Anterior CompositeRestorationsGerard Kugel, DMD, MS

Sponsored by Brasseler USA 2 Hours of Continuing Education Credit

A Supplement to Contemporary Esthetics and Restorative Practice® An MWC Publication

©2001. Dental Learning Systems Co., Inc.

Esthetic Technique

™

Clinical Case Studies and Technique Review

Vol. 1, No. 1, 2001

Dear Reader,

I am excited to announce that Brasseler USA is partnering withDental Learning Systems to publish Esthetic Technique, a quarterly pub-lication devoted to case studies for achieving excellent clinical results.This alliance with Dental Learning Systems was formed because ourcore values and vision for the future of dentistry are so closely aligned.

This peer-reviewed publication utilizes an extremely talented andforward-thinking board. The board members have a variety of back-grounds that include university based, private practice, and dental labo-ratory. Our review board is dedicated to ensuring that the highest-qualitycontinuing education (CE) articles are published in Esthetic Technique.

Brasseler USA is committed to supporting CE and is dedicated toworking with the world’s leading clinicians to create innovative dentalrotary instrument systems for consistently achieving esthetic excel-lence. Esthetic Technique is one of the vehicles we feel will best allowus to express our commitment to educating the profession on these sys-tems. Our goal is to provide a comprehensive CE piece that is focusedon providing the key elements necessary to implement these techniquesin your practice.

As always, Brasseler USA is committed to focusing on the bestinterest of the profession by providing uncompromising quality andintegrity in our products, support programs, and services. We provideour product direct to you with more than 115 field technical sales repre-sentatives dedicated to working closely with our customers to ensurewe meet your goals for quality and service.

At Brasseler USA, we have a vision: To serve the dynamic needs ofour customers, by continually striving to exceed expectations throughinnovative dental rotary instrument systems, which are developedthrough a partnership with the profession’s leading clinicians and ourmotivated employees, and delivered directly to the dental profession.

We hope that through our commitment to dentistry and Esthetic

Technique we are adding value to your practice. Thank you for time,consideration, and support.

Sincerely,

Don L. WatersPresident and CEOBrasseler USA

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Bruce Crispin,DDS

Nasser Barghi,DDS

Lee Culp, CDT

John Kois,DMD

Gerard Kugel,DMD, MS

Edward A.McLaren, DDS

Larry Rosenthal,DDS

Howard Strassler, DMD

Douglas A.Terry, DDS

Thomas F.Trinkner, DDS

ADVISORY BOARD

Dental Learning Systems Co., Inc., is an ADA Recognized Provider

Academy of General Dentistry Approved National Sponsor. FAGD/MAGD Credit

7/18/1990 to 12/31/2002

3ESTHETIC TECHNIQUE VOL. 1, NO. 1, 2001

LEARNING OBJECTIVESAfter reading this article, the reader should be able to:

• understand how form and function will impact the successof proposed esthetic restorations.

• describe how the adaptive process compensates for wear.• describe how conservative direct composites can be placed

after the causes of tooth wear are determined.

Today, dental professionals are witnessing an unprece-dented change in the manner in which patients considerdental treatments, as well as the manner in which clini-

cians administer a variety of restorative alternatives. Thewidespread coverage in consumer media of the benefits andcapabilities of esthetic restorative dentistry and advertisingcampaigns targeted directly to the patient have resulted in farmore educated consumers seeking esthetic enhancements andalmost immediate results.1

However, dental professionals know that patients, inreality, can present with more clinically involved conditionsthat require attention before initiating any esthetic restorativedental treatment. In such cases, the clinician—and subse-quently the patient—must understand how form and functionimpact the success of proposed esthetic restorations.Therefore, clinicians should become skilled in both identify-

ing clinically sound interim restorative options and knowl-edgeable in the armamentarium available to ensure at leastinterim success of the provisional restorations. This articlereports the issues faced by a clinician when a patient exhibit-ing anterior wear and the need for functional treatment pre-sented requesting “immediate” esthetic enhancements.

