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Composite in Everyday Practice - How To Choose The Right Material and Simplify Application Techniques in The Anterior Teeth
Composite in Everyday Practice - How To Choose The Right Material and Simplify Application Techniques in The Anterior Teeth
Composite in Everyday
How to Choose the Right Material
and Simplify Application Techniques
in the Anterior Teeth
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Practice: esse nc e n
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Abstract
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mimetic.
cal results.
from.1,2
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among clinicians that the layering techniques are rather complex and it is difficult
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Introduction
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Fig 2
teeth.
Fig 3
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Fig 4
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Fig 5
Fig 6
Fig 7
Fig 8
flowable composite.
Fig 9
Fig 10
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touched.
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Fig 11
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The finished case with good esthetic integration achieved at relatively low biological and financial cost.
The situation before and after the intervention: the additive solution allows for re-intervention
without dental sacrifice should the patient subsequently decide to resort to other restoration solutions, or require
root canal treatment in the future.
In recent years, there has been a breakthrough not only in the use of composite
resin, but also in the way it is being manipulated. Initially, the materials were seen as
nothing more than an esthetically agreeable way of filling cavities.3 Only later did
clinicians begin to layer predetermined
thicknesses of dentin and enamel to build
up a natural looking restoration.4-8 This
technique, known as stratification, has its
origins in the way ceramicists operate and
Fig 13
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a
Fig 14a
Fig 14b
ral tissues.
clinical experience.16
been simplified.
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Consequently, the choice of dentin
te is now on
ss e n c e
focused on a single base hue with different
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Fig 15
Fig 16
Fig 17
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Three-dimensional
thickness
Utilization of the silicone guide and interproximal matrix allows one to manage the
two dimensions of the restorations space:
height and width. The greatest difficulty
remains managing the third dimension
thickness of the toothand this, in the authors' experience, is the primary cause of
esthetic failure.
The correct calculation of the thickness
of the alternating opaque and translucent
materials is a crucial step when reconstructing a tooth using composite materials. It is well known that enamel materials
tend to increase the grayish effect the
thicker they are, and thus dull the underly-
Fig 19
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How to resolve this problem
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Fig 20
el, after evaluating the opacity of the patients natural enamel as well as the choice
of composite to use (see clinical case).
As a general rule, authors advise leaving space no larger than a half of a natural enamel thickness.
One of the more interesting innovations
in the world of composites is the recent introduction of high refractive enamel that
has a refractive index very close to that of
natural enamel. As can be seen in the example in Figure 21, the use of this kind of
enamel increases the thickness without increasing the graying effect; on the contrary,
Fig 21
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miraculous
esthetic
mechanical
and
chameleonic properties.
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Nanofillers deserve a separate discussion.
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Composites made of these materials were
percentages
of resin.
of
microfiller
composites
ronment.
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be a wise decision.
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thickness of the residual enamel,
te which on
ss e n c e
physiologically loses value or whiteness
Presumably,
the
above
mentioned
phies.
restoration).
bleaching restorations.
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structions that come with products are often of little use (Fig 22). What is more, clinicians often fall into the trap of dividing
materials into those considered simple
and those designed for the esthetically
obsessed, as if there might be patients or
dentists interested in esthetically displeasing restorations. Moreover, clinicians request materials with chameleonic properties, as if a syringe could possibly contain
Fig 23
guides.
Fig 24
alytical evaluation.
missing completely.
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stains
stains
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Composite
features
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Table 1
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Suggested key parameters for evaluating the ideal choice of material.
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Enamel
Dentin
Opalescence Intensity
Dark
Light
Deep dentin
Mamelon
masses
Fluorescence
Hybrid
5
5
Opalescence
Nanofill
Microfill
Flowable
Opacity
Translucency
Chroma
Value
0: not desirable, 1: not appealing, 2: somewhat appealing, 3: appealing, 4: very appealing, 5: desirable
Fig 25
Fig 26
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thickness variation of the tooth. A rigid silicone impression, taken from an integral
DEVOTO ET AL
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copy, the tooth was divided into three layers: dentinal body, dentin (creates internal
anatomy like mamelon and opalescence),
and the vestibular surface enamel (Fig 27).
