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One of the main challenges in daily clinical practice is the replacement of old restorations, either due to caries or poor aesthetics. To do it in a simple and efficient way, we first need to know the anatomy of the tooth to be treated, meaning not only the macro- and micro-morphology, but also its internal structure, to imitate it perfectly with different opacities and thickness of composite resin. In this case, the biological foundations to use a certain thickness and shape of dentin, the step by step and some tips to achieve a simple anterior restoration with two opacities will be described.
Fig.1
Before reviewing the clinical case, it is important to look inside an upper incisor and understand its internal composition, not only conceptually but also physically, to try to imitate it with restorative materials. For this purpose, analysis with dental micro CT equipment is very useful, which allows us to separate the tooth by different densities thus obtaining a graphic representation of the enamel, dentin and pulp chamber.
Fig.2
If we look closely, we can see that human dentin is very irregular and usually ends in the shape of a knife edge, determining an individual dentin pattern for each patient.
Fig.3
Image after removing the enamel using 5% formic acid to check the shape of dentin.
Fig.4
Once the biological bases have been presented, changing the restoration on a central incisor with the concept of simple stratification of two opacities, to reach a final A3 shade will be presented. Once the patient’s occlusion has been checked, the first step will be the preparation of a guide by silicone putty.
Fig.5
Good isolation before removing the old restoration. It is very important to make the color selection before the isolation. In this case where the shade was A3, the Styleitaliano Custom Shade A3 Dentin + A3 Enamel for simplified layering technique was used.
Fig.6
Check that the isolation doesn’t interfere with the silicone guide, and that it reaches the correct position.
Fig.7
Complete removal of the old restoration.
Fig.8
The preparation should be done in a way not to see the limit between the future restoration and the tooth. The bevel must be wide and the proximal area should have a clear limit to give a space for the new proximal wall.
Fig.9
Delimitation for the enamel layer on the silicone guide, using LM Arte Fissura instrument.
Fig.10
Always protect neighboring teeth during acid etching.
Fig.11
Application of a universal adhesive (3M Scotchbond Universal).
Fig.12
Once the adhesive is light-cured, a layer of enamel is placed on the silicone key, according to the delimited area, and then positioned in the mouth.
Fig.13
After creating the palatal layer (Enamel A3 z350 XT 3M) with the help of the silicone key, LumiContrast matrix (Polydentia) was positioned and secured with a wooden wedge.
Fig.14
Proximal wall reconstruction (Enamel A3 z350 XT 3M).
Fig.15
Matrix and wedge removal to check the contact point.
Fig.16
Placement of a dentin increment (Dentin A3 z350 XT 3M) and thickness calibration with the help of LM Arte Misura instrument to keep 0.5 mm for the enamel layer.
Fig.17
Once the thickness of the dentin has been calibrated, match the dentin pattern according to the biological concept (knife-edge ending towards the incisal edge) and define the mamelons.
Fig.18
Check the space for the enamel layer once the increment was light-cured with the multi-wave Curing Pen device (Eighteeth).
Fig.19
The final enamel layer was added (Enamel A3 z350 XT 3M) to finish the restoration.
Fig.20
Finishing of the restoration, by respecting the macro and micro anatomy of the neighboring incisor, performed with a low speed bur from Style Finale, the Styleitaliano Finishing Kit by Intensiv.
Fig.21
For polishing, spiral soflex (3M) was used.
Fig.22
And for the final finish, diamond polishing paste (Premier) and felt disc.
Fig.23
Restoration finished.
Fig.24
Photograph with cross-polarization filter to check the color integration of the finished restoration. Picture was taken with a smartphone and Smile Lite MDP (Smile Line, Switzerland)
Fig.25
Perfect integration of shape and color of the new restoration.
Fig.26
Conclusions
A simplified layering technique with only two composite opacities can solve most of our anterior restorations, if we respect the biology and the shape of the restoration. To achieve good aesthetic results, and to do a fast and efficient job, smart materials, products and instruments should be used to facilitate our daily work.