Aesthetics is one of the key driving forces in dentistry today, and a renaissance in the realization of the beauty of the human dentition is being propelled through the evolution of new restorative materials and techniques. More conservative options continue to take precedence, and simultaneously, manufacturers are introducing newer and better direct composites that can be placed more simply and cost effectively. Thanks to their efforts, delivering an aesthetic change in the mouth can be accomplished reliably and predictably through the use of improved bonding agents, light-curing systems, placement armamentarium, and, of course, restorative materials.
In recent years, a clinicians dilemma regarding which type of direct composite to use for a given clinical situation has been solved, to a certain extent, with the introduction of universal composites that are suitable for placement anywhere in the mouth. These microhybrids have been developed to combine aesthetic qualities with necessary physical properties, thereby rectifying the situation of using a microfill only for anterior restorations and a hybrid in the posterior areas.1 However, despite the fact that the issues regarding strength and polishability have been addressed, often we are still required to use more than one composite shade—and in multiple layers and thicknesses—to achieve the aesthetic results our patients demand, particularly in the anterior region.2
Fortunately, today represents a new era of direct composite restorative technology nanotechnology. These direct composites, a new breed that manufacturers assert is suitable for placement anywhere in the mouth based on its inherent physical and optical properties, are essentially formulated from nanometer-sized fillers and polymers reinforced with assorted particles. As a result, nanocomposites demonstrate enhanced strength, polishability, light-reflective properties, color-matching and chameleon-like abilities, and ideal handling characteristics.1,2
This article describes the material characteristics of one nanocomposite material and demonstrates how it was placed quickly, easily, and predictably to aesthetically restore a patient with anterior diastemas and a class IV fracture.
MATERIAL
In the case presented, Tetric EvoCeram (Ivoclar Vivadent) was selected as the restorative material. Tetric EvoCeram represents a new universal composite for anterior and posterior restorations that is light-cured, radiopaque, and combines 3 types of nanoparticles fillers, pigments, and a modifier in a single composite. Based on the results of ongoing research at indepen-dent universities, the physical and optical properties of the Tetric EvoCeram material are designed to enhance productivity in the dental office, performance of the restoration, and aesthetics for the patient.3
The chemistry of the material in particular the presence of ceramic fillers and different-sized particle fillers lowers shrinkage and shrinkage stress, lowers wear rate, and allows fast and easy polishability. Additionally, the fillers of Tetric EvoCeram have been enriched with prepolymers, which consist of micromilled composite that has been precured and preshrunk prior to incorporation into the material in order to achieve a composite that demonstrates low abrasion and low polymerization shrinkage. These prepolymer fillers enable comparatively large increments to be cured without the risk of high shrinkage stress, according to the manufacturer.
Additionally, Tetric Evo-Ceram contains finely distributed nanopigments that facilitate shade adaptation to the surrounding tooth structure and enhance the chameleon effect of the restoration. The material demonstrates high radiopacity, low sensitivity to ambient and operatory light, and ample time for the placement of a restoration. Additionally, it can be contoured with ease, does not stick to instruments, and demonstrates excellent stability.
Supplied in both screw-type syringes and unit-dose Cavifils, the material is available in 19 shades (11 Vita shades, 3 opaque Vita shades, 4 extra white bleach, and a transparent shade). All individual delivery forms include expiration dates and batch/lot number information, and are color-coded.
CASE PRESENTATION
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| Figure 1. Full-facial preoperative view of the patient. | Figure 2. Preoperative retracted frontal view of the patient showing the class IV fracture on tooth No. 8 from a previous sports-related injury. |
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| Figure 3. Right lateral preoperative retracted view of the patient demonstrating the post-orthodontic spacing between teeth Nos. 6 and 7. | Figure 4. Left lateral preoperative retracted view of the patient demonstrating the post-orthodontic spacing between teeth Nos. 10 and 11. |
A 29-year-old male was referred by his orthodontist for a consultation to address fractured tooth No. 8 (from a previous sports-related trauma) and post-treatment spacing between teeth Nos. 6 and 7 and teeth Nos. 10 and 11 (Figures 1 through 4). As with all new patients, a complete oral examination was necessary, and previous records were obtained from his orthodontist and general practice dentist.
The patients medical history was noncontributory, and he had no history of TMD symptoms. Periodontal status was within normal limits, and there was no radiographic evidence of hard-tissue disease.
