Ivoclar Vivadent National Direct Restoratives ‘COMP’etition Background 26 year old female patient Ms J attended my clinic as a new patient in 2013. Presenting Complaint Her presenting complaint was of poor appearance and bleeding ‘gums’, she was due to get married and wanted to have her teeth in a more presentable condition. History of Complaint She had not been attending GDP for a number of years. She had noticed her teeth getting worse and felt self-conscious of their appearance deteriorating. Dental History Not registered with GDP Previous Fixed orthodontics Only occasionally brushing once a day No Mouthwash No Floss or Interdental brushing Social History Very recently stopped smoking Currently no alcohol, previously drank approximately 14 units per week Occupation - support worker Diet - regular sugary drinks Medical History Generally fit and well No allergies 5 Weeks pregnant Clinical exam Extra orally there were no remarkable findings Intra-orally the soft tissue exam found nothing other than generalised plaque induced marginal gingivitis, with calculus on the lower anteriors. Examination of the dentition found a number of interproximal and buccal/labial lesions especially notable on the upper anterior teeth due to previous orthodontic fixed appliances and sub-optimal oral hygiene. The presence of old orthodontic composite was also discovered on upper anteriors. Ms J had a class I incisor relationship with a unilateral posterior cross bite on the right hand side. Her BPE scores were as follow:
Richard Ellingham BDS 5 Glasgow Dental School richardellingham@hotmail.com 07966 424479
3 3
2 2
3 3
There was no mobility of the teeth or gingival recession Radiographic examination was indicated for detection of interproximal caries. Left and right digital bite wing radiographs were taken indicating further carious lesions. Blunting of the interproximal alveolar crests was evident which this is in-line with the BPE scores. Pre-treatment Charting
Diagnosis Primary caries Mild generalised periodontal disease with marginal gingivitis Treatment Initial treatment involved improving oral hygiene and addressing the periodontal condition. This was undertaken over a number of sessions and included Firm oral hygiene instruction, diet education, supra gingival scaling and root surface debridement. Once the periodontal condition had improved to a situation where the gingival inflammation had diminished the cervical and interproximal carious lesions could be addressed without the issue of gingival bleeding. All upper anterior teeth had interproxmal lesions with the 11 and 22 and 23 having labial lesions. The interproximal lesions had progressed quite far, to approximately 20% of coronal width meaning clearly into dentine. The labial surface lesions appeared to correspond with the space between gingiva and fixed appliance brackets. We could surmise that poor OH existed during orthodontic treatment lead to decalcification with further carious activity due to continued poor OH post orthodontic treatment. A decision was made to restore using the Ivoclar Empress direct composite system. The patient’s requirement for improved aesthetics was well met by the numerous composite shade options Richard Ellingham BDS 5 Glasgow Dental School richardellingham@hotmail.com 07966 424479
included in the Empress Direct kit using dentine, enamel and translucent variants. Anterior tooth shades were taken in natural light prior to the operative work with agreement on the shade from the patient on A3 with translucent edges. The anterior teeth were prepared along with the visual field aid OptraGate allowing comfortable retraction of the patient’s lips and clear vision for the operator and dental nurse. Interproximal cavities were prepared and caries removed followed by the same procedure for the labial surface lesions. The dentine shade was then taken again in natural light to match clean dentine uncovered during the operative procedure resulting in dentine shade A3. Enamel and dentine surfaces were differentially etched with phosphoric acid gel and then washed and lightly dried to prevent collagen collapse. The bonding system ExciTE F was then used on each of the cavities to prepare for composite restoration, air thinned and cured using the Bluephase style curing light. Cavities were incrementally built using enamel/translucent shell then filled with dentine shape for interproximal sites, while for labial sites dentine shade was placed first then enamel shades. Teeth were built up with attention to tooth shape and labial contour. Finishing of the restorations was with multigade polishing discs and a diamond polishing paste. The final result was greatly improved on the starting point, however there did exist some variable texture with the colours due to smooth surface changes coinciding with the fixed appliance brackets. To correct such defect would have required a more invasive approach that could not be justified in this case. When the patient attended for a review appointment 2 weeks later she expressed how much more confident she felt about herself and her appearance having now started wearing make up to work and had her hair and nails done. Her oral hygiene was improved although not perfect so further guidance was offered. The use of Ivoclar Empress Direct composite enabled the restoration of this patient’s dentition to a standard where it had more impact than merely filling carious cavities, it facilitated a near perfect return to the original dentition aesthetics. The follow on benefit was shown with the patients improved self-confidence and motivation. Pre Operative photos Anterior View, clearly showing carious lesions and inflamed interdental papillae
Richard Ellingham BDS 5 Glasgow Dental School richardellingham@hotmail.com 07966 424479
Intra-oral photograph; The interproximal shadowing indicated the presence of caries into dentine.
Richard Ellingham BDS 5 Glasgow Dental School richardellingham@hotmail.com 07966 424479
Post operative Post operative, the appearance is much improved, gingival margins are more defined and the patient had a renewed confidence
Richard Ellingham BDS 5 Glasgow Dental School richardellingham@hotmail.com 07966 424479
Comparison Anterior Before
After
Richard Ellingham BDS 5 Glasgow Dental School richardellingham@hotmail.com 07966 424479