Anterior Aesthetics Using Direct Composite With a Custom Matrix Guide

The familiar expression, “necessity is the mother of invention” is called to mind when presented with challenging cases. The technique and case presentation described in this article by Dr. Ian Shuman was conceived in 2002 by Dr. Martin Goldstein.1,2 At that time, the patient, a 13-year-old male, had lost both maxillary central incisors due to trauma 3 years prior. Orthodontic treatment had repositioned the lateral incisors to the central incisor positions. Accordingly, the canines were moved into the lateral incisor position, and so on for the remainder of the teeth in the maxillary arch. This left the patient with a less-than-desirable final aesthetic outcome (Figure 1). Two options were available to correct this situation. Ceramic veneers, while offering the control of the lab bench, were not the ideal treatment for a patient still in the growth phase. Seemingly, a more appropriate solution was direct composite bonding (Figure 2).

Figure 1. Preoperative view of case that initiated “Split-Splint Technique” development.	Figure 2. Postoperative view of the first case.

This approach offered the advantage of modification as the patient’s dental and gingival architecture matured. The difficulty in these cases is the amount of composite and composite sculpting required to restore the patient’s smile. It is a formidable task even for the most gifted of composite sculptors. It became apparent that this restoration bore many similarities to placing a set of porcelain veneer provisionals. In the past, Smile-Vision’s resin replica mock-ups and hard/soft templates had been implemented to fabricate such provisionals. It seemed logical that a similar approach might be taken using a composite that would possess enough flow to form a void-free restoration within the confines of the matrix atop the etched and bonded teeth. The only challenge would be in keeping the teeth individual versus splinted, as is the case when forming veneer provisionals. The solution was provided when it was decided to separate the teeth in the matrix with a No. 15 blade to allow the introduction of Mylar strips, as you will see in Dr. Shuman’s case. As it was easier to seat the matrix and place Mylar strips in the absence of composite, it was then decided that the composite, if warmed by AdDent’s Calset heater, could be injected into each tooth compartment through a created portal (a hole) sized to the tip of the compule used. In this manner, direct bonded veneers could be applied one at a time or, as was done on subsequent cases, all at once before removing the template.
The advantages of such a technique are several. Most obvious would be predetermined dental anatomy. The need for accurate sculpting is eliminated. Additionally, as the case is pre-waxed by Smile-Vision on an adjustable articulator, a protective occlusal scheme can be incorporated. It’s quite conceivable that as many as 6 to 8 direct composite veneers can be placed in as little as an hour’s time with just a little bit of experience. One will, however, spend considerable time after the veneers are placed, making small additions, removing excess resin, finishing, and polishing. This type of activity, however, is low stress compared to the rigors of freehand sculpting multiple composite resin veneers. From a “tooth conservation” standpoint, the dentist may also take comfort in knowing that the absence of path of insertion concerns, eliminated by the injection process, results in less tooth structure removal than is often needed to accommodate indirect restorations.
Other advantages include a single-visit case delivery accompanied by the ability to deliver a smile rehab for half the cost of the typical ceramic rehab. This, of course, puts an enhanced smile within the budget of many more of your patients. It is not unreasonable to promise patients a 6- to 8-year lifespan on such rehabs before they might expect them to look “shopworn.” They must also be told that occasional repairs will likely be necessary if and when a composite fracture occurs. Such repairs can typically be billed out at an hourly rate or as multisurfaced composite restorations. If employing a rugged microhybrid such as DENTSPLY Caulk’s TPH³ (unheated), Coltène/Whaledent’s Synergy D6 (heated), or Kerr’s Premise (heated), you will find repairs to be infrequent and minor in scope. If your case was necessitated by excessive wear, it is also prudent to build a nightguard into the treatment plan to protect your work. Current favorites include Trident’s Bite Soft splint for night-time protection.
One should also keep in mind (and inform patients) that these cases can easily be converted to all-ceramic restorations at a future time, perhaps when the cost is more manageable, or as was the case with the 13-year-old patient noted above, when he reached his 18th birthday (Figure 3).

Figure 3. Five years later, case converted to porcelain veneers.	Figure 4. The upper anterior teeth were different colors, rotated, and had failing resin bonded restorations.