With the aid of calibration and a thickness
gauge, three types of samples were mechanically prepared:
I
Fig 27
models that could be inserted in a specially created laboratory flask using a transparent silicone guide (Fig 29).
By analyzing the color samples on the
prefabricated scale, two colors of dentin
and three different types of enamel were
identified for each composite system available on the market. The choice of samples
was based on the analysis of two expert
clinicians, one newly graduated dentist
and a dental technician, who analyzed the
color scales without knowing the product
brand or the masses. The panel was asked
to identify masses and base their decisions on knowledge and clinical experi-
Fig 29
tal ages.
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moved mechanically.
Fig 31
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Fig 30
nicians
an
extraordinary
authors during this experience was certainly empirical, but very close to the clini-
possess
analyzing
sertions above.
using
color-
suitable
spirit of collaboration.
for
emphasizing
particular
materials
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Clinical case
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Fig 32
11. Alterations to the pre-existing restorations and evidence of the degree of contamination by bacterial plaque.
examination
not
only
Fig 33
quent
periapical
asymptomatic
lesion
(Fig 33).
After careful cleaning and a motivating
oral hygiene session (Fig 34), the treatment plan proceeded with an accurate
cleaning of the cavity to eliminate the carious infiltrations. The margins were polished to eliminate areas which could retain
bacterial plaque and the root canals were
then correctly re-treated.
Fig 34
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Only at this point did research begin
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ce
form of the teeth, and the first step swas
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ask the patient to provide photographs taken before the restoration work was carried
out. A diagnostic waxup was made on extra hard plaster casts (Fig 35). These plaster models were used to create a series of
Fig 35
the waxup.
compiled,
subsequent
to
careful
scalpel blade where necessary, the provisional composite fillings were removed using a medium grain cylindrical diamond
bur (Fig 36).
The preparation of the enamel was limited to clean, well-finished margins and a
chamfer on the vestibular finishing line to
render the transition from composite to
natural enamel invisible. Great care was
taken to finish the preparation margins using silicone points mounted on a blue ring
counter-angled hand piece, at a low
speed, to carefully smooth the preparation
and eliminate the prisms of unsupported
Fig 37
enamel which would break off during polymerization contraction and lead to discoloring and infiltration of the restoration. This
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Once the cavity preparation was finished, a silicone stent made it possible to
visualize form, thickness, future dimensions, and correct interproximal relationships. This is of significant help as it renders the work predictable, allowing for
time management and limiting chair time.
Also, sectional transparent matrixes with
multiple convexities (KerrHawe, Bioggio,
Switzerland) are a useful aid for time man-
Fig 38
Fig 39
Fig 40
elements.
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Fig 41
Fig 42
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on a waxup.
interproximally.
Fig 43
Fig 44
stent.
Fig 45
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Fig 46
ternal features.
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Fig 47
to 48).
Fig 49
Fig 50
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Fig 51
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Fig 52
Two-year follow-up.
canal treatment (a) and radiographic check of restorations 2 years after treatment (b) with resolution of apical radiolucency.
tients.
favored.
Conclusions
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Fig 53
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Constant practice and a good knowledge of the materials allow clinicians to reproduce every detail,
even serious esthetic defects such as a tooth which has been discolored by antibiotics
Acknowledgements
The authors wish to express their heartfelt gratitude to
the following people: Dr G Paolone (Rome) for his help
to) for the root canal and surgical treatment of the clin-
References
1.
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17. Devoto W, Pansecchi D. Composite restorations in the anterior sector: clinical and aesthetic performances. Pract
Proced Aesthet Dent
2007;19:465-470.
18. Devoto W. Clinical procedure
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Dent 2002;14:541-543.
19. Paris JC, Andrieu P, Devoto W,
Faucher AJ. Les canons de la
beaut. Le guide esthtiuque.
Paris: Quintessence, 2003:
105-234.
20. Devoto W. Direct and indirect
restorations in the anterior
area: a comparison between
the procedures. QDT Yearbook
2003;26:127-138.
21. Yamamoto M. The value conversion system and a new
concept for expressing the
shades of natural teeth QDT
Yearbook 1992;19:9.
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22. Fiechter PA. The reproduction
t
ess Dentc e n
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en
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