Putty in My Hands by Dr. Varsha Rao

Introduction
More often than not, when a patient walks into our practice wanting to restore anterior teeth that have a Class IV or Class III cavity, we take an impression, get a lab wax-up made and make a palatal putty index, which is then used to restore the cavity.

Or we make a direct composite mock-up on the tooth itself and proceed with making the palatal putty index. In this case report, I share a third option: the Bertholdo/Ricci/Barrotte (BRB) technique, which allows clinicians to make a quick chairside palatal putty index.

The case report also discusses the controlled-body-thickness philosophy: Ensuring that the final layer of enamel is at least 0.5 millimeter is crucial to achieving a final positive outcome.

Case Report
A 62-year-old patient presented with a desire to restore the distal of the right central and mesial of the right lateral. She also wanted to finish her treatment in a single sitting.

I used a combination of two techniques learned from the Styleitaliano website. First, I used the BRB technique to make a lingual matrix, controlling the body thickness using a Misura instrument. This allowed me to create a quick chairside palatal putty matrix, which ensured a stable palatal stop and allowed me to build an anatomically precise palatal shelf.

In this technique, a putty matrix is made without doing any chairside mockup on the tooth. Once the base and catalyst of silicone putty are mixed, the putty is adapted on the palatal aspect of the teeth involved. Once set, it’s modified with a bur to create the final restoration desired. This putty matrix then serves as the palatal index needed to make an anatomically precise palatal shelf.

It’s necessary to have a definite stop on the palatal aspect of our buildup in any Class IV or Class III restoration. This ensures we have the correct amount of enamel and dentin shades in the layering.

Correct layering of the enamel and dentin is one of the most important goals in aesthetic stratification. The controlled-body-thickness philosophy advocates that enamel and dentin are more than enough to obtain ordinary or high-end aesthetic results in most cases. This technique was developed by Walter Devoto and Angelo Putigano.

After thorough studies of the composite enamel and composite dentin refraction indexes, opacity values and other optical features, clinical evidence and research suggests that a 0.5mm enamel thickness gives the most consistent result in its systematic use and in a wide range of materials. Use of a 0.5mm gauge (the Misura instrument) ensured that the topmost layer of enamel is limited to 0.5mm.

The patient wanted to reduce a diastema between 11 and 12, which I did by making the restoration on the central slightly overcontoured. She also didn’t want to change the old, discolored composite restoration on the distal aspect of 12 in this sitting.

Once I completed the restoration on the central, I used an interproximal strip on the restoration to do some gross finishing, which removed the oxygen-inhibited layer on the restoration. The composite resin that was in contact with ambient oxygen was not able to polymerize; this apparent “disadvantage” was the factor that allowed composite to bond from layer to layer.

Newly placed material covered the previously oxygen-inhibited layer, and the two layers polymerized together. Removal of this layer by finishing—using polishing protocols—ensured that the two separately done composite restorations didn’t bond to each other.

The case report also discusses the controlled-body-thickness philosophy: Ensuring that the final layer of enamel is at least 0.5 millimeters is crucial to achieving a final positive outcome.

I then proceeded with the restoration on the adjacent tooth without using a cellophane strip—ensuring no visible gap between the two restorations, which is what the patient desired.

I finished and polished the restorations using Soflex discs by 3M in sequence, starting with coarse and finishing with superfine. For polishing, I used a diamond polishing paste with a felt disc.

Conclusion
This is an easy, time-saving technique, especially if the patient wishes to complete his or her restoration in the same sitting.

References
styleitaliano.org.
Manauta, J., Paolone, G. Devoto, W. 2013. IN ‘n’ OUT - A New Concept in Composite Stratification. Labline Magazine, 3 (2), pp. 110-127
Salat A, Devoto W, Manauta J. Achieving a precise color chart with common computer software for excellence in anterior composite restorations. Eur J Esthet Dent. 2011
Aesthetic & restorative dentistry http://www.styleitaliano.org Autumn 6(3):280-96.
Manauta J, Salat A. Layers, An atlas of composite resin stratification. Quintessence Books, 2012.
Baratieri LN. Soluciones Clinicas: Fundamentos y Te?cnicas. Sa?o Paulo: Livraria Santos, 2009.
Dietschi D, Ardu S, Krejci I. A new shading concept based on natural tooth color applied to direct composite restorations. Quintessence Int 2006:37:91–102.
Vanini L, Mangani F, Klimovskaia O. Conservative Restoration of Anterior Teeth. Viterbo, Italy: Acme, 200

Dr. Varsha Rao has been in clinical practice for more than 16 years. She received extensive training in implant and aesthetic dentist, and has a certificate of merit from NYU in implants and oral rehabilitation and a certificate in aesthetic dentistry. She is a fellow of the Indian Society of Oral Implantologists and the International Congress of Oral Implantologists. In 2015, Rao published a case study on the microbrush stamp technique in Dentaltown. She is trained in composites (initial) with the Styleitaliano philosophy.