CASE REPORT

Appointment 1: The Consultation

The patient, a 65-year-old female, presented with the chief complaint that her upper anterior teeth were different colors, rotated, and had failing resin bonded restorations (Figure 4). Following a complete examination, including a full-mouth x-ray series using digital radiography (Trophy RVG [PracticeWorks]) and study models, several treatment plans were presented, including direct and indirect restorations with or without orthodontic therapy.
After consultation, the patient chose the treatment option that would achieve the desired result in as few appointments as possible. Therefore, a simplified treatment plan was created that would treat the existing carious lesions and correct the aesthetic deficiencies, all with minimal tooth reduction.

Lab Fabrication: Custom Matrix

Figure 5. A computer-enhanced portrait image created for patient approval.	Figure 6. A diagnostic solid model wax-up was fabricated and processed in resin.
Figure 7. The split-splint custom matrix.	Figure 8. Holes are created midcoronal to provide a tight seal for the composite compule of choice.

The study models and patient photos were sent to Smile-Vision lab. The patient’s smile was digitally corrected to ideal proportions and desired shade (Figure 5). Upon approval, a diagnostic solid model wax-up was fabricated and processed in resin (Figure 6). It is on this model that a reduction guide and the unique custom matrix were fabricated (Figure 7). This matrix has 2 unique features: the interproximal spaces have vertical slits to allow Mylar strip insertion, and holes are created midcoronal to provide a tight seal for the composite compule of choice (Figure 8).

Appointment 2: Preparation

Figure 9. Existing resin and caries removed, and teeth prepared.	Figure 10. Adequate preparation confirmed by a reduction splint.
Figure 11. Cavity preparations restored with direct composite.	Figure 12. All surfaces are microetched using the EtchMaster, a portable handheld device to enhance bonding retention.
Figure 13. Following acid-etching, the central incisors are isolated usng Teflon tape, and a primer/bond is applied and cured.	Figure 14. The split-splint is seated intraorally and Mylar strips are placed to isolate the interproximal contacts of each central incisor.
Figure 15. Composite resin is prewarmed in the Calset Composite Warmer.	Figure 16. Composite is injected until the matrix is filled for the right central incisor, and light-cured.
Figure 17. The completed central incisors.	Figure 18. The patient’s new instant smile.
Figure 19. The patient before.	Figure 20. The patient after.

Following administration of local anesthesia, lips and cheeks were retracted using OptraGate (Ivoclar Vivadent), gaining unobstructed access to the operative site. All existing composite resin and caries was removed (Figure 9). Minimal tooth reduction then followed, with adequate preparation confirmed by the reduction splint (Figure 10). The cavity preparations were restored using direct composite (Figure 11). All tooth surfaces and cured composite were then micro-etched (Figure 12) using the Etch-Master (Groman), a portable handheld device to enhance bonding retention. It has been demonstrated that air-abrading enamel and dentin surfaces prior to and followed by acid-etching will dramatically increase composite bond strengths.^3,4
Preparations were rinsed, dried, and treated with a 35% phosphoric acid etching gel. This was then rinsed and gently dried. The central incisors were isolated using Teflon tape placed in the interproximal space between the central and lateral incisors, and a fifth-generation bonding agent (Opti-Bond Solo Plus [Kerr]) was applied (Figure 13). Following removal of the Teflon tape, the custom matrix was seated intraorally, and Mylar strips were placed to isolate the interproximal contacts of each central incisor (Figure 14). Ivoclar Vivadent’s 4 Seasons, a fine particle microhybrid composite resin, was prewarmed in AdDent’s Calset Composite Warmer (Figure 15). Prewarming composite resin has a significant effect on its properties that includes increased depth⁵ and degree of cure, shortened curing time by more than 80%, improved composite flow by 68%, reduced microleakage, and improved physical properties.^6,7
The tip of the composite compule was inserted, and composite was injected until the matrix was filled for the central incisor (Figure 16), and light-cured. The distal Mylar strip was removed, and a new strip was placed to isolate the unrestored central incisor. Prewarmed composite was then injected into the matrix as before. Upon complete setting of the composite, the Mylar strips and ma-trix were removed, revealing the restored central incisors (Figure 17). Composite was added to enhance the aesthetics, and the composite veneers were trimmed and polished. The right and left laterals, canines, and premolars were isolated and restored as previously described (Figure 18). The patient was thrilled with her new instant smile (Figures 19 and 20).

CONCLUSION

A technique has been demonstrated that removes much of the anxiety of placing composite resin veneers by eliminating the need to hand-sculpt accurate tooth anatomy. While case delivery is time consuming and labor intensive, it remains low stress and profitable for the time spent as well as emotionally rewarding.

