Diastema closure using minimally invasive direct composite

focus
with Paul Mandon-Gassman
Edition 3 - March 2015
www.dental-education.co.uk // www.ivoclarvivadent.co.uk
Diastema closure using
minimally invasive direct
composite restorations
Composite resin has been available since the 1950s with Buenocore discovering
that acids will create an etched pattern on enamel to aid bonding. Early materials
had poor mechanical and aesthetic properties but in recent years most of these
limitations have been over come. Traditionally, ceramics have been used where
strength and aesthetics are possible but the necessary biological loss of tooth
preparation and financial cost have sometimes been limited. However as this case
shows it is now possible to use direct composite bonded to sound tooth structure to
predictably create lasting smiles that can be easily repaired.
Presenting complaint
Amy has been attending my practice for some years
expressing a wish to change her dental appearance.
She had always disliked the spaces between her upper
front teeth, but had been put off porcelain veneers by
the expense and excessive damage of her virgin enamel
that preparation would cause. In fig 1-3 you can see
Amy’s pre-treatment situation, she was getting married
later in the year and really wanted her prefect smile in
time for the big day.
I discussed with her my experiences with composites in
similar cases with some before and after’s. I had gained
confidence in the long term potential for the material
having treated a number of severe wear cases using free
hand composite build ups, using Tetric EvoCeram® material
as an inexpensive way to restore aesthetics and function.
Some of these cases dated back 8+ years and had required
Fig 1
Amy’s pre-treatment smile.
Amy was getting
married later
in the year and
really wanted
her prefect smile
in time for the
big day.
Fig 2
Amy initial presentation side view
Fig 3
Amy initial presentation
Fig 4 Previous wear case using Tetric composite
Fig 6&7
Fig 5
Post op wear case which was completed in 2004
Diagnostic wax up and silicone index which will be used to control composite placement
wax up which will be used to control composite placement.
Having used ExciTE® F, I would now be using Adhese® Universal
which was not available at the time but allows for total etch, self
etch and selective etching depending on the enamel/dentine
available to bond to, It is important not to underestimate the
time it takes to place, contour and finish such restorations and
in a private practice, setting this time needs to be charged for.
Remember, if you allow 30-60 minutes per tooth, the cost
for the patient to treat all six teeth in this case is likely to be
less than providing 2 traditional porcelain veneers, but the
biological cost is much lower with the option to proceed to
more invasive option in the decades to come.
Fig 8 Similar case showing Optradam placed UR3 to UL3 with floss ligatures placed into gingival sulcus interproximally to allow subgingival bonding
and emergence profile development
minimal repair and maintenance despite some teeth having
been built up over 7mm with no tooth preparation other than
etching of enamel and dentine bonding as seen in fig 4 & 5.
Treatment provision
Having discussed with Amy the potential for direct composite
bonding in her case, I used white wax sculpted into her
diastemas to demonstrate how her new smile might look. I have
in the past used digital image simulations to approximate a new
smile but this was not necessary in this case.
The process
Having gained consent to the procedures and having explained
that the process would be purely additive I took impressions for
study models and provided diagnostic wax up of the proposed
new smile. Once Amy was happy with this new look, a silicone
putty index was fabricated and appointment booked to provide
treatment. Fig 6&7 shows silicone index adapted to diagnostic
At the appointment, OptraDam® was placed 5-5 with ligatures
into gingival sulcus to aid retraction as seen in fig 8. In smaller
cases and alternative to OptraDam® is OptraGate®, which
allows excellent moisture control for upper anterior teeth with
little or no suction necessary during restoration placement.
Upper posterior and lower anterior teeth are equally accessible
with OptraGate® with lower posteriors easily worked on with
an attentive nurse with suction available to prevent the ‘tide
rising’ as saliva collects at the back of the mouth.
No anaesthetic was required and the enamel was prepared
with pumice on a rubber cup. Wave wedges (Triodent) were
placed interproximally to help to temporarily retract the
papillae and expose sub gingival tooth structure to allow the
optimum emergence profile and control the ultimate gingival
contour. The enamel was etched with 35% phosphoric acid
15-30 seconds (it is likely that some root dentine may have
been etched also, so it is important to limit the time of etch
to 15sec to reduce post op sensitivity) washed and air-dried
to give a frosted appearance. ExciTE® F bonding agent applied
using and Vivapen left in contact with the tooth for 10-15
seconds then air thinned and light cured, using Bluephase®
Style for 10 seconds per surface to give a glossy finish.
