Third Place - Robert Campbell

Ivoclar Vivadent IPS Empress Direct- Student Composite Competition Student: Robert Campbell Aberdeen University (BDS 5) Case Presentation: Mr LN, 63 year old male patient.

Medical HistoryPatient suffers from chronic obstructive pulmonary disorder for which he uses a Seretide 250 inhaler (25 micrograms of salmeterol and 250 micrograms of fluticasone) twice daily. He also has a 100 microgram Salbutamol inhaler to use when required for shortness of breath but rarely needs to as his condition is well controlled.

He has a history of osteoarthritis affecting his back for which he takes Naproxen 500 mg twice daily and co-codamol (30mg codeine and 500mg of paracetamol) when required for breakthrough pain.

He also has a history of repeated chest infections for which he has had multiple short term courses of penicillin antibiotics which is currently being further investigated by his General medical Practitioner.

Social HistoryUntil the start of 2014 the patient had been a long time smoker (over 20 years) of around 5-10 cigarettes daily however has managed to quit since the new year without any pharmacological assistance.

He is a light social drinker, estimating to consume around 8 units of alcohol weekly.

He is employed by the city council and works full time.

Dental HistoryThe patient was a regular attender of an area general dental practitioner and has had numerous dental treatments in the past including fillings in both amalgam and composite, crowns. After around 20 years of treatment the patient’s dentist retired prompting him to self-refer to Aberdeen Dental School. His first exam was around 4 months post his last appointment at the previous dentist.

Patient ConcernsOriginally the patient presented with some occasional pain from tooth 22. His main concerns were to treat his pain and reassess his heavily restored dentition for any further treatment required. He was aware that in his maxillary anterior region a number of composite restorations had become quite unaesthetic; however felt that the function of these teeth was more important to him than their appearance.

A full examination both clinically and radiographically was made of his dentition and a treatment plan formulated including; EMERGENCY TREATMENT- Root canal treatment of teeth 21 and 22.

PREVENTATIVE TREATMENT- Diet analysis, tooth brushing, interdental brushing and further oral hygiene instruction. A full mouth scale to remove calculus. Monitoring this with plaque and bleeding analysis.

INITIAL RESTORATIVE TREATMENT- Initial restorations on teeth with failed restorations or active caries.

REVIEW/OCCLUSAL ANALYSIS- Assess the response to treatment initiated and improvement of patient’s maintenance of oral tissues. Get articulated study models and make occlusal analysis prior to definitive prosthodontic work.

DEFINITIVE RESTORATIVE TREATMENT- Replacement of failed crowns and placement of any new prosthodontic work as appropriate.

MAINTENANCE TREATMENT- Regular review to ensure no disease recurrence or development of new disease During the initial restorative phase of the patient’s treatment the multiple aesthetic and restorative problems in the anterior portion of his mouth needed to be addressed. Tooth 21 had a large distoincisal-palatal restoration that had failed, causing marginal leak and a fracture of a small portion of the composite. Due to multiple failures of previous composite fillings on this tooth this restoration also had a dentine pin placed to aid retention. It was decided that this restoration would be an ideal opportunity to use Ivoclar Vivadent’s IPS Empress Direct composite to achieve an aesthetic restoration with minimal destruction of the patient’s remaining tooth tissue On discussion of treatment options for restoration of this region the patient was explained about Ivoclar Vivadent’s IPS Empress Direct Student Composite Competition. The materials differences to other available composites were explained and the process of entering the competition using clinical photographs and an anonymised write up. The patient indicated he was happy to be used in the competition and signed a consent form for the clinical photography required.

Pre-operative Photographs: Upper and Lower Occlusal views

Teeth In occlusion: Right, Anterior and Left views

Treatment Steps: 1. Pre-operative photograph of tooth 21 for restoration

2. Shade selection

3. Removal of previous Restoration 21 and bevel of enamel (retaining pin as retentive advantage)

4. Post Etching, Pre Bonding

5. Bonding using Excite F after Teflon applied to adjacent tooth

6. Cure of Bonding with Blue Phase lamp

7. Masking of dentine pin using Empress Direct opaque

8. Palatal build-up of enamel using Empress Direct enamel shade A2

9. Build-up of dentine to within 0.5mm of incisal edge (to mimic patients loss of incisal enamel from attrition) with Empress Direct dentine shade A3

10. Buccal build-up of enamel using Empress Direct enamel shade A2

11. Final layer of Empress Direct Transopal 30 applied to interproximal region and incisal edge.

12. Contouring of restoration using high speed finishing burr and polishing using polishing discs

13. Restoration post polishing and check of occlusion

Post treatment:

Post-Operative instruction to the patient: Local anaesthetic Lignospan special (lidocaine 3% and adrenaline 1:80000) was given in a volume of 2ml as an infiltration buccal to 21 prior to treatment. Post operatively the patient said that sensation in the area was beginning to feel normal again so postoperative warning about numbness was deemed irrelevant.

The patient was warned that despite careful adjustment to his occlusion the restoration was dimensionally different to its predecessor, so to watch for any occlusal discrepancies that may become apparent which can be adjusted at his next appointment.

The patient was thanked for his time and agreeing to be used for the composite competition and left very pleased with the aesthetic result that had been achieved.

Better aesthetics could have been achieved if a darker dentine shade would have been used. We selected D3 under normal day light as a dentine colour, but because we didn’t have it on our kit we used A3 dentine instead. However, the patient was really satisfied with the final restoration and didn’t wish to change it.

I would like to thank everyone at Ivoclar Vivadent involved in setting up this competition. It was an excellent opportunity to get the chance to improve my direct aesthetic restorative skills using an excellent group of products.