This patient’s many problems necessitated a comprehensive treatment plan and a systematic approach to complete direct and indirect tooth rehabilitation. His finances were limited and he was extremely self-conscious regarding the appearance of his front teeth. It was decided on this first visit to address his chief complaint, the maxillary front teeth – to “give him back his smile”.
Tooth 7 had a PFM in place that was still clinically serviceable and the shade (A3) was not an issue for the patient. Teeth 8, 9, and 10 had old composite restorations in place with varying amounts of caries present. The plan was to remove the decay and defective portions of the composite resins and rebuild these teeth in composite resin. The patient understood that these teeth ideally would need full coverage indirect restorations after this “rebuilding” process, but as finances would not allow this, and posterior teeth also needed to be addressed, these composite replacements would be stabilizing “interim” restorations and full coverage would be done at a later time.
1. A pre-operative view of teeth 8. 9. and 10.
2. This facial view shows the teeth after caries excavation prior to removal of the pin in tooth 10. The composite in the distal of tooth 8 is clinically acceptable at this point, so rather than remove it all, it was decided to simply overlay this area with Empress Direct as the tooth is rebuilt to proper dimensions.
3. After removal of the pin in tooth 10, it is apparent that there is not a lot of remaining tooth structure to work with. A pin-retained composite build up will be done as an intermediate restoration.
4. A diode laser is used to trough around the proximal gingival cavity margins to make placement of the gingival increments of composite more precise, without the possibility of contamination from blood or saliva.
5. Three pins were placed to help retain the composite on this “vertically challenged” tooth. (Intentional endodontics, post build up, and crown would be more predictable, but again is financially not feasible at this time.)
6. The deeply excavated areas are first filled with glass ionomer cement (GIC) as a dentin replacement. Due to the depth of some of these excavated areas, GIC will seal and help remineralize any affected dentin that may remain.
7. The GIC is being placed in the mesial of tooth 9.
8. The GIC is packed and shaped into the excavated area using a plastic filling instrument.
9. After the basing procedure with GIC is complete, the prepared surfaces are etched with 37% phosphoric acid for 15 seconds, rinsed, then dried with an air syringe.
10. The desiccated dentin is rewet with a desensitizer and the excess removed with high volume suction.
11. Excite dentin adhesive is placed on the prepared teeth using a VivaPen delivery system.
12. The adhesive is light cured using an LED curing light.
13. A layer of Tetric EvoFlow flowable resin is placed on all teeth to a thickness no greater than 0.5 mm. Note the placement around the pins ensures intimate contact of composite around the retaining pin.
14. After building up the dentin with an A3 dentin shade of Empress Direct to match opacity, an 8-fluted bur is used to sculpt the mammelons and grooves between facial lobes in a similar fashion as the dental ceramist would build up porcelain.
15. A facial view of teeth 8, 9, and 10 after sculpting of the dentin layer is completed.
16. A strip of Tapetrix teflon tape is used to facilitate contact placement during the freehanded bonding process. Note that the contact points are scraped away so contact to the adjacent tooth will be assured. Some Tetric Color white composite tint is applied on the dentin layer and cured prior to placement of the enamel layer to simulate a “white washed” natural effect when viewed through the clear enamel layer.
17. The translucent enamel layer of Empress Direct, Trans 20, is placed using a composite placing instrument.
18. A ContacEZ proximal diamond strip is used to smooth the proximal margins of the restoration.
19. Finishing begins with the use of an 8 fluted carbide composite finishing bur (ET 9: Brasseler, TDS 9: Axis Dental) to contour the restoration. Water spray and high-speed rotary instrumentation along with the 8 fluted carbide bur will allow the operatory to contour the restoration and create surface texture at the same time.
20. The use of Optidiscs flexible polishing discs allows access to proximal surfaces during the contouring phase to accentuate the proximal facial line angles of the restoration. The active surface of the disc faces the handpiece so that the flexing action of the disc can help duplicate the geometric planes of the natural tooth surface.
21. Following the contouring phase, polishing starts with a medium grit (Astropol P rubber composite polishing disc. Using the side of the instrument and moving it horizontally over the surface of the restoration will allow the operator to polish the surface without flattening and eliminating the anatomic surface texture. The process is then repeated using the Astropol HP (High Polish) disc.
22. The final luster is imparted to the restoration using an Astrobrush polishing brush.
23. A facial view of the finished result. The patient leaves the office with a dramatic change in his smile! The translucent shade (Trans 20) of Empress Direct creates an amazingly lifelike surface that blends aesthetically with ceramic and natural tooth.