Using the silicone matrix as a guide a palatal enamel layer was
built up interproximally on all teeth almost to the contact point.
Each contact was sculpted using the wave wedges and matrix
strips to give emergence profile and make sure the contact
was ideally placed to encourage ‘papilla infill’ as per the work
(‘Papila infil’ was originally the work of Tarnow et al which
relates to the effect of contact point placement in relation to
bone levels to allow papilla re-formation). Teflon “plumbers
tape” can be used on adjacent teeth to prevent inadvertent
bonding of composite material. A layer of Empress® Direct
Dentine was added interproximally to mimic natural tooth
structure and then layers of IPS Empress® Direct Enamel and
translucent were added to give appropriate contour”
Fig 9 Amy finished full smile
Fig 10
Fig 11
Amy finished full smile
Amy finished full smile close up
Conclusion
Final contouring was achieved using Diamond and T/C
finishing burs and Optrapol NT points. Amy was happy with
the result and returned from her honeymoon smiling. 12
months on, the restorations retained polish well and Amy’s
excellent oral hygiene has lead to ideal gingival contour, fig
9-12. All dentistry has a finite life expectancy and the less
invasive an option that is chosen then the more scope to redo
it over time or move onto more extensive work in the future.
An audit I carried out for Denplan Stairway program showed
that 85% of my composite restorations last 6 years and I
have been using much more direct composite (often in
combination with Short term orthodontics) to align bleach
and bond teeth rather than using tooth preparation and
ceramic restorations.
Fig 12 Amy after honeymoon with new smile
Paul Mandon-Gassman was born in Yorkshire and qualified with BDS from Sheffield
in 1987. Having worked in Doncaster he moved to Kent in 1994 where he has been
practicing dentistry ever since. Paul Mandon-Gassman is Co-owner of Sturry Dental
Practice in Canterbury which is a private practice with Denplan excel accreditation.
“I’ve always had an interest in Cosmetic and Restorative dentistry and have attended
courses given by some of the foremost dental speakers in the world. I have developed
my cosmetic dentistry skills over many years of post-graduate training and am a full
member of the British Academy of Restorative Dentistry (BARD) ; member of the British
Society of Occlusal Studies (BSOS) and the Association of Dental Implantology UK (ADI).
I am the No.1 contributing dentist to www.allaboutteeth.co.uk an award winning
website which aims to answer patient dental questions, and as an Opinion Leader for
Ivoclar Vivadent”.
Paul Mandon-Gassman
Exclusive Smiles, Laurel House, 36 High Street, Sturry, Canterbury, Kent, CT2 0BD
e. info@exclusivesmiles.co.uk
Intelligent
Prep Design
with Paul Mandon-Gassman
Objectives:
As a structured programme, this course provides comprehensive hands-on training, focusing
on how to achieve perfect preparations and gaining optimum results using accurate
impression taking techniques. Guiding you through the science behind this compelling
subject area, Paul Mandon-Gassman will provide you with the knowledge and techniques
required to expertly prepare teeth for modern restorative materials and record the
information accurately to achieve functional, aesthetic anterior and posterior restorations.
All materials, models and equipment are provided on each course.
The course aims to provide participants with the knowledge and
understanding to confidently apply techniques learnt in
conjunction with advanced materials to promote aesthetics
and function in clinical dentistry.
DATE: 1st May 2015 // 31st July 2015
30th October 2015
VENUE: Ivoclar Vivadent, Compass Building
Feldspar Close, Leicester, LE19 4SD
• Clarify the history of materials
used
• Clarify restoration types and
materials available
• Recognise preparation designs
applied for restorative materials
• Comprehend protocols for
adhesive and conventional
cementation
• Understand the requirements
of impression materials in
conjunction with accurate
preparation design
Products Mentioned
IPS Empress ® Direct
Adhese ® Universal
OptraPol ®
OptraGate ®
OptraDam ®
Bluephase ® Style
For more information on products
used on this course please speak
to your local Product Specialist.