Any aesthetic treatment requires the practitioner to listen, understand and guide the patient based on his demand. Clinically examining the patient, together with taking x-rays and pictures is mandatory before taking action. In the following case, a young female patient came to the office to replace two old composite restorations on teeth 11 and 21, while maintaining the diastema. We know, thanks to material evolution, that 2 new composite resin restorations will reinforce the teeth and improve the aesthetics. Composite resin is today a great material which should be considered as permanent, as it can be repaired and corrected over our patient’s life, so that’s why it should be the first-choice material in this kind of treatment.
In this case, before changing the old composite resins, the patient underwent a 2-weeks at home bleaching treatment (White Dental Beauty 16% CP, Optident). We know that we have to wait for 2 weeks before restoring the teeth in order allow residual radicals to leave the enamel surface so as to ensure optimum bonding onto the bleached enamel, but also to make sure the color is stable.
The picture with retractors and contrastors (Flexipalettes, Smile Line) of the initial situation shows improper fillings, both in terms of color and shape. Modern dentistry enables us to rely on fast and simple protocols to reach a satisfying result. Proper planning and observation will help in choosing the best technique and the right composite material.
The cross-polarized picture shows opalescent and opaque areas. We need to choose materials that are able to mimic these optical properties. At this point we know that only one material won’t be enough to restore the mesial part of the teeth.
Color matching is not categorical between A1 and B1 that’s why we take a picture with light-cured composite samples on the teeth. For the button try we used B1 and A1 new Filtek Universal composite and some enamel (Filtek Supreme XTE A3E) and translucent (Filtek Supreme XTE CT) composite masses.
The button try is validated by cross-cross-polarisation (Polar Eyes, Bioemulation). B1 Filtek Universal is chosen and will be combined with XTE A3E and CT to create aesthetically integrated fillings.
The bacterial contamination of the dentin following a preparation or a non-sealed restoration is a biological reality that can lead to pathological consequences on the pulp. In addition, the presence of fluids such as saliva, blood, sulcular fluid or moisture in the exhaled air, will all reduce the bond strength. The operative field makes it possible to overcome these problems and also protects the patient from accidental inhalation (instruments, milling residues…) and improves the vision of the area to be treated by keeping the lips, the cheeks and the tongue away. The rubber dam is properly placed using a probe, a spatula, and some floss to invaginate all the edges to ensure a proper seal.
The old restorations were removed. The preparation consists of a buccal chamfer and flattening of the palatal and proximal surfaces. Polishing of the preparation completes the sequence.
After the preparation, the silicone index, derived from a wax up, is marked using the LM Arte Fissura instrument to mark the palatal surface of the future restoration and avoid an overcontour.
Now we could proceed to bonding. We first sandblasted with 50 micron aluminum oxide particles, and then etched, rinsed, dried and applied the adhesive, and then light-cured it for 40 seconds.
Palatal walls were built with the chosen enamel mass. One of the challenges of such restorations is to keep the teeth symmetrical; that’s why we used a disc to correct to shape of these areas to make them straight and even.
One amount of universal B1 shade is applied, calibrated with LM Arte Misura, to ensure proper spacing for the enamel mass.
Mammelons were sculpted with LM Arte Fissura to create a space for some translucent material.
Restorations must be checked with occlusal and side views to ensure a proper volume restitution.
And here we checked the lateral appearance before the last step, meaning before adding clear translucent resin in between the mamelons and the enamel mass all over the restoration.
The finishing and polishing procedure is a crucial step. A successful composite resin restoration must not be ended thinking that the essential act was done by the layering the right composite in the right place. Optimum aesthetics is only reached when a few critical steps are followed: restitution of the shape and the volume without over-contours or composite excess, texturing and polishing to reduce the surface roughness. The life of the restoration will be longer if these steps are thoroughly executed.
The final outcome, after rubber dam removal, shows a difference between the color of the teeth and that of the restorations. This is due to the dehydration of the teeth caused by the rubber dam isolation, and a few days later a check-up will validate the aesthetic integration of the restorations.
On the lateral views we can observe the correct volume restitution.
Both the buccal curves and the lip line were respected.
After 3 days, teeth are hydrated and color matching is satisfying. Contour and texture allow the light to play with the surface. This picture is taken with non-softened flash light to analyze the restorations.
The cross-polarized picture shows a good color integration of the material.
The occlusal view shows the volume restitution and the correct position of the transition lines.
Lateral view shows the macro- and micro-textures of the restorations complying with that of natural structure.
Lateral view with deported flashed shows the macro and micro textures and the volume of the restoration in line with that of natural structures
Final smile of the patient.
Before & After.
Composite resins are probably the most used materials in a dental office. Indeed, they combine ease of use, aesthetics, biological protection, function and drability over time. To achieve these goals, it is mandatory to follow a precise protocol, to know how to put the right materials in the right place, and to know what aspects you should verify in the process. In this clinical case, listening to the patient, observing her teeth, choosing the right materials and using the most appropriate techinque allowed us to achieve a satisfactory result for both the patient and the practitioner.
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