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Caroline Werkhoven

Intraoperatory tips: When shape goes wrong

30647 Views - May 2016

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With great restorative power comes great responsibility. When a young patient suffers a severe dental trauma and comes into our office for treatment, the dental team has a chance to do it right at the first attempt, which means we have the possibility and the duty of providing our patient with the best initial treatment, i.e. the best basis to work with later on. The final treatment will be about restoring the patients teeth and regaining the patient's beautiful smile without sacrificing any more tooth structure than the trauma already did.
This patient had fallen in the bathroom and suffered uncomplicated crown fractures on the maxillary left and right central incisors. Teeth #12, #11 and #21 had been luxated; the dentist splinted the front teeth at the emergency visit. After a week the patient was seen by endodontologist Dr. Marga Ree and a CBCT scan showed that tooth #11 and #21 were still displaced out of their sockets. The splint was loosened and tooth #21 en #11 were handled to be repositioned more apically back in their sockets. Repositioning succeeded completely for tooth #11. The apices were fully developed. Root canal treatment had to be performed on teeth #12, #21 and #11. The splint was applied again to stay in situ for two weeks.
The goal was to provide a restoration that would last long on all grounds, both functionally as esthetically so that the tooth could be kept untouched for as long as possible in the future. Direct composite is the material of choice for this restoration.

Img. 1 - During the endodontic emergency visit tooth #11 still showed great mobility despite having been splinted for a week. The central palatal papilla was also still heavily swollen. A CBCT scan was to be made. (photo courtesy M. Ree)
Img. 2 - The CBCT scan showed the extrusive luxation to be corrected. (Photo courtesy M.Ree)
Img. 3 - Preoperative situation frontal view. Showing the uncomplicated crown fractures on tooth #11 and #21.
Img. 4 - Preoperative situation frontal view. Note the gingiva of tooth #11 still recovering from the repositioning procedure.
Img. 5 - Preoperative left lateral view in occlusion.
Img. 6 - Preoperative left lateral view. Besides the crown fracture cracks in the enamel are highly visible in tooth #21.
Img. 7 - Preoperative right lateral view in occlusion.
Img. 8 - Preoperative right lateral view.
Img. 9 - Preoperative upper left lateral view.
Img. 10 - Preoperative upper right lateral view.
Img. 11 - Preoperative upper frontal view.
Img. 12 - Preoperative palatal view of upper incisors. Temporary Cavit restorations on root canal accesses tooth #12, #11 and #21. Canals were temporarily filled with calcium hydroxide following preparation and irrigation with 5% NaOCl by the endodontologist Marga Ree. Patient had an appointment scheduled for final endodontic treatment.
Img. 13 - Preoperative view left lateral, lip framed.
Img. 14 - Preoperative view right lateral, lip framed.
Img. 15 - Preoperative frontal view, lip framed. Preoperative photographs were taken to communicate with the lab about desired shape, length and width. A preliminary color analysis reduces color mock-up chairside time.
Img. 16 - The wax-up made by the lab shows proper form and shape, angulation and incisal thickness. If the incisal edge is too thick the three planes on the buccal are off and you might end up correcting the incisal third of the restoration, thereby loosing any applied characterizations. The waxed-up teeth should recall the same shape and anatomical features of the neighboring intact teeth. In this case the angles are quite round as the ones of a young unworn teeth.
Img. 17 - When restoring the incisal third of a tooth full of characteristics, the exact right placement of the different colors and translucencies is crucial. The silicone index is impressed on the waxed-up cast to transfer shape of the restorations directly into the mouth, significantly reducing any corrections that would have to be made afterwards. On the palatal side the occlusion is correct and on the labial and incisally only minor adjustments are necessary, thus ensuring correct incisal edge position and preservation of the characteristics of the restoration.
Img. 18 - High contrast and low brightness set on the picture is useful for preliminary color analysis. Note how the residue of orthodontic cement is clearly visible.
Img. 19 - The color mock-up is made intraorally before the rubber dam is in place while the teeth are still fully hydrated. The composite is light cured before analysis. Dehydration of teeth alters the color scheme drastically within minutes. Note the round crack on tooth #11 caused by the trauma.
Img. 20 - The rubber dam in place.
Img. 21 - The silicone index in situ. The fracture outline is marked with the Fissura instrument (LM-Arte). Composite is placed on the putty without crossing the line thus avoiding a surplus on the palatal side that would need to be removed when checking occlusion.
Img. 22 - Bevels were made on the edges of the fracture outline. In order not to sacrifice anymore enamel it was chosen to keep the round crack highly visible just above the fracture line (see also the colour mock-up picture img. 19).
Img. 23 - The first layer of white enamel composite is applied on the matrix first and then transferred to the mouth and adapted to the tooth structure with the outlines respected before light curing.
Img. 24 - For the first mamelon application a dentin-like A3 composite was used.
Img. 25 - On top a body enamel A2 to mask the intense opacity of the dentin mass applied.
Img. 26 - With a mini brush a white effect colour mixed with sculpting/composite instrument wetting resin is applied alongside the the outline of the palatal shell. The mix ensures the intensity of the color level of the color effect drops down. See the article `The Power of Color: Blurred Lines´. After light curing a dash of super translucent composite is placed in between mamelons giving it a grey/blueish effect in the final result.
Img. 27 - The last layer of white enamel composite is applied on the labial surface. It is the same that was used for the palatal shell; they meet on the incisal edge again creating a sandwich.
Img. 28 - Final adjustment of the approximal side with a diamond strip is done now because of the great accessibility of the mesial.
Img. 29 - Tooth #21 is ready to be restored.
Img. 30 - Same procedure as on tooth #11 is performed on #21.
Img. 31 - First step of the finishing phase starts with perfecting the incisal edge with the help of a pencil and the silicone index according to the article The Power of Pencil.
Img. 32 - With a pencil the present transitional lines are identified by drawing passively. The lines are full of irregularities and need to be refined.
Img. 33 - The pencil lines are pushed in the right direction.
Img. 34 - The transitional lines are now straightened and show symmetry of both central incisors.
Img. 35 - From a frontal view a discrepancy in the midline is obvious.
Img. 36 - To correct the midline and preserve a good contact point the two elements are slightly separated by a thick dental floss. No force is exerted on the floss.
Img. 37 - To correct the use of a thin finishing disc is mandatory. A thicker one will be less subtle and give unwanted impressions in this delicate area.
Img. 38 - After correcting tooth #11 the midline of tooth #21 is corrected.
Img.39 - The midline is corrected now, but the teeth still appear unnatural and unlively. Creating secondary and tertiary anatomy and gloss will bring it to life.
Img. 40 - For the secondary anatomy a coarse diamond bur is used with very low speed for maximum control. The amount of white dust is the indication how much composite is removed. Therefore no water is used.
Img. 41 - The last finishing step is polishing for gloss and that consists of multiple steps to achieve a low surface roughness and minimize the chance for future staining of the composite. Starting with the beige Sof-Lex Spiral elastomer wheel on a wet surface.
Img. 42 - Next step is the pink Sof-Lex Spiral Diamond also on a wet surface.
Img. 43 - The final step is a felt coated disc used together with an aluminium oxide paste.
Img. 44 - Composite restorations are finished. Because the teeth are dehydrated the final outcome cannot be judged on the spot. The color mapping from the beginning should be trusted.
Img. 45 - Final result. The teeth are now rehydrated. The transition from composite to tooth structure is invisible: only the round crack on tooth #11 caused by the trauma is visible (see img.19). The qualities of the composites used - opacities, translucencies, white spots - are completely in sync with the natural dentition creating a harmonious effect overall.
Img. 46 - Final outcome, right lateral in occlusion.
Img. 47 - Final outcome, right lateral.
Img. 48 - Final outcome, left lateral in occlusion.
Img. 49 - Final outcome, left lateral.
Img. 50 - Final outcome, upper right.
Img. 51 - Final outcome, left lateral, lip framed.
Img. 52 - Final outcome, right lateral, lip framed.
Img. 53 - Ultra close-up shows full integration of the restorations. The transition from tooth structure to restoration is untraceable despite very moderate beveling.
Img. 54 - Final result: incisal edge position of the restorations perfectly resting on the vermilion border. With tooth display at rest according to her relatively young age.
Img. 55 - Final result: the residue of orthodontic bracket cement was completely removed from the lateral incisors too.
Img. 56 - Final result: full smile.