A few additional helpful tips:

1. Use of high magnification greatly assists the marginal trimming process, allowing one to remove flash with little or no harm to tissue. This author prefers Orascoptic’s EyeMax loupes (4.8x) and Zeon SunBurst LED headlight.
2. To extend working time with your composite be sure to limit exposure of resin to strong operating lights that are not filtered.
3. Allow yourself more time than you think you need to allow for stretch breaks and rest for one’s eyes.
4. Be careful to maintain a perpendicular midline, free of cants. If separating teeth Nos. 8 and 9 prior to bonding, it is helpful to use a long, slim diamond so as to make a controlled cut perpendicular to the interpupillary line.
5. Ensure there is enough space between the matrix and underlying tooth structure to allow for easy insertion of the compule tip (usually 0.5 to 1 mm; the wax-up buildout can provide additional thickness if needed).
6. Note: Smile-Vision will fully prepare the matrix (slits and portals) if you supply the compule brand that you will be using.
7. If preoperative diastemas are large, it is helpful to “pre-close” by hand at the gingival aspect to provide a definitive, guided slot to assist in Mylar strip positioning.
8. A liquid glaze such as DENTSPLY’s Lasting Touch can enhance case appearance if applied after final surface preparation.
9. Note: A DVD-based demonstration of this technique is available at the Web site drgoldsteinspeaks.com. 

References

1. Goldstein MB. Direct bonded composite veneers for the artistically challenged dentist. Contemp Esthet Restor Pract. 2002;6:55-59. http://www.smile-vision.net/art_articles.php. Smile-Vision Web site. Accessed January 28, 2008.
2. Goldstein MB. A multiphase approach to direct composite veneering. Dent Today. Feb 2003;22:92-95.
3. Silva PC, Gonçalves M, Nascimento TN, et al. Effect of air abrasion on tensile bond strength of a single-bottle adhesive/indirect composite system to enamel. Braz Dent J. 2007;18:45-48.
4. Roeder LB, Berry EA III, You C, et al. Bond strength of composite to air-abraded enamel and dentin. Oper Dent. 1995;20:186-190.
5. Burtscher P, Rheinberger V. Temperature influence on the depth of cure of a composite. Presented at: IADR/AADR/CADR 83rd General Session; March 9-12, 2005; Baltimore, MD. Abstract 1345. http://iadr.confex.com/iadr/2005Balt/techprogram/abstract_59632.htm. IADR Abstract Search Form Web site. Accessed January 28, 2008.
6. Littlejohn L, Greer SC, Puckett AD, et al. Curing efficiency of a direct composite at different temperatures. Presented at: 32nd Annual Meeting and Exhibition of the AADR; March 12-15, 2003; San Antonio, TX. Abstract 0944. http://iadr.confex.com/iadr/2003SanAnton/techprogram/abstract_27966.htm. IADR Abstract Search Form Web site. Accessed January 28, 2008.
7. Trujillo M, Newman SM, Stansbury JW. Use of near-IR to monitor the influence of external heating on dental composite photopolymerization. Dent Mater. 2004;20:766-777.

Dr. Shuman maintains a full-time general, reconstructive, and aesthetic dental practice in Pasadena, Md. He is an internationally known lecturer and author, known for his advanced, minimally invasive techniques and entertaining style. He is a frequent contributor to the dental literature, having published more than 65 articles on topics including creating cosmetic smiles, adhesive resin dentistry, crown and bridge procedures, fabricating perfect dentures, and natural periodontal therapy, among others. He is a Master of the AGD, a Fellow of the Pierre Fauchard Academy, a member of the ADA, and was named one of Dentistry Today’s Top Clinicians in Continuing Education, 2005 to 2008. To have Dr. Shuman speak at your next seminar or to order educational materials, call (877) 4-SHUMAN or visit his Web site at ianshuman.com.

Dr. Goldstein, a member of the International Academy of Dento-Facial Esthetics, practices general dentistry in Wolcott, Conn. Noted as one of Dentistry Today’s Top Clinicians in Continuing Education for the last 5 years, he lectures and writes extensively concerning cosmetics and the integration of digital photography into the general practice. A regular Contributing Editor for Dentistry Today, he has also authored numerous articles for multiple dental periodicals both in the United States and abroad. He can be contacted at martyg924@cox.net. His current speaking schedule can be found on his Web site at drgoldsteinspeaks.com

Disclosure: Dr. Goldstein is a consultant for Smile-Vision, DENTSPLY Caulk, Coltène/ Whaledent, Kerr, and Orascoptic.