Jurnal Ultraconservative and Minimally Invasive Aesthetic Restoration of Crown Fracture

C l i n i c a l D e n t i s t r y , M u m b a i S e p t e m b e r 2 0 1 2 37

Abstract|| Brief Background

In aesthetic zone composite bonding procedures are considered the most conservative and least invasive technique. For com-posite restorations to mimic tooth structure, the clinician must have a comprehensive understanding of material sci-ence and techniques involved in direct bonding proce-dures. The article presents techniques to master the anterior direct composites with the help of two clinical cases.

|| Materials and Methods

In the first case, the most ultraconservative technique is fol-lowed by reuniting the fractured tooth fragment to the tooth in question. All the parameters of etching, bonding and composites are followed. In the second case, silicon index (putty index) is fabricated to make lingual enamel as ideal as possible and then layering concept of composite is followed to reproduce dentin, enamel.

|| Discussion

Discussion focuses on necessary techniques involving an understanding of colour, adhesive principles to create poly-chromatic in effects and perfect finishing and polishing.

|| Summary and Conclusions

The restorations final aspect, smile design and full face photography was done in both the cases and results were evaluated and minor corrections were done.

|| Key Words

Composite, tooth fragment, putty index, layering technique.

Ultraconservative and minimally invasive aesthetic restoration of crown facture

Dr. Neeraj MahajanProfessor and Head

Correspondence AddressDr. Neeraj Mahajan Pedodontics and Preventive Dentistry Guru Nanak Dev Dental College and Research Institute Sunam PunjabE-mail: [email protected]

Pedodontics

NEW CD September 2012.indd 37 9/13/2012 2:02:35 PM

C l i n i c a l D e n t i s t r y , M u m b a i S e p t e m b e r 2 0 1 238

|| Introduction

Aesthetic restoration of crown fracture at the central incisors level may be one of the greatest challenges a paediatric dentist can face. Generally, this affects children and teenagers and represents the consequence of accidental injuries. Much attention has been given in recent years to the need for clinicians to embrace minimally invasive and conservative technique when providing patients with both necessary and elective dental treatments. We are fortunate to be practising in an era when sound science and beautiful aesthetics can be applied in a less technique sensitive manner in order to answer todays dental challenges in conservative and rewarding ways.

Mastering anterior direct composite is a necessity for the contemporary clinician who appreciates and understands the art and science of cosmetic dentistry . In the aesthetic zone, composite bonding procedure is considered the most conservative and the least invasive technique to return missing, diseased and unsightly tooth structure to enhanced colour, form and function. The attractiveness and popular composites are easy to explain because these restorations have excellent aesthetic potential, very good to excellent prognosis and reasonable fee.

For composite restorations to mimic tooth structure, the clinician must have a comprehensive understanding of material science and techniques involved in direct bonding procedures. The presentation will focus on necessary techniques which involved an understanding of colour, adhesive principles to create polychromatic in effects and perfect finishing and polishing.

Dignosis and Treatment Plan

Here are two patients with crown fractures in central incisor. In the first case, a female of 14 years reported with fracture of tooth 11. Adhesive reattachment of dental fragment (ultraconservative technique) was carried out. In the second patient, a boy of 13 years reported with fracture of 11 and 21. Crown morphology was reconstructed with composite resin using silicon putty matrix technique (minimally invasive) for 11 and 21 which were fractured 2 years before and were endodontically treated. For

fractured 21 composite veneer was planned. The goal of minimally invasive dentistry is ultimately to curtail the restoration /re - restoration cycle.

Armamentarium

Lignocainewith 2%Adrenaline local anaestheticinjection solution.

Vitaclassicalshadeguide.

Flameshapeddiamondfinishingburs.

Compositeplacementinstruments.

35%phosphoricacidetchinggel.

Bondingagent5thgeneration.

Compositematerialofdifferentshades.

Opaquers

Tints

Lightcureunit.

Siliconimpressionmaterial.

Clear mylar strips, finishing and polishing discs,inter proximal finishing strips, composite polishing brushes.

Compositepolishingpaste.

DigitalCamera.

|| Treatment

Case I.

In this case, (Fig. I) after proper isolation and endodontic treatment , the fractured dental fragment was washed and brushed until anaesthesia took effect . Once the patient was comfortable , the teeth was polished to remove any plaque and dental fragments fit was checked on tooth.

Fig. (1) (case 1): pre operative



Fig. (1) (case 2): Pre operative

Fig. (2) (case 2): Lingual putty index being fabricated in labFig. (3) (case 1): Fragment in place after finishing

After proper isolation the tooth in question was prepared for acid etching, washing, drying and adhesive application on both the remaining crown abutment and retrieved dental fragment (Fig. II) . During this time, the adjacent teeth were protected with celluloid strips. Bonding was done with adhesive resin cement and proper shade material, the excess material being removed before the onset of polymerization.