The patients desire was to have an aesthetically pleasing smile through as conservative a treatment as possible. Of the various options discussed, the use of direct composite was the obvious choice in order to meet the patients specific objectives. It was decided to restore the class IV fracture on tooth No. 8 and close the post-orthodontic diastemas utilizing Tetric Evo-Ceram.4
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| Figure 5. A conservative labial-lingual preparation of the class IV fracture on tooth No. 8 was completed using a fine-grit diamond to create a chamfer. | Figure 6. The Contour Strip was positioned around the gingival margin of the prepared tooth No. 8. |
Conservative preparation of the enamel surfaces was completed with a fine-grit, flame-shaped diamond (Diatech USA) to create a distinct bevel on the labial and lingual aspects of tooth No. 8 (Figure 5). A Mylar matrix band system (Contour Strip, Ivoclar Vivadent) was placed and secured with an unfilled bond resin (Heliobond, Ivoclar Vivadent), which was applied to the dried adjacent teeth and soft tissues, then cured with a visible light source (Bluephase LED, Ivoclar Viva-dent) for 10 seconds to hold it in place (Figure 6). This created a sealed mold gingivally and interproximally in which to complete the restoration. When closing a diastema with the Contour Strip, it is helpful to wedge the matrix against the adjacent tooth and across the space using a flat-bladed instrument prior to applying and light curing the unfilled bonding resin onto the adjacent teeth and soft tissues.
Historically, the shaping and polishing of anterior resin restorations has been viewed as challenging, and in some cases tedious, especially below the free gingival margin. There are several advantages to placing this matrix band.5 First, it creates a sealed system for the operator that is free from saliva, hemorrhage, and crevicular fluids. The dentist can now work in a clean, dry environment and obtain a superior seal with todays dentin bonding agents. Additionally, the ability to place the composite material into this mold saves time and increases efficiency for shaping the restoration, since the Contour Strip establishes the contour of the final restoration when properly placed around the tooth. Third, the highly polished Mylar surface transfers to the composite material a high level of polish. (Because of the nano-optimized composites properties, this benefit was incidental in this case.) Finally, the use of this band eliminates the need to use rotary instruments below the free gingival margin for finishing.
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| Figure 7. Etchant was applied to the class IV preparation, rinsed with water spray for 10 seconds, and lightly air-dried. | Figure 8. Application of dentin-enamel bonding agent according to manufacturers directions using an applicator tip and cured with the LED light. |
The class IV preparation was cleansed prior to acid etching with 5% sodium hypochlorite on a stiff-bristled disposable brush, then rinsed for 10 seconds with water and lightly air-dried. Following the application of a low-viscosity 37% orthophosphoric etchant (Enamil Prep, Ivoclar Vivadent) for 15 seconds, the preparation was rinsed with water for 15 seconds, then gently air-dried (Figure 7). A single-component dentin bonding agent (Excite, Ivoclar Vivadent) was placed according to the manufacturers directions and cured for 10 seconds (Figure 8).
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| Figure 9. A flowable composite was applied to the labial and lingual surfaces using a sable brush, thinned with a stream of air, and cured with the LED light. |
A thin layer of flowable resin (Tetric Flow, shade A1, Ivoclar Vivadent) was applied with a brush, coating the labial and lingual surfaces of the tooth beyond the preparation margins. This layer was air-thinned prior to curing (Figure 9).
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| Figure 10. The first increment of Tetric EvoCeram in shade B1 Dentin was placed and manipulated using the OptraSculpt spatula instrument. The composite was then cured with the LED curing light for 20 seconds each from the labial and lingual aspects. |
A classic layering technique, which is most familiar to dentists, was used in restoring the class IV fracture and the diastemas. Two shades of the nano-optimized composite were used to create the aesthetic result: shade B1 Dentin as the first layer and Bleach Medium for the surface or enamel layer. The first layer was placed, shaped, and manipulated with the OptraSculpt (Ivoclar Vivadent) spatula-shaped composite modeling instrument and built up to the initial distal-incisal contour (Figure 10). This layer was then cured for 20 seconds from the labial and 20 seconds from the lingual aspects with the LED light source.
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| Figure 11. The second layer of nano-optimized composite shade Bleach Medium was applied over the cured initial layer. | Figure 12. The second layer was contoured prior to curing using a G-2 ceramist brush lightly lubricated with Heliobond. |
The second layer was syringed onto the tooth (Figure 11), and the final pre-cure contouring was completed with a G-2 ceramist brush (Ivoclar Vivadent) lightly lubricated with Heliobond (Figure 12). The second layer was cured for an additional 20 seconds from both the labial and the lingual aspects.