Conclusions




Conclusions

In cases in which a young patient is involved it is of primary importance to preserve hard and soft tissues. This kind of restoration, made with a minimal preparation not to sacrifice anymore tissue than it is necessary can still provide the patient with a very pleasing result esthetically. Because of the available bonding techniques we nowadays have, the long term bonding of the restoration is, in most cases, not the bottleneck of the restoration. The aesthetic demands of the patient are indeed. Making sure the patient is satisfied on that level is, in fact more challenging than stay of the restoration itself into the patient´s mouth for a long time, which is, of course, not optional. Hence, reducing the need for (multiple) replacement(s) of the restoration when the patient becomes older should anyway be a concern. In case of trauma, time pressure and emotional aspects and demands of the patient are to be integrated and can be thus resumed: right solution at first attempt is the goal.

Thanks to dental technician Ronald Mak for the laboratory work.
 

Bibliography




References

  1. Manauta J, Salat A. Layers, An atlas of composite resin stratification. Chapter 10 Surface and polishing Quintessence Books, 2012.

  2. Villarroel M, Fahl N, De Sousa AM, De Oliveira OB Jr. Direct esthetic restorations based on translucency and opacity of composite resins. J Esthet Restor Dent. 2011 Apr;23(2):73-87.

  3. Fahl JR, N. (2011) Mastering Composite Artistry to Create Anterior Masterpieces - Part 2. Journal of Cosmetic Dentistry: 42-55, Winter.

  4. Abzal MS, Rathakrishnan M, Prakash V, Vivekanandhan P, Subbiya A, Sukumaran VG Evaluation of surface roughness of three different composite resins with three different polishing systems.J Conserv Dent. 2016 Mar-Apr;19(2):171-4. doi: 10.4103/0972-0707.178703.

  5. Diangelis AJ, Andreasen JO, Ebeleseder KA, Kenny DJ, Trope M, Sigurdsson A, Andersson L, Bourguignon C, Flores MT, Hicks ML, Lenzi AR, Malmgren B, Moule AJ, Pohl Y, Tsukiboshi M. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol 2012; 28: 66-71.




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