Re: Aesthetic Restoration of Maxillary Central Incisors

CASE REPORT
The patient, a 22-year-old male, visited the clinic after having broken teeth Nos. 8 and 9 in a fall the previous night (Figure 1). The patient’s college graduation was in 3 days, and he was seeking a way to repair the teeth quickly and aesthetically. Radiographs were taken, and because of the severity of the break on tooth No. 9, it was also tested for vitality with an electric pulp test, a cold test, and a percussion test prior to determination of treatment. All test results showed the tooth to be vital, and the patient agreed to proceed with a resin buildup. The patient was informed at this time that tooth No. 9 would have to be monitored closely with regular 6-month checkups to ensure its ongoing vitality, and he understood that a root canal might eventually become necessary.

An alginate impression was taken for the creation of a diagnostic wax-up, and the patient was sent home with glass ionomer temporaries. The wax-up was used to fabricate a lingual index with a vinyl polysiloxane putty material (Exaflex putty [GC America]).

The patient returned to the office the following day for the final restorations. Local anesthesia was administered and shade selection was performed. A significant amount of white stain was noted on the patient’s teeth during this step.

Next, a rubber dam (Hygenic Dental Dam Latex [Coltène Whaledent]) was placed and ligated with floss. Then, the preparations were done using a flame diamond (8862-014 [Brasseler USA]) to create a bevel around the teeth. A flexible disc (Sof-Lex Contouring & Polishing Disc [3M ESPE]) was then used to blend the bevel on the tooth surface and to round the sharp angles interproximally (Figure 2).

The smaller break on tooth No. 8 was repaired first. Enamel was etched with phosphoric acid etching gel and Adper Easy Bond Self-Etch Adhesive (3M ESPE) was applied. Although a separate etching step is not always necessary when using Adper Easy Bond, I elected to perform it in this case due to the high amount of enamel with which the restoration was being used. The adhesive was cured, and the lingual matrix was tried in place to ensure its fit.

A small amount of Filtek Supreme Ultra Universal Restorative (3M ESPE) in shade A1E was placed in the lingual matrix (Figure 3), and the matrix was then held to the lingual of the teeth. This composite is available in an expanded range of body shades. I have found that the availability of new bleach shades makes it simpler to create a restoration that blends in with bleached teeth, an important ability as the popularity of whitening grows. I have noticed that the handling of the material’s translucent shades has been improved as well, in response to previous concerns that these shades were sticky. The resin was attached to tooth No. 8 with a football burnisher and cured in place (Figure 4). This process created a lingual shell upon which to build the remainder of the restoration, with the proper width and height predetermined by the diagnostic wax-up (Figure 5).

A fine line of white tint was then applied at the incisal edge to create a “halo” on the tooth (Figure 6), and the dentin buildup was then performed with the more opaque and dark A2B shade (Figure 7). The dentin component was cured, and incisal translucent material was placed in the incisal third. These layers were followed with additional white tint to recreate the white spot effect on the patient’s other teeth. The final enamel layer was placed with A1E material, and was then shaped with an interproximal carver, a gold Almore instrument, and brushes to make the surface smooth and to bring the restoration to the proper contour (Figure 8).

Following completion of tooth No. 8, tooth No. 9 was treated similarly. Celluloid strips (Epitex clear matrix [GC America]) were placed to protect the adjacent teeth during etching and bonding, then removed following curing of the bonding agent. Composite resin was again placed first in the lingual matrix (Figure 9), then brought to the teeth and attached with a football burnisher (Tarno hac No. 6 [S.S. White]) and a brush to create the lingual shelf. A metal matrix (Original Tofflemire matrix band No. 1, .0015 in [Water Pik]) was placed and the distal contact and surface were built with A1E material (Figure 10). The same process was then used to create the mesial contact, surface and embrasure (Figure 11).

With the lingual, mesial and distal components in place (Figure 12), the dentin buildup was performed with A2B material. The dentinal lobes were shaped and cured, and an incisal halo was again created using white tint. Clear translucent material was used in the incisal third between the dentinal lobes, and white tint was then applied and cured. The final layer of A1E was placed and shaped as described for No. 8 (Figure 13).

Finishing was performed with Sof-Lex Contouring and Polishing Discs, which were used to open up the incisal embrasures and refine the incisal contour and length. Surface anatomy was refined with a fine diamond (8862-014), and a No. 12 scalpel blade was used to remove excess material at the gingival as well as to refine the embrasures. A series of coarse, medium and fine polishers was then used, and an aluminum oxide polishing paste completed the finishing procedures.
The completed restorations showed a very natural emergence profile and the overall match to the patient’s teeth was excellent (Figures 14 and 15). The patient was very pleased with the final result and felt confident heading in to his graduation. Despite the success of this treatment, the patient understood that the area must be monitored carefully in the future due to the trauma the teeth suffered. However, if tooth No. 9 remains vital, it is hoped that these restorations will serve for a number of years.