A direct composite resin stratification technique for restoration of the smile

Transcription

1 A direct composite resin strtifiction technique for restortion of the smile Jun Crlos Pontons-Melo, DDS, MSc 1 / Adilson Yoshio Furuse, DDS, MSc, PhD 2 / Jose Mondelli, DDS, MSc, PhD 3 Composite resins cn e used to improve the esthetics of the smile t low cost nd with reltively high clinicl performnce. The im of this rticle ws to descrie n pproch to restore nd enhnce the esthetic ppernce of the nterior dentition through vitl tooth whitening nd the direct lyering of composite resin during predictle esthetic procedures. (Quintessence Int 2011;42: ) Key words: composite restortion, dentl esthetics, lyering technique Nowdys, the cosmetic nd esthetic prmeters dictted y society hve compelled ptients to seek dentofcil hrmony nd improve their physicl ppernce. Additionlly, the evolution of dentl mterils hs incresed the indiction of esthetic restortive procedures. In this context, composite resins occupy prmount position mong restortive mterils for nterior teeth ecuse they offer good predictility, cceptle longevity, nd the possiility of more conservtive procedures t lower cost thn indirect restortions. 1 6 In ddition, during the replcement of decyed or missing dentl tissue, composite restortions llow either minimlly invsive or no preprtion. They lso provide n excellent esthetic outcome, due to the vriety of ville colors nd effects Professor, Deprtment of Restortive Dentistry, School of Dentistry, Sn Mrcos University, Lim, Peru; Professor of Esthetic Dentistry, Spzio Orl Dentl Eduction, Lim, Peruw. 2 Professor, School of Dentistry, Positivo University, Curiti, Brzil. 3 Professor, Deprtment of Restortive Dentistry, Buru School of Dentistry, University of São Pulo, Buru, Brzil. Correspondence: Dr Jun Crlos Pontons-Melo, Av Alerto del Cmpo 452 Dpto 303 Sn Isidro, Lim 27, Lim, Peru. Emil: drjcpontons@spzioorl.com The rnge of composites llows the use of different comintions of shde, hue, trnslucency, nd opcity. Thus, specific detils nd spects tht exist in the ptient s nturl dentition my e otined. This restortive pproch of lyering pproch hs een clled n ntomic uildup technique, 11 trendy three-lyer concept, 12 or nturl lyering concept. 3 The gol of these methods is to mimic the nturl ntomy of enmel nd dentin. 13 The ppliction of lyering concept through the use of seprte composite resin msses tht mimic the nturl tooth ntomy presents cler dvntges for the clinicin nd mkes the entire procedure more efficient nd predictle. 3 When evluting the polychromtic chrcteristics of tooth, ge should lso e tken into ccount. With incresing ge, there is n increse in chrom, decrese in vlue, nd proly chnge in hue. Actully, phenomen such s wer, cquired or dysplstic discolortion, nd crcks or microfrctures will require n individul pproch for the restortive work. 7 Thus, s is true of ll rt, heightened sense of oservtion is required. 14 The excellence in esthetic dentistry demonstrtes further confirmtion VOLUME 42 NUMBER 3 MARCH

2 Fig 1 Preopertive photogrphs tht show n indequte incisl disply nd dishrmonic reltion with the lips. Fig 2 Initil ppernce of the mxillry incisors. Fig 3 The in-office tooth leching process crried out with 35% hydrogen peroxide. of Leonrdo D Vinci s elief tht rt nd technology re one nd the sme. In ddition to composite resin restortions, vitl dentl leching my e employed to increse dentl esthetics. Two techniques re currently ville: in-office nd wlking leching. Both techniques my e employed, s the procedure is considered simple, sfe, nd incple of cusing mjor ltertions of enmel nd dentin structure. 15,16 The im of this rticle is to descrie n uncomplicted pproch with which to restore nd enhnce the esthetic ppernce of the nterior dentition vi tooth whitening nd direct composite resin restortions with the id of lyering technique for predictle esthetic procedures. CASE REPORT A 35-yer-old womn presented for tretment. She complined of disstisfction with her smile, especilly with the position of her mxillry centrl incisors (Fig 1). A clinicl exmintion reveled worn mxillry incisors nd compromised color, s well s old, defective composite restortions (Fig 2). Rdiogrphs nd dignostic csts were tken. Vitl in-office leching ws proposed nd conducted with 35% hydrogen peroxide (Lse Peroxide Sensy, DMC) (Fig 3). At the 1-week follow-up ppointment, the ptient did not report ny tooth sensitivity t ny point during the leching tretment. After 3 weeks, which is the recommended 206 VOLUME 42 NUMBER 3 MARCH 2011