EVALUATING TOOTH WEAR WHEN PLANNINGESTHETIC RESTORATIONS

The effects of tooth wear present ever-increasing esthet-ic problems to patients and dentists alike. Unfortunately,many practitioners believe tooth wear is a problem reservedfor older patients, although it has been reported that 15% ofchildren demonstrate tooth wear apparently as a result ofbruxism.2 The causes of this wear may be multifaceted andmay include attrition resulting from abrasion, bruxism, and/ordietary erosion that often results from acid dissolution.3

Before initiating treatment for tooth wear, dentists mustunderstand how the adaptive process compensates for wear.Specifically, the distinction must be made between physiolog-ic wear and excessive wear. Physiologic wear is considerednormal and is evidenced by slow loss of convexity on thecusps, flattening of cusp tips on posterior teeth, and loss ofenamel on anterior teeth. Excessive wear is defined as wearthat requires corrective intervention to preserve the dentition.Such excessive wear may destroy the anterior tooth structurerequired for acceptable anterior guidance function or foresthetics.4

Therefore, when patients present requesting estheticenhancements to teeth with visible signs of wear, dentistsmust evaluate, diagnose, and develop the most medicallysound treatment plan. They should then educate patientsabout what offers not only the best esthetic result but whatwill also enable them to function long term. In the followingcase, a patient had immediate esthetic requests but, on com-prehensive evaluation, was found to require therapies to cor-rect the causes of wear.

ABSTRACTWhen patients present requesting “immediate” esthetic

enhancements to their smile, the clinician may find that func-tional issues must be addressed first to ensure the longevity oftreatment success. In such instances, a strategic interim treat-ment process may satisfy patient and dentist requirements.This article describes the materials, instruments, and tech-niques used in the provisional esthetic treatment of a patientwho presented 2 weeks before his wedding with posteriorinclines that deflected the mandible forward, driving thelower incisal edges forward and resulting in anterior wear.

Provisional Esthetic EnhancementsFollowing Initial Treatment to Correct Anterior WearGerard Kugel, DMD, MS

Gerard Kugel, DMD, MS

Professor

Dean for Research

Tufts University School of Dental

Medicine

Private Practice

Boston, Massachusetts

Figure 1—Preoperative close-up facial

view of the patient presenting with obvious

diastemas and incisal wear.

Figure 2—Posterior inclines that deflect-

ed the mandible forward resulted in a

bruxing pattern.

Figure 3—A rounded wheel bur was used

to reduce the occlusal tooth surface to pro-

mote maximum intercuspation.

4 VOL. 1, NO. 1, 2001 ESTHETIC TECHNIQUE

CASE PRESENTATIONA healthy 27-year-old man was

referred to the author’s office 2 weeksbefore his wedding. The patient’s den-tist referred him for placement ofporcelain veneers to improve theappearance of his teeth and close thediastemas present between teeth Nos. 7through 10 (Figure 1). The patient’s pri-mary concern was “to look good for hiswedding.” However, the patient exhibit-ed anterior wear that was especiallynoticeable on the upper lingualinclines. Tooth No. 8 had an existingcomposite restoration.

A complete examination was per-formed that included a head and neckexam, full-mouth radiographs, periodon-tal probing, and a masticatory evalua-tion involving palpation of muscles,

joint analysis, and occlusal analysis. Thecentric bite record was captured usingthe bilateral manipulation method.Maxillary and mandibular models weremade, along with a face bow recording,and the case was mounted using theconfirmed centric recording.4

During the examination, thepatient did not exhibit any specific signsor symptoms of temporomandibulardisorder (TMD). His mandible could bepositioned in centric relation (CR),with no discomfort. When upwardpressure was applied toward the joint,no tenderness or tension was noted.Also, no joint sounds were heard, andthe patient could open his mouth with-out difficulty or any deviation. Further,no tenderness of the masticatory mus-cles was elicited.

