dietschi, D., Fahl, N. Shading concepts and layering techniques to master direct anterior composite restorations: an update (2017). British Dental Journal 221: 765-771.
2. Carey, CM. Tooth Whitening: What we know. J Evid Based Dent Pract (2014), 14(suppl): 70-76
3. Knosel, M., Attin, R., Becker, K., Attin, T. A randomized CIE L*a*b* evaluation of external bleaching therapy effects on fluorotic enamel stains. Quintessesnce International (2008); 39(5): 391-9.