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.