COMPREHENSIVE TREATMENTDETERMINATION

After the anterior guidance hadbeen established and the models wereexamined to identify any posterior bal-ancing, working, or protrusive interfer-ences, the patient was ready for equili-bration. The wear on the maxillaryteeth appeared to be the result of pos-terior inclines that deflected themandible forward (Figure 2). Thisinterference drove the lower incisaledges forward into the upper lingualsurfaces, resulting in a bruxing patternthat wore the anterior teeth.

The patient was informed thatbefore permanent restorations couldbe placed, his bite and wear conditionswould have to be addressed. Hisrestorative options were fully disclosed

Figure 4—Occlusal view of the posterior

mandibular teeth after removal of the

interference.

Figure 5—Prospective composite shades

were tried directly on the unprepared

teeth.

Figure 6—A diamond bur was used to

remove the preexisting composite from

tooth No. 8.

Figure 7—Removal of the old composite

and further tooth preparation resulted in

a significant reduction in tooth structure.

Figure 8—Palatal view of tooth No. 8

after preparation.

Figure 9—An irregular bevel was pro-

duced with an esthetic trimming bur to

facilitate composite blending.

Figure 10—The single-component bonding

agent should leave the tooth surface shiny.Figure 11—An opaque composite was

placed to mimic the lost dentin.

Figure 12—The previously selected body

shade of composite (A1) was placed.

5ESTHETIC TECHNIQUE VOL. 1, NO. 1, 2001

and, because of time constraints and hisfinances, it was decided to place directcomposite restorations as an interimsolution to provide the immediate es-thetics the patient desired. Porcelain ve-neers and/or full-coverage ceramic crownswould be placed after the patient’socclusion was stabilized and he becamecomfortable wearing a night guard.

Because the patient had alreadyinitiated the whitening process with hisdentist, composite shades were select-ed with the understanding that whiten-ing would continue.

ACHIEVING EQUILIBRATIONWhile manipulating the mandible

into CR, a slow opening and closingmovement was continued and the pa-tient was asked to indicate when he feltfirst contact. The mesial incline of the

maxillary left second molar producedthe first contact. The patient was askedto hold the position and then squeeze,demonstrating an anterior slide.

Using a rounded wheel bur (909-040a,*) the slide was eliminated, allowingthe mandible to close to maximum inter-cuspation without any displacement(Figure 3). When this interference wasremoved (Figure 4), the equilibrationcontinued by adjusting the CR stopsusing the same 909 rounded wheel bur ina high-speed handpiece. After all stopswere acceptable on CR, the mandiblewas bimanually manipulated, and thepatient was asked if he perceived anytooth to be touching first. A slow speedwas then used until the patient per-

ceived all teeth touching together.At a later appointment, the patient’s

occlusion was verified again. He indi-cated that he had no problems after theequilibration appointment and that hisbite felt “even” and very comfortable.

SHADE SELECTIONIt was determined that a microhy-

brid composite (Esthet•X™,b) would beused. Selection of the compositeshades was completed directly on theunprepared tooth surfaces (Figure 5).

TOOTH PREPARATION ANDCOMPOSITE PLACEMENT

Using an anterior preparation dia-mond bur (6850-018a), the preexistingcomposite on tooth No. 8 was removed

Figure 13—An anodized-aluminum com-

posite instrument was used to contour the

composite.

Figure 14—The specially designed

sculpting instrument was used to achieve

proper contour.

Figure 15—Only the enamel shade of

composite was used to restore the incisal

edge of tooth No. 9.

Figure 16—Excess cement was removed

from the margins with a 30-µm bur.

Figure 17—A gray medium disc was

used first to shape the restorations.

Figure 18—A 12-mm green fine disc fur-

ther shaped the restorations.

Figure 19—An 8-µm bur was used for

final contouring.

Figure 20—Adjustments were made

using a 15-µm bur.

Figure 21—A diamond-impregnated point

was used to prepolish the restorations.

a Brasseler USA®, Savannah, GA 31419; 800-841-4522*Similar burs are available from other manufacturers

that may be appropriate for use in this type of case.

b DENTSPLY® Caulk®, Milford, DE 19963; 800-LDCAULK

(Figure 6). It was noted that a signifi-cant amount of tooth structure wasmissing (Figures 7 and 8). The futureplacement of a full-coverage restora-tion, along with the limitations of usingdirect composite at this time, was dis-cussed with the patient.

