simple and beautiful: dual-layer technique in the anterior ...€¦ · reasons are a seemingly...
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Simple and beautiful: Dual-layer technique in the anterior region.
Simple and beautiful results from a direct restorative dual layering technique. The described technique is easily taught and learned. It enables every dentist to obtain beautiful results despite a highly efficient procedure. However, these results are only achieved if high quality materials are used and if the practitioner has developed a thorough understanding of the employed materials. Instead of magic, it is precise preparation and careful planning that leads to the desired, repeatable and therefore, predictable outcomes loved by the patients.
by Dr. Paulo MonteiroDate of Original: March 2017 - Espertise Magazine.
When a restoration is needed in the upper anterior region of a patient with particularly high aesthetic demands, many dental practitioners prefer indirect over direct restorative techniques. Reasons are a seemingly higher predictability and easier handling of the materials inside the mouth. However, it is possible to achieve beautiful results with little effort using direct composite materials as well – provided that several basic rules are respected.
Figure 1: Beautiful teeth of the young, female patient.
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Rules for direct procedure success
One of the most important preconditions for high-quality outcomes is that the character of the tooth is analysed properly. In order to imitate its character, a stable material with a high colour stability and a high strength for easy finishing and polishing should be selected. These properties are offered by 3M™ Filtek™ Supreme XTE Universal Restorative preferred by StyleItaliano™. In addition, an understanding of the materials outside the mouth is essential for their successful intraoral use. This understanding is obtained by playing with different opacities and shades; and ideally by creating an individual shade guide. The StyleItaliano recipes and recommendations (e. g. the advice to always create an enamel layer of 0.5mm strength) support the dental practitioner in obtaining great shade guide results and treatment outcomes.
Beautiful results possible
With the StyleItaliano recipes and rules, any dentist is able to learn how to create direct restorations that fulfil high aesthetic demands. The procedure is easily taught and learned and does not lead to an unpleasant surprise, as the case of a young, female patient shows.
The patient had beautiful teeth, but the aesthetics of her smile were somewhat negatively affected by a small, discoloured composite restoration on her upper right central incisor (Figs. 1 and 2). The character of the teeth was analysed closely using images taken under
different light conditions. The image shows that it is relatively easy to read the inside of the tooth, which has varying opacities and a clearly visible mamelon structure, but no intensive intrinsic colours (Fig. 3).
Therefore, it was decided to restore the tooth using a dual-layer technique with one dentin and one enamel shade plus the Clear Translucent shade of Filtek Supreme XTE Universal Restorative.
The use of additional stains included in the restoration was not necessary.
For shade selection, the VITA classical A1-D4 shade guide was used (Fig. 4). Alternatively, the individual shade guide produced with the desired composite material may be employed. It is important to select the shade when the teeth are hydrated and not yet isolated with rubber dam, as the colour of the dam and drying may affect the natural tooth shade. In the present case, the shade A1 was determined. According to the StyleItaliano recipes, this shade is produced with Filtek Supreme XTE restorative shades A1D (dentin) and A3E (enamel).
A rubber dam was placed and the existing restoration was removed. To provide for a smooth transition between restoration and tooth structure, a labial bevel was created with a red 3M™ Sof-Lex™ Contouring and Polishing Disc (Fig. 5). Subsequently, the available space and the shape of the tooth were checked with a silicone key (Fig. 6).
Figure 2: The small discoloured restoration is visible and creates a disharmony in the overall picture. The proportion of the tooth is not ideal, either.
Figure 4: Shade selection with the two options A1 (left) and B1.
Figure 3: Analysis of the teeth’s character: The adjacent tooth shows different opacities including highly translucent areas on the incisal edge, but no intrinsic colours to be imitated.
Figure 5: Creation of a smooth, beveled surface.
Figure 6: Checking the shape of the tooth with a silicone key.
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and to obtain a uniform surface with 0.5mm space left for the final enamel layer (Fig. 12).
It is possible to check and, if necessary, adjust the available space with the Misura Instrument (LM Arte). At this stage of the treatment, the shade of the dentin core appears to be slightly too light. However, the final enamel layer in a darker A3E shade masks this effect reliably, as shown in Figure 13.
Making provisions for a strong bond
The adjacent teeth were protected with PFTE tape when etching gel with 35 percent phosphoric acid was applied to the enamel for 15 seconds (Fig. 7). The etchant was thoroughly rinsed off with water before the bond (3M™ Scotchbond™ Universal Adhesive) was applied (Fig. 8), rubbed in for 20 seconds, air-dried until the solvent had evaporated and the adhesive layer no longer showed any movement and finally, light-cured for 15 seconds.