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| Figure 13. After curing, the resin collar was removed with a Bates 7/8 scaler, and the Contour Strip was removed with a hemostat to facilitate finishing and polishing. |
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| Figure 14. Shaping and finishing of the class IV restoration was initiated with a 12-fluted, spiral-bladed carbide bur. |
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| Figure 15. Final polishing of the composite was accomplished using abrasive cups in a light, whisking motion without water spray. |
The light-cured Heliobond resin collar was then removed using a Bates 7/8 scaler (Amer-ican Eagle), and the Contour Strip was lifted from the sulcus using a hemostat (Figure 13). The smooth Mylar surface left by the Contour Strip was transferred to the cured composite below the free gingival margin in all cases. As a result, only supragingival finishing with 12-fluted, spiral-bladed carbides (Brasseler USA) was necessary (Figure 14). Final polishing of the restoration was achieved using abrasive cups (Astropol, Ivoclar Vivadent) in a light, whisking motion without water spray until a high luster was achieved (Figure 15). The re-maining partial composite ve-neers for closure of the dia-stemas were completed in a similar manner.
CONCLUSION
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| Figure 16. Right lateral postoperative retracted view of the patient demonstrating the lifelike, chameleon-like blending of the restorations with the natural tooth color. |
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| Figure 17. Left lateral postoperative retracted view. |
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| Figure 18. Postoperative retracted facial view of the patient. |
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| Figure 19. Final postoperative facial view of the patient in natural smile. Note the excellent color blending of the composite for the class IV restoration on tooth No. 8 as well as the diastema closures on teeth Nos. 7 and 10. |
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| Figure 20. Final view of the patient with the completed nano-optimized direct restorative restorations. |
This article has demonstrated the simple and time-efficient manner in which a new nano-optimized direct composite res-torative was used to restore an anterior class IV fracture and close 2 diastemas. The resulting restorations exhibit the natural aesthetics and chameleon-like blending with the adjacent natural tooth structure that essentially make them invisible, despite the fact that only 2 increments of composite and only 2 composite shades were placed (Figures 16 through 20).
Facilitating the ease with which this case was completed was the use of specific composite placement armamentarium such as the matrix band and composite placement instruments. The handling properties and consistency of the nano-optimized composite also contributed to its ease of use.
References
1. Davis N. A nanotechnology composite. Compend Contin Educ Dent. 2003;24:662-670.
2. Milnar FJ. Selecting nanotechnology-based composites using colorimetric and visual analysis for the restoration of anterior dentition: a case report. J Esthet Restor Dent. 2004;16:89-101.
3.Tetric EvoCeram Scientific Documentation. Ivoclar Vivadent Web site. Available at: http://www.ivoclarvivadent.com/com/en/products/evoceram/wissdoku.html. Accessed March 10, 2005.
4.Peumans M, Van Meerbeek B, Lambrechts P, et al. The 5-year clinical performance of direct composite additions to correct tooth form and position. I. Esthetic qualities. Clin Oral Investig. 1997;1:12-18.
5. Belvedere PC, Lambert DL. Advancing your direct composites through the use of a specialized matrix. Oral Health. 2002;92(4):75-83.
Dr. Lambert is a fellow in the American College of Dentists and the Pierre Fauchard Academy, a diplomate of the American Board of Aesthetic Dentistry, and an accredited member of the American Society of Dental Aesthetics. He has been recognized as one of the Leaders in Continuing Education by Dentistry Today in 2004 and 2005 and as a Top Cosmetic Dentist by Minneapolis/St. Paul Magazine the past 5 years. He has held many societal positions in organized dentistry, including past president of the Minneapolis District Dental Society, and is currently the trustee to the Minnesota Dental Association. He has presented numerous lectures and hands-on seminars nationally and internationally for dental organizations, universities, the American Academy of Cosmetic Dentistry, American Society for Dental Aesthetics, Academy of General Dentistry, Academy of Sports Dentistry, and numerous study clubs. Dr. Lambert is a partner in an aesthetics-based practice in Edina, Minn, emphasizing cosmetic, comprehensive, and sports dentistry. He can be reached at (952) 922-9119.
Disclosure: Dr. Lambert occasionally receives a lecture honorarium from Ivoclar Vivadent.