3 Fig 4 The pltl silicone guide ws fricted on study cst fter optimizing the shpe nd function of the incisors with wx-up. Fig 5 Cosmetic contouring ws performed to etter lign the mxillry centrl incisors prior to strting definitive restortions. c Fig 6 () After prophylxis, modified ruer dm isoltion ws estlished. () Restortions were removed with the id of rsive disks nd dimond urs. (c) Finl preprtions efore restortive tretment. Fig 7 () Etching with phosphoric cid. () After rinsing nd lotting with n sorent pper, onding gent ws pplied nd light cured. mount of time to wit efore creting n dequte ond fter the leching process, 17 new tooth positions nd restortions were plnned with the id of wxed dentl cst. Enhnced predictility of the tretment cn e otined with silicone index (Fig 4). 18 To void ny interference in the chrom nd opcity evlutions due to tissue dehydrtion, tooth shde ws determined first. Cosmetic contouring ws performed to correct the lignment of the mxillry centrl incisors (Fig 5). After tooth prophylxis, modified ruer dm isoltion nd retrction cord were plced. The compromised old restortions were removed, nd circumferentil chmfer evels were creted (Fig 6). Prior to the restortive procedure, 15 seconds of etching with 37% phosphoric cid, followed y wter rinse, ws pplied. Then, n dhesive system (Adper Single Bond 2, 3M ESPE) ws pplied in ccordnce with the mnufcturer s guidelines (Fig 7). Using composite resin instrument VOLUME 42 NUMBER 3 MARCH

4 Fig 8 () Appliction of trnslucent resin to reproduce the pltl portion of the teeth with the id of the silicone index. () Appliction of dentin shde to crete mmelons nd reproduce the region tht corresponds with the deepest dentin. Dentin cn e pplied nd plced precisely in reltion with the future incisl edge. (c) Appliction of shdes A1 nd High Vlue for the lyer tht corresponds to the fcil surfce. (d) Artificil enmel of the finl desired shde is pplied from the cervicl third to the middle nd incisl thirds. c d Fig 9 (left) Completed restortions efore removing ruer dm isoltion. (IPC-T, Cosmedent), thin lyer of trnslucent enmel composite (YT, Filtek Supreme, 3M ESPE) ws spred on the silicone index s lingul shelf to estlish the pltl contour nd new incisl edge. The excess mteril ws removed, nd the composite resin ws light cured in position for 20 seconds. The rtificil dentin (shde A2 dentin, 4 Sesons, Ivoclr Vivdent) ws plced over the fcil portion nd sculpted in the shpe of mmelons. The hlo effect (ie, thicker volume long the incisl edge) ws sculpted with shde A2 dentin (4 Sesons). To mimic the oplescent effect of nturl enmel, smll increment of Blue Effect (4 Sesons, Ivoclr Vivdent) ws pplied to the region of the incisl third etween the mmelon spces (Fig 8). The finl lyer, which corresponded to the rtificil enmel, ws restored with shde A2 enmel (4 Sesons) for the cervicl third; shde A1 enmel (4 Sesons) for the medium third; nd High Vlue (4 Sesons) for the incisl third (Fig 8). All composites were crefully pplied with flt sptul nd lended with the id of no. 4 flt-tipped rush (Kot). Increments of composite resin were light cured for 20 seconds for ech lyer. A Mylr strip ws plced interproximlly nd pulled through to help crete tight contct point nd the correct fcil emrsure forms (Fig 9). Finlly, oth the uccl nd pltl surfces were light cured for 40 seconds. Before polishing, excess mteril t the mrgins ws removed with no. 12 surgicl sclpel lde 208 VOLUME 42 NUMBER 3 MARCH 2011

