INTRODUCTION
Composite resin has been widely used during most of my dental career, which began in 1978. When light-cured composite resins were introduced to practicing dentists, many found that these materials answered the aesthetic desires of their patients while providing the physical properties needed for many restorations. With these materials, art can literally be created directly on the patient’s tooth structure. Matrix materials can be used to build the shape of the restorations, or they can be applied in a freehanded fashion. The final outcome is literally in the mind’s eye and hands of the dentist and it is well known that some clinicians have more artistic ability than others. The good news is that it’s an art that can be learned.
In today’s economy, some of my patients are choosing direct composite resin restorations rather than indirect restorations due to the cost alone. Some choose this modality as a first step in gaining or regaining aesthetics while planning to eventually replace the composite restorations with indirect restorations later on.
Advantages of direct composite over indirect aesthetic restoration include:
Minimal preparation—While most indirect restorations require preparation of the tooth to develop “draw” and eliminate undercuts, direct restorations can be built into undercuts and around corners, often requiring less preparation. Indirect restorations need a certain thickness for strength and then need to be cemented or bonded in to place. Directly applied composite resin can be made to be “paper thin” in areas.
Lower fee to the patient—Fees can often be lower for direct than for indirect procedures because of the time savings (no second appointment or laboratory charges).
Easily removed—When it is necessary or desirable to remove composite resin from the tooth, it can be accomplished by using a carbide-finishing bur in a high-speed handpiece without damaging the underlying natural tooth structure.
Easily repaired—When it is necessary to repair a fracture or chip, composite resin can be roughened by microabrasion (or with a diamond bur) and treated with phosphoric acid to clean the abraded surfaces. Then, a bonding agent can be applied and new composite resin can be added and light-cured. Once the new material has been finished and polished, the repair is often imperceptible and long-lasting.
Longevity Expectations
In my clinical experience, I have found that direct composite resin restorations can be expected to last 10 years (or more) when properly treatment planned and placed. Of course, occlusion and home care play big roles in determining the longevity of these materials.
Modern Materials
With today’s microhybrid and nanohybrid composites, we can expect both strength and a long-lasting polish. Materials with dentin, enamel, and incisal shades are now available allowing the clinician to implement aesthetic layering techniques. Handling properties have also steadily improved and offer a variety of choices; some composite resins have a stiff and sculptable feel while others are creamy and can be contoured with a brush. The material of choice for the individual dentist often comes down to shading and handling properties. Different clinicians will choose different materials according to their own likes/dislikes and get equally good results.
CASE REPORT
A male patient in his 50s presented with previously placed composite resin restorations in his maxillary central incisors and his left lateral incisor. He stated that they had been in place for more than 10 years, and while they were still in relatively good physical condition, they had darkened in color. The mesioincisal edge of the left lateral incisor was chipped. The patient wanted to improve the aesthetics of his restorations and also to have the appearance of better tooth alignment. Indirect ceramic restorations were discussed, but he preferred direct composite for several reasons including cost. The agreed upon treatment plan included replacement of the existing restorations and the addition of direct veneers. To maximize the aesthetic result, he chose to have us place a direct composite veneer on the right lateral incisor as well.
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| Figure 1. Preoperative facial view. | Figure 2. Preoperative incisal view. |
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| Figure 3. Facial view of prepared teeth. | Figure 4. Incisal view of prepared teeth. |
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| Figure 5. Facial view of completed composite application; the first tooth (tooth No. 8). | Figure 6. Incisal view of completed composite application; first tooth. |
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| Figure 7. Facial view of finished restoration; first tooth. | Figure 8. Incisal view of finished restoration; first tooth. |
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| Figure 9. Completed buildup of second tooth (tooth No. 9). | Figure 10. Facial view of final result. |
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| Figure 11. Incisal view of final result. | Figure 12. The patient’s smile, preoperatively. |
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| Figure 13. The patient’s smile, after treatment. |
In this case, a strong yet easily polished nanohybrid composite resin (Esthet•X HD [DENTSPLY Caulk]) that could be easily sculpted and placed/contoured with a metal spatula was chosen. Furthermore, this material was chosen because it provided dentin, enamel, and incisal shades for the aesthetic layering technique required for this patient.