Fig. (2) (case 1): Fragment of fractured tooth

A thin layer was applied on both involved adhesive surface maintaining the fragments closely related in their position during photo polymerization . A groove was carried across the fracture line into enamel thickness by means of a flame shaped diamond finishing bur in order to strengthen the bonding, the groove was filled by composite of matching shade. The treatment was then completed with standardized finishing and polishing procedures, abrasive discs and strips with decreasing granulation; abrasive composite polishing brushes with polishing paste to refine the outline from , develop texture and anatomy and smooth margins of restoration (Figure III ).

Case II:

After proper isolation, a long circumferential concave bevel preparation was carried out with irregular outline on the fractured tooth. The facial bevel was carried 2-3mm beyond the fractured area , with an up and down motion, so that the finishing line would not go against straight across and would seem disappear in the middle one third effectively.

A silicon putty matrix was placed over the mock up (which was repositioned at the arch level) to serve as a confirmer to restore the crown morphology . Before the silicon putty matrix was repositioned, the prepared tooth surface was etched, washed and dried; then bonding agent was applied. (Fig. I).

The proper restoration was achieved by composite layering technique on the silicon putty matrix surface so that optical effects simulate to the adjacent tooth could be achieved (Fig. II). This is also known as multiple layering technique. But to do so one has to understand the basic nature of composites, colour, optical effect, translucency, opalescence etc. (Figure III).


C l i n i c a l D e n t i s t r y , M u m b a i S e p t e m b e r 2 0 1 240

|| References

1. W. M TAY- Resin bonded bridges. Martin 1992. Ronald and E. Goldstein.

2. Reality Reality, Publishing company 1997.

3. Esthetics in dentistry- second edition B.C. Decker Inc 1998.

4. Bernard Touati, Paul Miara, Don Natahanson Esthetic dentistry and ceramic restoration. Martin Dentist - 1999.

5. Jens Fisher Esthetics and Prosthetics. Quintessence pub Inc 1999.

Fig. (3) (case 2): Finished composite build in tooth 1

The first layer of composite is given corresponding to the palatal enamel , then selected shade of greater opacity for dentinal reproduction , then again a new composite layer to represent enamel and finally a thin layer of shade translucent . ( incisal edge reproduction). (Fig. IV).

In this case , the treatment was completed with standardized finishing and polishing procedures, abrasive discs and strips with decreasing granulation ; abrasive composite polishing brushes with polishing paste to refine the outline form , develop texture an anatomy and smooth margins of restoration. The use of silicon putty matrix during composite layering process facilitated the finishing and polishing procedures. This tool minimized the amount of lingual finishing required and developed a relatively accurate in edge contour.

|| Discussion

The general aesthetic outcome was evaluated by the patient and her mother in the first case and the patient and his father in the second case and by the dentist . Everyone as satisfied especially the patient and parents who were really thankful to the dentist as this can be easily judged in their eyes.

The restorations final aspect , smile design and full face photography was done in both the cases and results were evaluated and minor corrections were done.

When faced with class IV fracture of central incisors, the minimalist approach to treating such cases dictates that the operative decision be based on what would extend the life time of the remaining tooth structure with as little future intervention as possible . To this end, it is now possible to conservatively place direct composite restorations in the anterior region- for such indication of class Iv fractures that replicate the form , function and aesthetics of natural teeth.

|| Conclusion

By achieving adhesive reattachment in the first case and reconstruction with silicon putty matrix technique in the second , the rationale behind a minimalist approach is ultimately to curtail the restoration cycle, to benefit the patient over his or her lifetime. The goal is to conserve as much healthy tooth structure as possible through these clinical procedures. Visible damage to the maxillary central incisors of an adolescent or young adult patient is a common clinical presentation and we are often challenged to restore chipped and fractured dentition in this patient group. To answer the professions demands, manufactures have recently introduced direct composite material that demonstrates improved physical properties , durability and strength for long term function and polychromatic qualities for the placement of restorations that essentially reproduce natural tooth structure.

What determines the restoration technique selected is the patients age: the younger the age, the more the conservative treatment should be . And from this viewpoint reattachment involved in the fracture and crown morphology restoration by means of composite materials represent the best options.



6. Claude R. RufenacktI Principles of Esthetics integration. Quintessence pub Inc 2000.

7. DCNA- New Techniques in Esthetic and Restorative Dentistry-2001.

8. Pascal Magna, Urs Basler. Bonded Porcelain restorations in anterior dentitions-a biometric approach , quintessence

pub. 2002-2003.

9. Orr. C. Accreditation Clinical case report Case type IV ; Direct Resin Restoration The journal of Cosmetic Dentistry 21(I) 49 55 ; 2005.

10. DCNA Successful Esthetic and Cosmetic Dentistry for Modern Dental Practice . April 2007.


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Jurnal Ultraconservative and Minimally Invasive Aesthetic Restoration of Crown Fracture