Using an esthetic trimming bur(DET6F, ET Diamond/Combo Kita), anirregularly shaped long bevel was creat-ed to allow natural blending of the com-posite to tooth structure (Figure 9).

The tooth was etched with 32% phos-phoric acid (UNI-ETCH®,c) for 20 sec-onds, rinsed for 15 seconds with an air-water spray, and then lightly dried, leav-ing a moist surface. Then, two coats ofa single-component bonding agent(3M™ Single Bondd) were applied. Notethat when using a single-componentbonding agent, the tooth surface mustappear shiny; if it does not, additionalcoats should be applied (Figure 10).The bonding agent was gently air-driedand then cured for 10 seconds with ahalogen curing light (Elipar® Highlighte).

The extensive preparation on toothNo. 8 (Figures 7 and 8) necessitated alayering technique for the placement ofthe direct composite to maximize theesthetic results. First, a layer of opaquecomposite was applied (Figure 11),sculpted, and light-cured for 20 sec-onds using the halogen curing lightfrom both the facial and lingual as-pects, keeping in mind that sufficientspace would be required for placementof the body and enamel shades. A layerof A1 body (Figure 12) was placed andcontoured using a composite instru-ment (250F4a). The advantage of usingthis anodized-aluminum instrument is

that little stick or pullback is experi-enced during the application process(Figure 13). This layer was then light-cured for 20 seconds from the facialaspect. Finally, the CE enamel shadewas placed. This transparent layer wasplaced along the mesial and distal lineangles and at the incisal edge, sculptedto proper contour, and light-cured for20 seconds (Figure 14).

Tooth No. 9 was facially reducedby 0.3 mm using an esthetic trimmingdiamond bur (DET9Fa). The facial andincisal aspects and mesial and distalline angles were restored with only theenamel shade of composite becauseonly minimal reduction and replace-ment of missing enamel was necessary(Figure 15). Teeth Nos. 7 and 10 wereprepared and restored in a manner sim-ilar to tooth No. 9, using only the CEenamel shade of composite.

FINISHING AND POLISHINGLittle excess composite resin was

present because of the esthetic con-touring performed using the compositeinstrument (250F4a). Any excess alongthe gingival margins was first removedusing a 30-µm diamond bur (DET6F andDET9Fa) (Figure 16). Next, the restora-tions were recontoured using an inte-grated polishing system (EP EstheticPolishing System, Kit #EP200a).

The composite restorations wereshaped first with a 12-mm gray mediumdisc (EP2LR) (Figure 17) and then a 12-mm green fine disc (EP3LR) (Figure18). Final contouring was done usingan 8-µm bur (DET6UF, ET Diamond/Combo Kita) (Figure 19). Occlusionwas verified with a very thin two-sidedocclusal film (Accu-Film®IIf), andadjustments were made with a 15-µmbur (DOS1EFa) (Figure 20). Anterior

guidance was checked to verify thepresence of smooth lateral and evenprotrusive excursions.

Final polishing was accomplishedusing a polishing kit designed specifi-cally for composite restorations(Diacomp Composite Polishing Kita

144-21). Here, the green diamond-impregnated synthetic rubber pointwas used for the prepolish step (Figure21). The gray high-shine disc was thenused as the final step (Figure 22).

POSTTREATMENTImmediately after placement of the

restorations, impressions were taken forthe fabrication of a CR occlusal splintto address the patient’s bruxism,reduce tooth wear, and evenly distrib-ute occlusal forces. The day after thetreatment appointment, postoperativephotographs were taken and the oc-clusal splint was delivered (Figure 23).After 3 months, the patient chose to keepthe direct composite restorations.