Figure 1 shows the maxillary 4 incisors from the facial view as he presented, and the incisal view of the 4 teeth is shown in Figure 2. Preparation involved removal of the old composite resin restorations using a round diamond bur in a high-speed handpiece and slight facial contouring with a flame-shaped diamond bur (8852 fine finishing diamond [Brasseler USA]). The finished preparations can be seen from the facial view in Figure 3 and the incisal view in Figure 4.
Restoration began with the right central incisor, tooth No. 8. A total-etch technique was used: the prepared tooth was etched for 10 seconds using 37% phosphoric acid and then thoroughly rinsed with water. Next, a wetting agent and desensitizer (Calm-It [DENTSPLY Caulk]) was used to rewet the tooth. The excess moisture was removed with an evacuator tip and the tooth surface was left slightly moist for the wet-bonding process. A fifth-generation dentin and enamel bonding agent (Prime & Bond NT [DENTSPLY Caulk]) was liberally applied with a small cotton applicator and then gently dried with air to remove the water and alcohol carrier. A glossy surface illustrated that the bonding agent was still present after drying. The bonding agent was then light-cured for 10 seconds using an LED light-curing unit (SmartLite Max [DENTSPLY Caulk]).
Composite placement was performed in layers. A dentin shade was placed first to replace the dentin area of the tooth (A2 O). The first layer was then light-cured for 20 seconds. Then, an enamel shade (A1) was layered over the entire facial surface to replicate the appearance of enamel but leaving room for a translucent incisal layer. This layer was light-cured for 20 seconds. Finally, an incisal layer was added (YE) and light-cured for 20 seconds. The layered composite surface can be seen from the facial view before finishing in Figure 5, and from the incisal view in Figure 6.
The composite was contoured using carbide finishing burs (ET burs [Brasseler USA]) in a high speed handpiece. Final contouring and smoothing was accomplished with abrasive cups, points, and discs in a slow speed handpiece (Enhance [DENTSPLY Caulk]). Polishing was performed with composite polishing discs and cups (PoGo [DENTSPLY Caulk]). Interproximal polishing was accomplished using aluminum oxide strips (EPITEX [GC America]). The first finished restoration can be seen from the facial view in Figure 7, and the incisal view in Figure 8.
The left central incisor (tooth No. 9) restoration was built up in the same fashion. It was built freehand without the use of matrix strips, directly against the adjacent finished and polished restoration to achieve a tight contact. The buildup can be seen in Figure 9 before contouring and polishing. After the composite was almost completely contoured using the technique described above, a stiff metal spatula (American 8A [Hu-Friedy]) was used in the interproximal area to “torque” the teeth slightly and a metal diamond strip (Gateway [Brasseler USA]) was eased between the 2 restorations to open the contact. Final polishing was performed as above for tooth No. 8.
The left lateral incisor (tooth No. 10) restoration was performed in the same fashion as both central incisors. The layering of composite resin for the direct composite veneer on the right lateral incisor (tooth No. 7) was slightly different; no dentin shade was used and only the enamel and incisal layers were placed.
The completed direct composite resin restorations are shown from the facial view (Figure 10) and the incisal view (Figure 11), 6 months after placement. Note the high gloss and vital appearance of the 4 direct composite restorations. The patient was extremely pleased with the result (Figures 12 and 13) and happy that he chose direct restorations.
CLOSING COMMENTS
In today’s economy, it is likely that more patients will choose lower cost alternatives to indirect restorations. For those clinicians who can provide direct composite restorations with aesthetic results that compete with indirect alternatives, there will surely be ample opportunities for treatment.
Dr. Nash provides aesthetic dentistry in both of his general practice locations in Charlotte, NC and Huntersville, NC. He lectures internationally on subjects in aesthetic and cosmetic dentistry and is a consultant to numerous dental materials manufacturers. He has authored chapters in 2 textbooks on aesthetic dentistry and published a book on aesthetic procedures. He is an accredited Fellow in the American Academy of Cosmetic Dentistry and is a Diplomate for the American Board of Aesthetic Dentistry. He can be reached at (704) 904-3458 or via e-mail at rosswnashdds@aol.com.
Disclosure: Dr. Nash reports no disclosures.
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