PRIVATE DENTISTRY JUNE 2016

n presentation, Master RS, a nine-year-old boy, fell over at school whilst playing sports with his friends in the playground. As a result he fractured both

maxillary central incisors, with no presenting symptoms or other extra or intra oral injuries (Figure 1). The patient had no allergies or medications and was medically fit and well. This was the first time he had fractured his front two central incisors.

The patient and his parents would like

Dev Patel presents a cases study showcasing direct composite restorations for a young patient who had fractured both central incisors

SINGLE TOOTH COMPOSITE

CLINICAL EXCELLENCEWITH CPD

O these teeth restored using minimally invasive techniques and natural looking restorations. Also, the patient requested to avoid any sort of injections if possible as he is quiet an anxious patient.

EXTRA-ORAL EXAMINATIONTMJ – no abnormality detected, full range of motion, no muscle tenderness, no clicking, no tenderness to palpation.No facial asymmetry detected.Salivary glands – no abnormality detected.

DEV PATEL BDS PGDIP PCD Dev graduated from the University of Manchester in 2012

and is currently enrolled on a master’s course in Implantology at the University of Sheffield. He is the principal and clinical director of 'Dental Beauty Swanley', a busy mixed practice

based in Swanley, Kent. Dev is also the co-founder of the UK’s largest dental professional network - www.DentalCircle.com Dev has been awarded highly commended for ’Single Tooth Composite’ case at the Aesthetic Dentistry Awards 2016 and

‘Best Young Dentist’ at the Dental Awards 2015. He has a special interest in cosmetic, orthodontic and

restorative dentistry.WEBSITE: www.dentalbeautyswanley.co.uk

Skin - appeared normal.Lymph nodes - showed no signs of lymphadenopathy.Muscles - showed normal function.

INTRA-ORAL EXAMINATION Gingivae – no abnormality detected.Soft tissues – no abnormality detected.Lips were competent.FOM - no abnormality detected.Labial mucosa – no abnormality detected.Buccal mucosa – no abnormality detected.Tongue – no abnormality detected.Hard palate – no abnormality detected.Soft palate – no abnormality detected.

SPECIAL INVESTIGATIONS CARRIED OUTFull set of clinical photographs

Radiographic examination (UL1, UR1 PA taken) Good bone levels, no PA pathology, no caries present, no root fractures, no root resorption, MI radiolucency UL1, UR1

Sensibility testing (UL1, UR1 ethyl chloride): +ve

UL1 and UR1 not TTP, not mobile

DIAGNOSES UL1, UR1 enamel dentine infarture

Class 2 Div 1 incisal relationship

TREATMENT OBJECTIVESRestore the UL1 and UR1 fractured teeth using minimally invasive restorative techniques.Figure 1: Pre-treatment images

Figure 1a

Figure 1b

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Written by Dr Dev Patel

PRIVATE DENTISTRY JUNE 2016

Ensure the restorations seamlessly blend aesthetically with the UR1 and UL1.

Provide a long-term upper mouth guard to protect the patient’s upper protruded incisors.

TREATMENT OPTIONSDo nothing: This would not harm the rest of the dentition but would leave the upper central incisors vulnerable to further fracture and poor aesthetics.

Use composite restorations: The benefits of restoring the UR1 and UL1 using composite restorations were: almost no tooth preparation required, composite is softer than porcelain thus will be ‘kinder’ and less abrasive as porcelain to the opposing dentition. In addition, composite is a lot cheaper and easier to repair than porcelain. The main drawbacks of using composite would be: staining, future risk of fracture and chipping.

Use porcelain veneers: Porcelain veneers can be used to improve the UL1 and UR1 appearance and restore the fractured teeth. This option would not only require irreversible tooth preparation and be an expensive option but also would have a lower long-term prognosis due to the extent of the fracture and exposed dentine. In addition this option was a considerably higher cost for the patient and would be harder to repair if fractured.

After offering all the options, Master RS and his parents decided to restore these fractured teeth using natural-looking layered composite restorations. It was also agreed to provide the patient with mouth guard to wear during all contact and non contact sports and activities.

TREATMENT PLANStabilisation: Oral health education including oral hygiene instruction and tooth brushing instruction in accordance to ‘Delivery Better Oral Health’ guidelines.

Definitive: Place two polychromatic composite restorations to restore the UL1 and UR1.

Maintenance: Provision of a upper mouth guard to be worn every night. Re-enforce oral hygiene instruction and tooth brushing instruction.

TREATMENTThe composite system used was ENA HRi nano-hybrid composite (Micerium). The hue, value and chroma was assessed using a full set of clinical photographs (colour, black and white) and numerous shades of freshly placed 1mm composite balls (Hri composite) along the relevant areas of the central incisors (Figures 2-4).

