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Ivoclar Vivadent
Smile Upgrade with a new composite resin system
by Ronald D. Jackson, DDS, FAGD, AFAACD, DABAD
The emphasis on appearance is pervasive in today’s media driven culture. It is particularly keen in adolescents as a result of constant exposure to images of beautiful young celebrities (real or media created) in magazines, television, pop music and everywhere on the World Wide Web. Because the smile is such a significant factor in facial appearance, the impact of this culture shift on dentistry has been enormous. In particular, even young teenagers are seeking out aesthetic oriented dentists and requesting correction of mild to moderate imperfections in teeth that previous generations tolerated because dentistry lacked a simple, predictable esthetic solution. (Figures 1-4)
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| Figure 1: 14 year old female with prominent white spot on right central incisor. | Figure 2: This “appearance lesion: was treated with a conservative 4 Seasons/Empress Direct restoration. | |
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| Figure 3: Influence of white spot on full face appearance. | Figure 4: This small treatment has a big effect on overall image. Note the patient underwent tooth bleaching prior to placing the restoration. |
Case report #1
History and Diagnosis
A sixteen year old female reported with a chief complaint of being dissatisfied with previous dental treatment of her maxillary central incisors. Her dental history revealed that she had large white spot lesions in the incisal one third of each of these teeth, which she said appeared following orthodontic treatment. She had seen a dentist a several months earlier who placed composite resin restorations in both centrals but she was dissatisfied with the result (Figure 5). The clinical examination showed these quite visible restorations to be lacking in natural appearance and to have marginal discoloration. Although the shade was close to being correct, the lack of a life-like appearance was deemed to be the result of using a single opacity of composite resin. The discoloration is likely due to inadequate enamel adhesion at the margins.
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| Figure 5: 16 year old female is dissatisfied with treatment of white spot lesions. | Figure 6: An egg shaped diamond is used to create a saucer preparation approximately .8 mm deep in the center. | Figure 7: The preparation is feathered and scalloped an additional 1 – 1.5mms beyond the white spot. | ||
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| Figure 8: Opaque Dentin shade A1 blocks the visibility of the white spot. | Figure 9: A1 Enamel shade is placed just short of the prepared margins and occupies approximately two thirds of the remaining depth of the preparation. | Figure 10: Tetric Color white is placed with a brush. |
Clinical Technique
It is important to take the shade quickly at the beginning of treatment to avoid the effects of dehydration. Using the middle third of the lateral incisors as a reference, the shade was determined to be A1. Also observed was mild dispersed white areas scattered irregularly in all the upper incisors.
The existing composite resin was removed on the right central incisor using an egg shaped diamond (Figure 6). No anesthetic was used. This would act as a guide to the depth of the preparation as there is no need to prepare to the dentin layer. The preparation using this diamond would be “saucer” shaped with the depth in its center approximately .8 millimeters and tapering to a shallow depth at the margins. The preparation is feathered and scalloped another 1.0 millimeter beyond the outline of the white lesion (Figure 7). The preparation, including enamel beyond the margins, was etched with 37% phosphoric acid for 20 seconds, then washed and dried. Since no dentin is exposed, Heliobond (Ivoclar Vivadent – Leicestershire, England), an enamel bonding resin without hydrophilic monomers or solvent was placed and light cured.
A new, naturally shaded composite resin system, Empress Direct (Ivoclar Vivadent – Leicestershire, England), was selected because of its accurate shades and consistent opacities. Since the combination of the dentin and enamel of the tooth yielded a shade of A1, the composite resins used to restore the cavity will be A1 Dentin and A1 Enamel. No recipes or combinations of a darker dentin and lighter enamel are needed.
The A1 Dentin is applied on the white spot area only and occupies about one half the depth of the preparation. Because of the opacity of the dentin composite resin, the white spot is no longer visible (Figure 8). After curing, the A1 Enamel is applied. This increment of material occupies approximately two thirds of the remaining depth of the preparation and is extended to just short of the prepared margins. Before light curing, multiple grooves and surface irregularities are sculpted with a thin bladed instrument (Figure 9). A small amount of Tetric Color white (Ivoclar Vivadent – Leicestershire, England) is then placed with a brush and light cured (Figure 10). Depth and life-likeness is now achieved by application of translucent composite resin, Trans 30 (clear), which completes the restoration to slight over-contour. This layer also extends beyond the prepared margins (Figure 11). Finishing and polishing are accomplished using aluminum oxide discs and the Astropol (Ivoclar Vivadent – Leicestershire, England) system. The patient was pleased with the result (Figure 12).
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| Figure 11: Translucent composite resin, Trans 30 (Clear) completes the restoration to slight over-contour. | Figure 12: Postoperative view of minimally invasive aesthetic restorations using 4 Seasons / Empress Direct Composite Resin System. |
Case report #2
History and Diagnosis
| An eighteen year old female patient was referred for evaluation by her orthodontist. She reported dissatisfaction with visibly prominent white spots located in the incisal 1/3 of both maxillary central incisors. (Figure 13) It is important to note that it is often difficult to determine preoperatively how much these opacities penetrate the surface. Some lesions can be removed with microabrasion and re-polished. Others will be deeper ending somewhere within the enamel layer and still others can penetrate totally through the enamel layer. (Case #1) These latter two lesions will require restorations upon removal or partial removal as the case may be. (Case #1) |
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| Figure 13: 18 year old female with prominent white spot lesions on maxillary central incisors. |
Figure 14: Appearance after supervised, custom take home bleaching. | Figure 15: Opacities still prominent in full face view after bleaching. | ||
Clinical Technique
| The patient desired a lighter color for her teeth so dentist monitored take home bleaching was carried out using a custom fabricated tray. Although the contrast between the white areas and the tooth color following bleaching was reduced somewhat, their opacity still interferes with a pleasing natural appearance. (Figures 14, 15) After taking the shade (Bleach L) and without local anesthesia, the white lesion was gradually removed using and egg shaped diamond. At a depth of approximately .3mm, the lesion is completely gone. The preparation is saucer shaped and beveled at the margins as in Case 1. (Figure 16) Since no dentin is being replaced and there is no discolored area to be blocked from view with an opaque composite (dentin), the missing enamel was replaced with Empress Direct Bleach L Enamel only. Although this system contains the necessary 3 opacities to treat a broad range of conditions, the opacities selected are determined by the requirements of the case and the tissues being replaced. The shallowness in this case obviates the need for a layer of translucent composite. Following finishing and polishing, the patient was pleased with the outcome. (Figures 17, 18) |
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| Figure 18: Full face view with “Smile Upgrade”. | ||||
| Figure 16: Same preparation design as in Case 1. The lesion is entirely removed at a depth of .3 - .4mm. |
Figure 17: Appearance two weeks post-operatively. | |||
Conclusion
Today’s patients want their dentistry more aesthetic but less invasive. Directly placed composite resin accomplishes both. Further, there is no question that the emphasis on appearance and, in particular, the smile, has raised the aesthetic standard in dentistry. Good enough is no longer good enough. Manufacturers have met this challenge by creating better materials that mimic tooth structure. The challenge for dentists is to learn the skills to use them in order to satisfy the desires of today’s discriminating patients.
Fortunately, this challenge is made much easier when using the naturally shaded composite resin system, Empress Direct. The broad range of shades which are true to the shade guide, the 3 opacities (dentin, enamel and translucent), each accurate in a narrow range, combined with excellent handling and ease of polish, significantly shortens the learning curve. The joy of creation is enhanced further for dentists when the patient sees the results. In addition to gratitude, patients express admiration for the clinicians’ artistic skills.
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