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CASE REPORTS

abstract

Received for publication: Feb. 9, 2006. Revised: Jul. 25, 2006.

rEZUMat

1 OdontoPrax Private Practice, Timisoara, 2 Dept. of Restorative Dentistry, Faculty of Dental Medicine, Carol Davilla University of Medicine and Pharmacy, Bucuresti

Correspondence to:Anca Valceanu, 18E Vuc St. Karadjic Str., 30068 Timisoara, Tel. +40722248966Email: asvalceanu@yahoo.com

IntrodUctIon

The crown fractures of the superior incisors are very often the outcome of childhood and adolescence injuries; aesthetically, they represent a shape and size disharmony at the dental and dento-labial composition.1-3 Teenagers’ concerns, after such an accident, are focused on hiding this disability, reason for which their smile design is usually altered.4

Aesthetical restoration of smile, after young teeth fractures, has to take into account teeth vitality

sIMULtanEoUs aEstHEtIcaL rEstoratIon oF cEntraL FractUrEd IncIsors

Anca S. Valceanu1, Constantin M. Varlan2

Introduction: From an aesthetic point of view, the crown fracture situated at the superior incisors, represents a shape disability, regarding dental composition. The treatment indication is generated by the patients' age, the lack of hard dental substance, occlusion and chromatic particularities of teeth. Case report: The patient (15 years old) presented two oblique fractures, IInd Ellis Class of 1.1. and 2.1. The aesthetic restoration was performed using an original direct technique; it consisted of the simultaneous restoration of the two incisors using two celluoid crown forms. Their vestibular surfaces were fenestrated in such a way as to preserve the oral and proximal surface form as well as the incisor margin and angle form. Conclusions: This method allows morphological and chromatic simultaneous restoration of teeth. This therapeutic solution is especially useful for young teeth with an extensive chromatic map where the main concern, besides the aesthetic rehabilitation, is to conserve tooth vitality.Key Words: direct restorations, esthetical restorations, fractured teeth

Introducere: Din perspectiv\ estetic\, fracturile coronare care afecteaz\ incisivii superiori, reprezint\ un dezechilibru de form\ la nivelul compozi]iei dentare. Indica]ia terapeutic\ este determinat\ de vrsta pacientului, de deficitul de substan]\ dur\ dentar\, ocluzie [i de particularit\]ile cromatice ale din]ilor. Prezentare de caz: Pacientul, o adolescent\ n vrst\ de 15 ani, s-a prezentat la cabinet pentru a solicita restaurarea din]ilor 1.1. [i 2.1., afecta]i de fracturi coronare oblice clasa a II-a Ellis. Tratamentul s-a realizat printr-o tehnic\ direct\ original\ de reabilitare estetic\ simultan\ a celor doi din]i, utiliznd dou\ cape conformatoare de celuloid. Dup\ pozi]ionarea capelor pe din]i, peretele vestibular al acestora a fost decupat, n a[a fel nct s\ se conserve integritatea suprafe]elor proximale [i forma muchiei [i a unghiurilor incizale. Concluzii: Aceast\ metod\ permite reabilitarea concomitent\ att a morfologiei din]ilor, ct [i a particularit\]ilor cromatice. Tehnica este indicat\ mai ales din]ilor tineri cu o hart\ cromatic\ variat\, la care pe lng\ obiectivul estetic trebuie avut\ n vedere conservarea vitalit\]ii lor.Cuvinte cheie: restaurare direct\, restaurare estetic\, fracturi dentare

preservation (when this was not compromised) and, if possible, minor sacrifice of hard dental substance; that’s why, the first therapeutic option has to be direct restoration with composite resin.5

Aesthetical dental parametersthat need to be taken into consideration are: position, shape, texture and tooth color.6

One of the most frequently used direct method for this kind of fractured teeth is that using a celluloid crown form. Unfortunately, this technique presents the disadvantage of not allowing an adequate chromatic reproduction of the prospective restoration, this meaning a correct positioning of shades (hues, chromes, values and characterizations); the main cause for this inconvenience is that, right in the moment of conforming matrix application on the tooth, the composite resin layers (judiciously laid inside the cup) aleatory mix between themselves.

