The goal was to find a simplified composite placement technique, without compromising function or aesthetics, where further removal of sound tooth structure is to be avoided, for patients requiring multiple anterior direct restorations.
The topic of minimally invasive dentistry has filled journals and lectures worldwide over the recent years. The definition of this phrase, which is closely related to the field of adhesive dentistry and its application in the mouth, is: “Minimally invasive dentistry is the application of ‘a systematic respect for the original tissue’. This implies that the dental profession recognises that an artifact
is of less biological value than the original healthy tissue. Minimally invasive dentistry is a concept that can embrace all aspects of the profession. The common delineator is tissue preservation, preferably by preventing disease from occurring and intercepting its progress, but also removing and replacing with as little tissue loss as possible.”
Modern multi-layering techniques may give beautiful ideal results for direct restorations in the anterior aesthetic zone. However, this does take time, practice and expertise, and is not predictable for many practitioners that do not regularly provide such treatments. Hence, the goal to simplify the process, using accurate laboratory ‘Wax-up and guide’ for precise and optimal reproduction.
Case description
The following clinical case details a guided approach to the aesthetic direct restoration of upper incisor teeth as part of a comprehensive treatment plan.
The patient was concerned about her missing upper right teeth and the worn look of her upper front teeth and did not wish to consider having a removable partial denture. A comprehensive assessment indicated that she had stained and leaking old composites in her front teeth that required replacing, as well as uneven incisal wear as shown in the initial photos (figs 1 and 2). The upper right central incisor was darker than the other anterior teeth and had previously been root filled. The upper right premolars and molars had been lost 12 months ago when a bridge that was placed (elsewhere) failed. The patient was unsure how
any treatment could improve the appearance of her front teeth without the use of crowns, so a simple direct mock-up was performed (without any bonding protocol) to show her an idea of what may be achievable (figs 3-5). The patient was delighted
with the prospect of what was being proposed and was keen to proceed with treatment.
The options presented were:
- Comprehensive cosmetic makeover.
- Records with full occlusal analysis and diagnostic set-up. Stabilisation of oral health with periodontal (gum health) supportive hygiene care and internally whiten upper right front tooth with provision of post and core in upper left premolar. Cosmetic evaluation with provisionalised restorations and smile assessment. CT scan for 3D imaging and detailed planning. Replace missing upper right teeth with dental implants.
- Comprehensive cosmetic smile makeover with a combination of ceramic veneers and a crown, restoration of implants with fixed, implant supported, aesthetic ceramic bridge.
Simplified cosmetic makeover
Records with full occlusal analysis and diagnostic set-up. Stabilisation of oral health with periodontal (gum health) supportive hygiene care and internally whiten upper right front tooth with provision of post and core in upper left premolar. CT scan for 3D imaging and detailed planning. Replace missing upper right teeth with dental implants.
Simplified cosmetic smile makeover with a combination of cosmetic bonding and a ceramic crown, restoration of implants with
fixed, implant supported, aesthetic ceramic bridge.
The patient chose to proceed with the second option as this provided a more cost effective alternative for her than multiple ceramic veneers. Following her records appointment with full occlusal analysis (fig 6) and laboratory request for a diagnostic
set-up, she had some supportive hygiene care and internal whitening of her upper right central incisor.
The wax mock-up was reviewed with the patient and she was happy with the proposed outcome and ready to proceed (figs 7 and 8). The patient had a small volume CBCT scan (40x40) for 3D imaging and detailed planning of her implant placement. The implant placement surgery took place with immediate loading using the wax-up guide to aid position and allow chairside construction of her provisional screw retained bridge 16-14 (fig 9). After a period for initial healing and reassessment of her internal whitening (11) her anterior bonding was scheduled.
The silicon guide was checked and trimmed to the gingival margins (figs 10-12) and then the six anterior teeth were prepared for bonding: the old restorations were removed and the cavities prepared with a beveled margin. The teeth were cleaned with a prophy-cup and pumice prior to commencing the adhesive procedures. Scotchbond Multi-purpose adhesive (3M/ESPE) was used as a bonding agent and the restoration of the tooth structure was done with Filtek Supreme XTE nanotechnology composite.
The composite was warmed in a composite heater to 30oC. A 1mm increment was expressed into the incisal areas of all the anterior teeth in the clear silicon guide, quickly followed by a dentine body being added and packed onto the enamel layer, so as to allow an interflowing blend of the two composites once under pressure. The guide is rapidly located (accurately) over the upper arch and firm finger pressure applied incisally and labially to the guide over all the teeth being restored. Once satisfied that the guide was fully seated the restorations were cured from every surface through the clear guide for 30 seconds per tooth.
Once the guide had been carefully removed a final 60-second lightcure was performed under glycerin to eliminate oxygen access to the restoration surface. This process provides complete polymerisation of the composite, improves the surface resistance and improves the polishability. The restorations were simply finished with a sharp 12D scalpel blade around the margins and a multi-fluted tungsten carbide composite shaping burs. The anatomical contouring is carried through to the restorations from the wax-up by the silicon guide, alleviating the requirement for timeconsuming shape development. Centric occlusal contacts were checked along with guidance on excursions. The contacts are partially broken through with a fine diamond disc (Komett, Brasseler), perforated metal polishing strips (Komett) and given an initial polish with the Soflex Spiral polishing system (3M/ESPE). At this stage the restorations are still slightly dull and will be re-polished after a week (fig 13).
One week later the patient returned for a review appointment at which the restorations polished with goathair and felt polishing wheels.
Impressions, facebow registration and occlusal records were then taken for the final ceramic bridge on the implants (upper right) and an allceramic crown on UL4.
The patient was highly delighted with the end result and highly aesthetic nature of the composite restorative material is evident in the final photographs (fig 14-17)
References available on request.