WAC focus: Restoration of upper central incisors
In the case described in this article, the patient – a 28-year-old who happens herself to be a dentist – is concerned about the wear in her front teeth which has been progressing.
Figure 1: Central incisors with tooth wear at the incisor edges: sharp-angled corners of the crowns, discoloration of the tissues along the enamel-dentinal junction due to food dies and chipping of the enamel. There is also a minor diastema resulting from a loss of the contact point: the medial surfaces of the central incisors are straightened with no S-shaped protuberance
Figure 2: The incisal edges of the central incisors are evenly ‘open’. The exposed dentin is discoloured due to its natural permeability and is wearing away forming a groove on the incisal edge. On the palatal surface of the upper incisors there is a typical stair-shaped facet, which was formed due to protrusion of the lower incisors. The latter is caused by a decrease in the height of the side teeth
Figure 3: The picture of the teeth in ultraviolet light shows the mismatch in fluorescence between the natural teeth tissues and the class V restorations. As the patient is a dentist, she knew exactly which material was used for these restorations (Gradia Direct) and was very surprised with what she saw in this picture
The signs are changing shape of incisors, shortening of crowns’ length, internal discoloration of the incisal edges and enamel chipping off. Class V restorations in the front teeth have been done recently with a popular nanohybrid composite.
During the clinical examination, wear facets with dentin exposure were found at the incisal edges and tips of molars’ cusps. As expected, these changes had been detected in all teeth. Therefore, it is beneficial to improve occlusion by restoring all teeth, rather than simply performing a restoration of tooth wear in the front teeth.
Direct restoration with a composite is particularly beneficial in teeth with mild tooth wear when indirect restoration is not yet indicated. Sealing the exposed dentin with a composite both protects the internal tooth tissues and prevents further loss of enamel.
Figure 4: In the anterior occlusion (above), only the central incisors contact each other, while in the right and left lateral occlusions there are multiple contacts between lower and upper teeth. The fact that there are multiple contacts between lower and upper teeth is particularly important for the lateral incisors which need canine guidance due to weak roots
Figure 5: The restoration of the length of the clinical crowns of upper central incisors and canines has achieved front (above) and lateral occlusions such that not all the upper teeth are in contact with the lower ones. This is particularly important for the upper lateral incisors given their relatively weak roots
In the case discussed in this article, the direct restoration of the upper central incisors was part of the systemic restoration of mild tooth wear when indirect restoration was not yet indicated.
The central incisors had a very thin layer of enamel at the approximal surfaces, which led to flattening of the contact points and, ultimately, a diastema.
In addition, the dentin at the incisal edge was discoloured due to exposure to food stains as a result of tooth wear. This discolouration shone through the enamel, thus compromising the aesthetics even further.
During the restoration the following clinical techniques were used:
• partial resection of the discoloured dentin
• restoration of the enamel and dentin using different composite materials with different mechanical properties
• imitation of the parapulpar dentin
• restoration of the enamel thickness at the approximal surfaces.
For enamel restoration, a body shade and a translucent enamel shade of micro matrix restorative composite material Esthet-X HD were used.
As a result of the restoration of the incisors, their anatomical shape was restored, the diastema was closed and their internal discolouration was removed.
The use of the micro matrix restorative composite material allowed a quality of surface polishing comparable with that of natural enamel. The systemic restoration of tooth wear also led to the restoration of the functional parameters of lateral and front occlusions. The estimated lifespan of the restorations is no less than 10 years.
Figure 6: The picture of the teeth in ultraviolet light shows an even fluorescence of the natural teeth tissues and the restorations made of Esthet-X HD. The previous restorations at the cervices of the incisors were of a high quality; they were therefore not removed completely. The remains of these restorations appear as a stripe of bright fluorescence on the upper left lateral incisor
• The author would like to thank Dr Andrey Astakhov from Oxford for the translation of this article into English
Serhiy Radlinsky will be speaking at the 2011 World Aesthetic Congress (WAC), to be held between 17-18 June at the Business Design Centre in Islington, London.
It will mark the 10th anniversary of WAC, the UK’s leading aesthetic dentistry event, and will offer the whole dental team show-stopping clinical and business sessions, an unrivalled panel of speakers, and an outstanding exhibition with more than 70 leading dental companies.
For more information or to book, visit www.independentseminars.com/wac.