In order to rectify this disadvantage, we have resorted to a simple solution: after the matrix cervical

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outline adjustment, in agreement with the gingival and the insertion of the tooth, a fenestration is performed, by means of scalpel blade tips, at the level of the vestibular wall.4,5 This vestibular matrix wall fenestration can managed material stratification very well, so that, a simultaneous chromatic individualization and crown morphology (primary, secondary and tertiary) result.7-9

MatErIaL and MEtHod

A 15-year old female patient presented at the dental surgery ward with an aesthetic disability, caused by two crown oblique fractures (Ellis IInd class), in the two central superior incisors.

The therapeutic objective was to improve aesthetic appearance and teeth anterior guidance functional restoration, using a restoring solution as conservative as possible.8

The clinical examination yielded the initial diagnosis of crown fractures without pulp implication; moreover, the left incisors exhibited a disto-vestibulary dyschromia, brought on by affected dentine.

Aesthetical examination emphasized the following aspects:

- Patient’s altered smile; (Fig 1)- Oblique fractures affecting both incisal angles of

the two incisors; (Fig. 2)- A distal dyschromia localized in the middle third

of the vestibular face of the left central incisor (caused by the coexistence of a carious process);

- Different position of lateral incisors to the central ones: 1.2. in palato-position, and 2.2. in vestibulo-position; (Fig. 3)

- The lack of interdental contact at the median line between central incisors crown abutment; (Fig. 3)

- Apparent face shape of lateral incisors (frontal view) is rectangular, and the remaining crown areas of the two fractured central incisors suggest their integration in the same geometry; (Fig. 3)

- The secondary morphology is characterized by growth mamelons; (Fig. 3)

- Teeth basic color, established by means of classic method (Vita shade guide) is A1; (Fig. 4)

- The individual chromatic characteristics are mostly noticed at the lateral incisors: strongly marked translucence in incisal third, interrupted by tiny white chalky stains, with irregular outline. (Fig. 2,3)

Treatment chronology:- Professional teeth brushing;- Affected dentine exeresis at the left central incisor

level (2.1.), in order to remove brown pigmentation

from vestibular surface area and to facilitate chromatic analysis; (Fig. 4)

- Setting up of surgical site (with rubber-dam and saliva ejector);

- Adhesive substratum preparation: enamel beveling, etching and amelo-dentinal adhesive application. In order to obtain similar optical effects in both teeth, the preparations were done with an irregular outline and, approximately at the same distance to vestibular marginal paradontium; (Fig. 5)

- Celluloid crown forms application, previously tried on and fenestrated at the level of the remaining abutments; (Fig. 6)

- Vestibular wall fenestration of matrix in such a manner as to preserve lateral walls and incisal angles form, so as to accomplish the morphological support for restorations; (Fig. 7)

- Composite resin stratification, according to the following shades: A1E (enamel shade), applied on the cups palatinal wall, followed by A1D (dentine shade), that rendered dentinal mamelons, and finally, TG (translucent grey shade), applied incisally and proximally; (Fig. 8-10)

- Final aspect examination of restorations from frontal and incisal incidence, after conforming matrix removal, but before finishing; (Fig. 11,12)

- Treatment completion with the well known finishing and polishing procedures of restorations; (Fig 13)

The following materials were used for carrying out the clinical case:

- Dentomin natur. Product (Geoproduct KFT MÁD Szabadság), professional teeth brushing paste;

- Shade guide - VitaPan Classical (Vident);- Rubber Dam /Kofferdam (SDI DIRECTA,

Svenska Dental Instrument AB);- Diamond flame burs;- 35% phosphoric acid etching gel (3M ESPE

Dental Products St. Paul MN USA);- Adper Single Bond 2 - adhesive (3M ESPE

Dental Products St. Paul MN USA);- Filtek Supreme Universale Restorative, composite

resin, shades: A1E, A1D and TG (3M ESPE Dental Products St. Paul MN USA);

- Elipar FreeLight, curing light (3M ESPE Dental Products St. Paul MN USA);

- Celluloid crown formes (Frasaco Franzsachs & co. Germany);

- Composite placement instruments (Cosmodent);- Finishing and Polishing Discs (3M ESPE Dental

Products St. Paul MN USA);- Interproximal finishing streps (3M ESPE Dental

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Figure 1. Patient's initial smile.