5 c Fig 10 () Lines were drwn long the proximolil regions to determine the light-reflecting nd mmelon res of the mxillry nterior teeth. () The surfce texture ws chieved with tpered dimond ur. (c) In sequence, the polishing ws completed with silicone ruer cups nd other finishing mterils. Fig 11 Mxillry ite splint in position. Fig 12 () Finl outcome fter recontouring nd restoring the nterior teeth. () Ptient s smile nd the new incisl edge position. (Swnn-Morton). A corse-gritted disk (Sof- Lex Pop-On, 3M ESPE) ws used to produce the primry ntomy nd chieve symmetry etween similr teeth. After the desired cervicoincisl nd mesiodistl lengths were reched, symmetric light-reflection res nd light-deflecting zones were outlined with pencil nd the distnce ws checked with shrp-ended cliper. The fcil nd pltl surfces were finished with corse silicone cup (Astropol, Ivoclr Vivdent) to prepre for the mcro surfce texture. Lines long the fcil surfce were creted with the id of fine-grit dimond ur (1190F, KG Sorensen) on 1:4 increser contr-ngle (T2 REVO, Siron) for optiml opertive control. The entire restortion ws then uffed with silicone cup to eliminte some of the ccentuted texture (Fig 10). The finl nturl gloss ws chieved with Astrorush (Ivoclr Vivdent), felt wheel nd n luminum oxide polishing pste (Enmelize, Cosmedent), nd rsive strips for refining nd polishing the interproximl res. To evlute the occlusion, the ptient ws plced in n upright position. The centric occlusion nd the protrusive nd lterl movements were exmined. Any equilirtion tht ws required to improve hrmony ws ccomplished with finishing dimond ur, nd the finl polishing procedures were repeted whenever necessry. Finlly, protection ite splint ws indicted for nighttime use (Fig 11). Figure 12 demonstrtes the finl result. VOLUME 42 NUMBER 3 MARCH

6 DISCUSSION Due to the evolution of composite resins, the old concepts of indiction tht limited their use in severl clinicl situtions hve chnged. This trnsformtion my e ttriuted to the evolution of the mterils properties, such s their durility, lod resistnce, esthetics, color stility, nd predictility. The clinicl performnce hs lso yielded fvorle results. These qulities llow for greter conservtion of tooth structure compred to indirect restortive mterils Frequently, the dentl prctitioner is chllenged to modify the configurtion of the smile y pplying n rtificil mteril to replce missing tooth structures or eventully rerrnging the disposition of the teeth. A good tretment must respect nd simulte the sptil rrngement, reltion, nd ppernce of nturl tissues. 7 The success of this procedure, however, depends on n understnding of the intimte structure of nturl teeth. 23 Despite the mny dvntges of composite resin, there re still some difficulties in regrd to color selection. This spect is considered prmount element for chieving esthetic success in restortion, ut if the ntomicl shpe is not dequte, the result will not pper nturl nd hrmonious within the dentofcil complex. Often, it is possile to chieve n esthetic result, even if the color is slightly different, s long s the shpe, surfce texture, nd opcity re hrmonic. 24 The shde of tooth is determined y the correltion mong enmel, dentin, nd light during the process of light refrction nd reflection. 11 Color mtching is prolem, especilly when there is lck of opcity in the dentin shde of the mteril. Such sitution decreses the vlue of the restortion. 25 This prolem is more likely to e noticed thn mistke in hue. 26 During the procedure of finishing nd polishing multiple nterior restortions, it is recommended tht light reflection nd deflection res e outlined in pencil nd checked with shrp-ended cliper. This procedure will enle the restortions to e s symmetric s possile. 27 Some procedures should e ddressed. Before the restortive procedure, n inoffice leching tretment ws performed. When leching is indicted prior to dhesive restortive tretments, it is importnt to wit t lest 24 hours efore onding to prevent ny negtive effects of ond strength of composite resin to the dentl structure. 16 A modified ruer dm isoltion technique s well s retrction cord were employed. This technique llows clinicins to hve free ccess to the gingivl re while keeping the field free of sliv. Further, only compromised old restortions were removed. Old restortions tht were not compromised y discolortion, mrginl stining, or recurrent cries were repired while seeking to improve esthetics so tht sound dentl structure ws not eliminted. The ptient should e wre tht the shde nd texture of the mteril will chnge over time. Restortions lso require periodic mintennce. Additionlly, orl hygiene protocols should e emphsized. The color of esthetic restortions cn e mintined for longer periods y introducing some restrictions on the ptient s dietry hits. 19 CONCLUSION Direct composite resin restortions hve the potentil to reproduce the ppernce of nturl tooth with highly esthetic outcomes. Additionlly, this procedure is good tretment option tht is less costly thn other indirect pproches. Therefore, this simplified pproch hs the potentil to extend the enefits of composite resin to lrger numer of clinicins nd ptients. 210 VOLUME 42 NUMBER 3 MARCH 2011

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