Author: Gaetano Paolone, DDS
Adjunct Professor Restorative Dentistry, Vita-Salute University, San Raffaele, Milan
EAED affiliate, AIC active member, IAED active member, AIOM active member
When planning a restoration, the color of the substrate should also be taken into account in order to achieve a satisfactory esthetic outcome. In some clinicalsituations, clinicians are asked to hide the substrate with the restoration; in other situations, clinicians can take advantage of an unaltered color substrate and therefore select less opaque materials that exploit the color of the underlying tissue. (Int J Esthet Dent 2017;12:2–15)
A 46-year-old male patient presented at our practice complaining about the esthetic appearance of his anterior teeth. Almost all of the maxillary and mandibular anterior teeth showed stained margins, a rough surface, and incorrect anatomy (Figs 1 to 4).
The patient reported that his teeth were restored 4 years earlier, and that they were retreatments of previous fillings made for caries. The clinical examination showed gingival inflammation. From an occlusal point of view, the patient presented a crossbite, and no sore muscles or joint pain. He reported not to care about his occlusal situation from an esthetic point of view, and reported no difficulty in chewing.
After thorough diagnosis and planning that also took into consideration the patient’s limited financial situation, a treatment plan was devised. The treatment procedure consisted of the following stages: thorough periodontal therapy involving scaling and oral hygiene, a color chart, composite direct restoration (teeth 13, 12, 11, 22, 23, 34, 35, and 43), with follow-up controls.
Careful cleaning during a motivating oral hygiene session was performed during the first appointment. One week later, no gingival inflammation was detected.
No silicone impressions were taken to make extra hard plaster casts and a diagnostic wax-up, while all the restorations had a buccal access. In the same appointment, personalized color and opacity charts were compiled (Figs 5, 6, and 7) under a light source of 5.500 K with a custom shade guide. The color chart was different for the maxillary and mandibular teeth due to a different shade match. The maxillary teeth were restored with A3/D3 (Brilliant EverGlow, Coltène/ Whaledent) and Translucent (Brilliant EverGlow) on top of the restoration (with a thickness of maximum 0.7 mm). The minor cavities were restored using only the Translucent mass. Due to a better match with the custom shade guide, the mandibular teeth were restored with A3B Estelite Asteria (Estelite Asteria, Tokuyama Dental), covered by OcE (Estelite Asteria) with a maximum thickness of 0.7 mm.
At the next appointment, the teeth were isolated from second premolar to second premolar with a medium-weight rubber dam (Isodam, Sigma Dental Systems) and two no. 2 clamps (Ivory, Heraeus Kulzer) (Figs 8 and 9).
The cervical area was not completely exposed by rubber dam isolation. No ligatures were applied because they were not strong enough to show the cervical portion of the isolated teeth. The application of other clamps (211, 212, 9, and 9s) one by one on each tooth to be restored (Fig 10) allowed access to the cervical area.
Each tooth was prepared and restored individually, one by one. All the treatments were completed over two appointments. The old composite filling was removed using a carbide multi-blade round bur (H1S-204-012, Komet/Brasseler) (Fig 11). Preparation (if any) was performed with a cylindrical diamond bur (880-314-012, Komet/Brasseler). For each tooth, the cavity design was almost always the result of the removal of the old filling (Fig 12). Little secondary caries were detected, especially around the margins of the old restorations.
Adhesive procedures were performed with a three-step etch-and-rinse system (OptiBond FL, KerrHawe). A 37% phosphoric acid (Ultra-Etch, Ultradent) was used to etch the enamel and dentin (both for 15 s). Primer was applied, and then air was gently applied. Bonding was applied and excesses were removed using paper points and dry brushes (Fig 13). Light curing (Valo, Ultradent) was performed for 20 s using the Standard program, moving the lamp tip in different directions.
Shades were chosen based on the initial color chart (Brilliant EverGlow; Estelite Asteria).
The (few) elements that had cavities involving the interproximal wall were restored with preformed sectional matrixes (Adapt Sectional 757, KerrHawe; Palodent, Dentsply), and adapted with a wooden wedge. Due to the low thickness of the interproximal area generally presented by anterior teeth, the same shade used for the dentinal body (more opaque than an enamel) was used to define the 0.5-mm interproximal frame (Fig 14). If a mass is used (enamel) that is too translucent, the interproximal area can appear gray.
Once the frame of the tooth was defined, where needed, dentin was layered, and its thickness checked with respect to the surrounding tissue, leaving about half a millimeter for the outer layer. No sagittal silicone index was used because thicknesses could be clearly understood from the boundaries of the cavities.
To model the outer layer of composite resin, synthetic flat soft brushes (da Vinci 374 sizes 2 and 4, DEFET) were used, along with a conditioner (Composite Wetting Resin, Ultradent) (Figs 15 to 29). Then, composite masses were cured for 20 s from the buccal side. The restoration was then finished and polished with a low-speed diamond bur (831-204-012, Komet/Brasseler) as well as silicone rubber (OneGloss, Shofu Dental) and diamond pastes (Opal L, Renfert) that were applied with natural goat brushes and felt.
At 1 month postoperative, the restorations showed a good integration with the marginal tissues, as was shown several months after the end of the treatment (Figs 30 to 32). Under black light, all the restorations can be detected (Fig 33) if a fluorescent composite has been used (almost every material is fluorescent nowadays). It is, in fact, possible today to select the correct fluorescence of the material to be used in order to match one of the natural teeth. Moreover, in composites almost all shades are fluorescent, which gives restorations a higher value.
The polarized image of the restorations (Fig 34) shows good integration.
Checking the final result from a visual point of view only is questionable. Photographs are generally influenced by several factors such as angle of view, magnification, and light position. Removing glares through a polarized filter helps to understand the correct shade matching and the real value of the restorations. Cold and EPT tests produced positive responses. The patient appeared motivated and has changed his attitude toward oral hygiene, which has resulted in the disappearance of the gingival inflammation.
Composite restorations in the anterior zone always represent a challenge. Understanding how to handle shades, value, and substrate can reduce the risk of an unsuccessful outcome. Other factors such as color changes of aged dentin and material aging should also be considered. Clinicians should also take into account the fact that different materials show different color stability while they are related to composition and degree of conversion and they are also influenced by a patient’s diet. The authors would like to see on the composite syringes or packaging not only the shades but also the opacity/translucency of the masses of at least 1-mm thickness. This would be very useful in order for clinicians to understand how to handle the materials.
Every tooth in the clinical case presented in this article was treated with just one medium translucency shade and one more translucent one because the color of the substrate was not so different from the surrounding tissue. When the substrate is unaltered (not discolored) or just slightly chromatic, the clinician can take advantage of composite shades that are able to blend with it.
Author, should this remain as masses or change to ‚shades‘?