Figure 2. Frontal, retracted initial view: oblique crown fractures IInd class Ellis 1.1. and 2.1.

Figure 3. Frontal superior teeth view, after damaged dentine exeresis at the level 2.2.

Figure 4. Teeth basic color determination.

Figure 5. Circumferential beveling of peripheral enamel at the fracture surfaces level, after an irregular outline.

Figure 6. Celluloid crown forms insertion at the remaining crown abutments.

Figure 7. Windows fenestration at the level of matrix vestibular wall.

Figure 8. Composite resin stratification.

Figure 9. Composite resin stratification.

Figure 10. Composite resin stratification.

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Figure 11. Restoration aspect before finishing.

Figure 12. Restoration aspect before finishing.

Figure 13. Restoration's final aspect.

Figure 14. The smile at the end of the treatment.

Products St. Paul MN USA);- Finishing Silicon Carbide Brush (3M ESPE

Dental Products St. Paul MN USA);- Composite polishing paste (SDI Limited,

Australia);- Canon digital camera (EOS 300D) with EFS 18-

15 mm lens.

rEsULts

Final appearance of the restored teeth emphasizes their satisfyng integration in the dental arch, both morphologically and chromatically. (Fig. 14)

dIscUssIons

Teeth aesthetical rehabilitation with crown fractures may be performed using more direct techniques: among these, the most frequently used are those realized by means of prefabricated morphological support (celluloid crown forms), or made up of silicone impression material (after a previous “mock up” and “wax up”).8 The proposed technique – celluloid fenestrated crown forms – is, as a matter of fact, a kind of hybrid between the two, which confers the morphological support necessary for the composite material oro-vestibular stratification, without a previous „mock up” or „wax up” (that prolongs working time).9

concLUsIons

Any kind of restoration regarding central superior incisors – the dominant element of dental composition – should be preceded by a rigorous aesthetical analysis, regarding both geometric and chromatic particularities of teeth.

The direct techniques of aesthetical restoration represent the best choice for teenagers, as a minor loss of hard dental substance is required.

Although, the option, for one or other direct restoration method for young fractured teeth, rests with the dentist, he has to take into account aesthetical and functional objectives, but also the necessity to limit working time.

rEFErEncEs

1. Valceanu A. O alternativa estetica de restaurare a dintilor frontali fracturati. Revista nationala de stomatologie, chirurgie maxilo-faciala si chirurgie orala 2004;2(II):19-25.

2. Rufenacht CR. Fundamentals of esthetics. Quintessence Publ. Co. Inc. 1992.

3. Fradeani M, Barducci G. Tooth analysis In: Fradeani M. Esthetic rehabilitation in fixed prosthodontics – Vol I, Esthetic Analysis a systematic approach to prosthetic treatment, Quintessence Publ. Co., 2004, p. 138-162.

4. Valceanu A. Limite in reabilitarile estetice directe - Oral presentation during Symposium „Espertise” - 3M ESPE Romania, Timisoara, 2005.

5. Valceanu A. Estetica in Medicina Dentara, Timisoara: Brumar Ed., 2004.

6. Feigenbaum NL. Aspects of aesthetic smile design. Pract Perio Aesthet Dent 1991;3(3):9-13.

7. Buda M. Form and color reproduction for composite resin reconstruction of anterior teeth. J Periodont Restor Dent. 1994;14:34.

8. Orr C. Accreditation clinical case report, case type IV: direct resin restoration. Journal of Cosmetic Dentistry 2005;21(1):49-55.

9. Dietschi D. Layering concepts in anterior composite restorations. J Adhesive Dent. 2001;3(1):71-80.