Direct Composite Restorations
Dr. Jenine Arab O’Malley
The trend in the dental profession is towards a bioesthetic approach which gives priority to an additive, minimally invasive procedure, for the preservation of tooth structure and morphology. With improvements in dental material technology, direct cosmetic bonding has now opened the doors to non-evasive, highly esthetic dentistry. Implementing composite resin in a stratification process has enabled dentists to use their artistic capabilities for the recreation of translucency, value, texture, form and function. The cosmetic outcome allows dentists to emulate natural dental morphology, which integrates seamlessly into the rest of the dentition.
A 22 year old female presented dissatisfied with the esthetics of her front teeth. She was unhappy with the chipped appearance on the left side, and found her top teeth looked blotchy, lacking consistency in color. She complained that the canines had unfavorable contour. Although she wanted a pleasing smile, she was not interested in cutting down her teeth for veneers. She did not desire her teeth to have a bleached or stark white appearance; rather she communicated she wished a soft, natural look that would emanate a natural smile.
For the preparation of the six anterior composite resin restorations, anesthetic was administered (1 carpule 2% lidocaine). A coarse long diamond bur was used to minimally prepare the maxillary anterior teeth to achieve bilateral symmetry and improve contours. With cotton roll isolation, the teeth were etched with phosphoric acid for 20 seconds. Scotchbond Universal Adhesive (3M) was brushed on, air dried for 10 seconds, then polymerized for 10 seconds using G2 Bluephase curing light (Ivoclar). The trimmed silicone putty matrix made from the diagnostic wax up was painted with wetting agent and loaded with a thin layer of Renamel Microhybrid Incisal Light (Cosmedent). This was adapted and cured to the tooth to create the lingual contours and provide a guide for the desired incisal length.
Ranamel NANO A2 was the next layer of restorative material placed on the maxillary teeth. The resin was feathered over the incisal third with the creation of mammelons. Translucent composite resin was rolled then placed in between the mammelons to achieve a soft translucent incised effect. Renamel NANO A3 was placed next in the cervical region and pulled through the interproximal regions, integrating it through the mid buccal aspect. Renamel NANO A1 was then feathered from the incisal third transitioning it into the body of the incisor restoration. Renamel NANO A2 was similarly applied to the canines. Further characterization was achieved by strategically applying Creative Color White Opaque (Cosmedent) with a perioprobe and selectively diffusing it with a sable hairbrush so as to gently integrate with the mandibular dentition. Creative Color Light Gray tint (Cosmedent) was supplemented in the incisal regions to create an incisal halo whereas light brown tint was placed in the cervical regions to elevate the chroma and prevent a monochromatic effect.
A final layer of Renamel Microfill Incisal Light (Cosmedent) was placed in the depressions of the incisors to accentuate incisal translucency and thinly feathered over the entire restoration. Renamel Microfill Incisal Medium was similarly placed over the canines. This microfill material was chosen for the final layer because of its effective and long lasting polishability. Prior to finishing the restoration, a 60 second final cure was administered.
Finishing and Polishing
The overall contours of the restoration were predominantly achieved during placement of the composite resin with hand instruments. The primary anatomy was refined with Cosmedent’s MiniFlexiDisc Coarse, on the incisal and interproximal aspect, medium long tapered diamond bur was used on the facial aspect, and an egg shaped diamond bur was used on the lingual aspect. Diamond finishing strips (Cosmedent) were used to complete contouring interproximally. The composite restorations were taken to final contour, defining the mesial and distal line angles, light reflective properties and height of contour.
Secondary anatomy was achieved with ET9 long tapered fluted carbide burs red/yellow/white using a pendulum like motion in the incisal 1/3 to accentuate the lobular anatomy. Final polishing was attained with fine and super fine rubber cups. Yellow discs were used interproximally and incisally. Finishing luster was achieved with FlexiBuff discs and Enamelize polishing paste (Cosmedent).