CONCLUSIONDentists have long dreaded treat-

ing worn anterior teeth. Over time, theincisal edges continued to wear, leavingthe dentist with full-coverage porce-lain-fused-to-metal restorations as theironly solution.5 However, when thecauses of tooth wear are determinedthrough proper occlusal analysis and ad-dressed through equilibration, usingthe conservative direct composite tech-niques described in this article can resultin a treatment plan that is both func-tional, esthetic, and almost immediate.

ACKNOWLEDGMENTThanks to Dr. Charles Habib for

assisting with the clinical photography.

REFERENCES1. Kugel G, Garcia-Godoy F: Direct esthetic restora-

tive materials: a review. Contemporary Esthetics

and Restorative Practice 4(9):6, 2000.2. Schneider PE, Peterson J: Oral habits: consid-

erations in management. Pediatr Clin North

Am 29(3):523-546, 1982.3. Bishop K, Kelleher M, Briggs P, et al: Wear now?

An update on the etiology of tooth wear.Quintessence Int 28(5):305-313, 1997.

4. Dawson PE: Evaluation, Diagnosis, and

Treatment of Occlusal Problems, ed 2. St.Louis, Mosby, 1989.

5. Strassler HE, Kihn PW, Yoon R: Conservativetreatment of the worn dentition with adhesivecomposite resin. Contemporary Esthetics and

Restorative Practice 3(4):42-52, 1999.

6 VOL. 1, NO. 1, 2001 ESTHETIC TECHNIQUE

Figure 22—A gray high-shine disc

achieved final polish.

Figure 23—Postoperative view demon-

strating the enhanced esthetics achieved

using specifically designed instruments.

c BISCO Dental Products, Schaumburg, IL 60193;800-BISDENT

d 3M Dental Products, St. Paul, MN 55144; 800-634-2249

e ESPE, Norristown, PA 19404; 800-782-1571 f Parkell®, Farmingdale, NY 11735; 800-243-7446

7ESTHETIC TECHNIQUE VOL. 1, NO. 1, 2001

A 16-bladed HET9F is used for

contouring and initial finishing

of the composite resin used to

mask the tooth discoloration.

Final finishing of all gingival

margin areas is done with a 30-

bladed HET3 or HET4.

The final texture and ultrafine

finishing are accomplished with

an HET9UF.

A DS37EF 15-µm

diamond strip is

used to finish the

contact areas.

Replication of natural tooth form and texturerequires meticulous finishing and polishing. An opti-mally developed surface luster enhances esthetics,reduces stain and plaque retention, and minimizeswear and fracture potential.

A necessary planning consideration shouldinclude the maintenance of the restoration’s color andstain-free appearance. Key objectives are to preventstains for as long as possible, then facilitate their elim-ination when they appear. Stain prevention initiallyrequires proper restoration design and a smooth stain-resistant surface.

Finishing techniques to ensure effective stain prevention:

• Avoidance of junctions between layers. For bestresults when placing direct composite resin restora-tions, ensure that the final layer has sufficient bulk toproperly finish the restoration without compromis-ing the initial layer.

• If using a hybrid, complete the final non–stress-bearing layer with a microfill for optimal polish.

• Counsel patients to avoid stain-inducing foods, bev-erages, and habits.

• Establish a comprehensive prophylaxis schedulewith increased frequency during the initial treat-ment stage to ensure early stain detection. If evi-denced, initiate finishing with a 30-bladed bur (ET,Brasseler USA, Savannah, Georgia; 800-841-4522).

• Document the finishing procedures for future refer-ence. Take close-up 35-mm slides or photographs, oruse an intraoral camera to record the exact layerplacement and fabrication procedure.

A superiorly finished restoration exhibits: (1)well-finished margins free of overhangs, voids, orextensions of restorative material; (2) a smooth sur-face to repel bacterial plaque and food stains; (3) sur-face texture and color shade that compare favorablywith surrounding natural dentition; and (4) flawlesssurface finish.

FINISHING DIRECT COMPOSITES TO ENSURE STAIN PREVENTION

The final full

composite bonding

was finished with

polishing disks after

the last 30-bladed ET

finishing carbide.

This information is provided by Brasseler USA.

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