Bringing anterior direct composite restorations to life with histologic layering protocols
22 yr old Male walked into our dental office saying that he had a fall many years ago and his front teeth were broken. There was no associated pain or symptoms and the problem was purely aesthetic. He was only seeking treatment because he needed to get married soon. He was low on confidence while smiling and required a solution within 4 weeks.
The two maxillary central incisors were fractured and non-vital with noticeable darkening of shade. They were mal-aligned buccolingually and there was a midline diastema as well. There was no tenderness on percussion. There were peri-apical lesions associated with both incisors in the radiograph.
Non-surgical endodontic treatment was done in the 1st week. After the symptoms resolved completely we were ready to restore form, function and aesthetics. Non-vital in-office bleaching was done. Pola office bleach was used for the same, 3 cycles of 8 minutes each. It appeared that the shade had corrected completely after bleaching but we waited for it to stabilize.
Two weeks later, the shade stabilized and the teeth were ready for bonding. We observed that the central incisors were still darker than the neighboring teeth. Direct composite veneers were planned with the help of a lab made wax up and a putty index. Bevels were placed and most of the preparation was in enamel. After the total etch protocol, 5th generation bonding agent was used. 3M Z350XT shades were used for the build up. A2 Enamel shade was used for the palatal shell and the proximal walls.
Desaturation was achieved by layering a deeper darker dentin [ A3 Dentin ] inside and a lighter dentin [ A2 Dentin] shade over it in the shape of three mamelons. Incisal Halo was achieved by layering an Achromatic Enamel [clear translucent] shade around the mamelons and the A2 dentin shade on the incisal edge. Final layer of A2 Enamel shade was used covering the restoration in 0.5mm thickness so as to avoid too much translucency. Finishing and polishing were done using the 3M Soflex discs and spirals as recommended by the manufacturer.
We have previously discussed the finishing and polishing protocols of this case in detail in an earlier article [click here for link]
Post-op instructions included regular follow ups to see if the peri-apical region was healing properly. Patient has been informed that composite resin is unable to bear shearing forces, the restoration may debond. And that he needs to come back for polishing every 6 months for routine maintenance.
Understanding the patient’s requirements in aesthetic cases is of utmost importance. Photography and documentation of aesthetic work helps in planning and execution. Having a set protocol with regards to the clinical work flow, makes these cases more predictable. Using a wax up makes it easier to control the palatal anatomy and emergence profile of the restoration. When used meticulously, direct composites can result in extremely aesthetic, life-like restorations.
With proper Layering Protocols and systematic finishing and polishing, a direct composite buildup can restore a smile as efficiently as an indirect restoration.
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