A lighting device (Optilume Trueshade) was also used to assess the shade match and to ensure the correct lighting conditions were obtained - 5500k colour temperature (Gokce HS et al, 2010). A detailed colour map was drawn (Vanini et al, 2001), highlighting the correct shades and characterisations that are visible within the tooth structure (Figure 5).

Figure 2: Pre-op using cross polariser

Figure 3: Shade analysis

Figure 4: Value analysis

Figure 1: Pre-treatment images

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Figure 5: HRI colour chart

A composite mock-up was performed without acid-etching, to mimic the final dimensions of the restored teeth (Figure 6). The occlusion was then checked, and final adjustments made using a Sof-Lex coarse disc.

A palatal silicone matrix was fabricated (Behle C, 1996); ensuring the silicone only extended along the insical edges of the anterior teeth (Figure 7). Isolation was achieved using a lip and cheek retractor (Opragate) and cotton wool rolls. Adjacent teeth protected with PTFE tape.

The composite mock up was then removed and an irregular-shaped 2mm long bevel was placed buccally. Palatally, a 1mm thick and 1mm long chamfer was placed, as the middle third of the central incisor will be subjected to the highest tensile stress, thus providing adequate space for a thicker layer of composite. All sharp angles were smoothed using a coarse Sof-Lex disc (Figure 8).

All surfaces of both central incisors were mechanically etched with a chairside MicroEtcher II containing CoJet 30-μm silanated ceramic particles (Swift EJ et al, 1992). A 35% phosphoric acid was used on enamel for 15 seconds and rinsed off. A thin layer of a dentine desensitising agent (Telio) was applied along the exposed dentine surface to reduce post-operative sensitivity. After careful air-drying to leave a moist dentine surface, a thin layer of bonding agent (Optibond FL) was applied to all surfaces of the central incisors. The bonding agent is then air-thinned and light cured with a LED light cure (Valo) according to the manufacturer instructions.

The palatal matrix was then replaced and with a scalpel the fracture line is gently marked on the matrix.

All shades of composite used were heated using a ENA heating container to 39 degrees (Vanini L et al, 2005). A 0.5mm thick layer of Hri OBN was placed on the matrix from the marked fracture line to the proximal and insical edges (UR1 and UL1) (Figure 9). This palatal shell layer (Vanini et al, 1995) was spread using a No.1 sable brush dipped into a small amount of unfilled ‘wetting’ resin (Sculpt and Brush).

The matrix was then firmly placed palatally and light cured for 30 seconds and then removed, and cured again palatally for 30 seconds.

To ensure no excess or rough edges remains around the palatal shell, a coarse Sof-Lex disc was used to smooth the edges proximally and insically.

Dentine Body Stratification (Vanini L, 2010): Mulitple layers of Hri UD4, 3 and 2 were placed on top of the palatal shell conforming to the natural anatomy of dentine and light cured (Figures 10-11).

Intensives: IWS shade Hri was sparingly placed in between and over the mammelon grooves to mimic the milky white flecks insically and in the mid mid third of the teeth.

Finally, a UE1 Hri layer is placed along all the buccal surfaces using a No.3 sable brush and

Figure 6: intra-oral mock up

Figure 8: Preparation

Figure 7: Fabrication of putty stent

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then light cured. A final cure through an oxygen inhibition gel (Deox) was carried out to ensure complete polymerisation of the air-inhibited layer (D, Arcangelo C et al, 2009).

The primary anatomy was shaped using fine, superfine finishing diamond burs (Croll TP, 1988) and coarse Sof-Lex disc to ensure correct incisal edge shape, embrasure form, transitional line angles and smooth marginal integration. The secondary anatomy was completed using a white stone to form vertical grooves to match the distal half of the maxillary central incisors. The tertiary anatomy was created with a no.15 Swann Morton scapel in a horizontal wavy direction.

A diamond impregnated polishing brush (Groovy diamond) was used for the initial polishing. This allows the clinician to assess the transitional line angles and surface texture.

Finally, an aluminium oxide paste (Enamelize) was used on a felt disc (Flexi-Buff) to provide the final lustre.

Further modifications were made at a two-week review appointment, where final post-operative photos were taken (Figure 12).

References are available on request. Please email andy.myall@fmc.co.uk

COMMENTS TO PRIVATE DENTISTRY@ThePDmag

CPDAIMS AND OBJECTIVES

To discuss the diagnosis, treatment planning and treatment - including composite layering - of a young

patient with fractured central incisors. EXPECTED OUTCOMES

Correctly answering the CPD questions on page 68 shows the reader has understood the process demonstrated of repairing fractured teeth with composite restorations.

VERIFIABLE CPD HOURS: 1

Figure 12a

Figure 12b

Figure 12c

Figure 12: Post treatment images

Figure 10: Mesial wall build up UE2

Figure 9: Polychromatic composite build up - palatal shell - OBN

Figure 11: Dentine build up UD4, 3, 2

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