Colour and the inner shape
The thin, palatal enamel layer was created with Filtek Supreme XTE res torative in the Clear Translucent shade (Fig. 9). For the build-up of the interproximal walls, the shade A3E (enamel) was used. Slick Bands™ XR Matrices (Garrison Dental) were placed in a vertical position between the teeth to ensure tight contacts and an anatomical shape of the restoration (Fig. 10). When the interproximal and incisal walls were finished, the dentin core (shade A1D) was added and modelled to imitate the anatomical structure of the adjacent central incisor (Fig. 11). As a matter of course, every single layer of composite was light-cured before placing the next. The dentin core was covered with a layer of Filtek Supreme XTE restorative in the Clear Translucent shade to increase the translucency in the incisal area
Figure 7: Selective enamel etching of the prepared tooth structure.
Figure 8: Application of the universal adhesive.
Figure 9: Placement of the first palatal layer of composite.
Figure 10: Vertical use of a posterior tooth matrix to restore the mesial interproximal wall.
Figure 11: The dentin core is created and mamelons are added to copy the natural look of the left central incisor.
Figure 12: Placement of a layer in the shade Clear Translucent to lay the foundation for a uniform thickness of the final enamel layer.
Figure 13: Situation prior to finishing and polishing.
Texture and the outer contour
The beauty of a restoration is not only determined by its colour and precise imitation of the natural anatomy with its convex shapes and different opacities, but also by its outer contour and texture. Thus,
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was obtained (Figs. 19 and 20). The difference between the adjacent natural teeth and the restoration was virtually imperceptible and there was no visible junction between enamel and dentin in one section of the tooth and the composite material in the other.
Simple and predictable technique
The described technique is easily taught and learned. It enables every dentist to obtain beautiful results despite a highly efficient procedure. However, these results are only achieved if high-quality materials are used and if the practitioner has developed a thorough understanding of the employed materials. Instead of magic, it is precise preparation and careful planning that leads to the desired, repeatable and therefore predictable outcomes loved by the patient.
When the rubber dam was removed, a dark triangle was visible between the anterior teeth due to the manipulation of the soft tissue (Fig. 18). After several days, the tissues had recovered and a beautiful overall picture
the finishing procedure is highly important. In the present case, Sof-Lex discs were used for contouring and texturing (Fig. 14). Afterwards, the 3M™ Sof-Lex™ Diamond Polishing System was employed to obtain a natural gloss. The beige spiral was used for pre-polishing (Fig. 15), followed by the pink one developed for the creation of a paste-like gloss (Fig. 16). Experience shows that even better results are achievable in this final step when the spiral is used in combination with water. Figure 17 shows the outcome immediately after polishing.
Figure 15: Pre-polishing with the beige spiral.
Figure 16: High-gloss polishing with the pink spiral and water.
Figure 17: Restoration after the finishing and polishing procedure.
Figure 18: The restoration is beautiful, while the soft tissue needs some time to recover.
Figure 19: Treatment result several days after the treatment.
Figure 20: Beautiful smile of the patient.
Figure 14: Contouring with the proven 3M™ Sof-Lex™ Contouring and Polishing Discs.
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Dr Paulo Monteiro DMD, MSc (Lisbon, Portugal)“My passion for aesthetic dentistry began when I attended the last year of the Dental Medicine course in 1998 at the Institute of Health Sciences Egas Moniz in Portugal. In 2005, I completed my specialisation in Aesthetic and Restorative Dentistry at the ISCSEM, Lisbon, Portugal. In 2010, I finished a Master’s degree in Dental Medicine and I’m currently taking a PhD in Dentistry at Universidade de Santiago de Compostela, Spain.” Paulo is author and co-author of many clinical publications and has lectured in more than 200 international courses and congresses in aesthetic dentistry and is a member of the StyleItaliano group.
Contact: Paulo Monteiro DMD, MSc - Coordinator and Professor, Aesthetic and Restorative Dentistry Post-graduation program at ISCSEM.
For more information on the 3M materials utilised in this case, please visit 3M.com.au/dental or 3M.co.nz/dental, or contact your local 3M Product Specialist.
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Published by 3M Oral Care. 3M, “3M Science. Applied to Life.” and Espertise are trademarks of 3M. 3M Health Care Academy is a service mark of 3M. Please recycle. © 3M 2017. All rights reserved.Disclaimer: Application and Technique guides used in this case on 3M products may not always align with 3M Product Instructions for Use. Please always follow the 3M Product Instructions For Use for best clinical results.
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