Show Your Work: In-Office Restorations by Dr. Anthony Mennito

by Dr. Anthony Mennito

Working in a building with 50 other dentists means there is no shortage of providers when one of the faculty members has a dental emergency. Over the past eight years, I’ve become the person my peers seek out to restore anterior teeth, especially when a direct Class IV composite is required. (I’ve missed many a lunch break because of this.)

This case, which stemmed from one of those experiences, was the first time I used the latest composition of IPS Empress Direct from Ivoclar Vivadent. Normally I place a rubber dam for this procedure, but the patient, a prosthodontist in my department, refused. I usually would insist, but as a fellow dentist he knows what the consequences of moisture contamination are, so I knew I could trust him to remain open. This procedure was performed during the lunch break with an assistant and cotton roll isolation.

Figs. 1a (above) and 1b: Preoperative. The patient’s existing Class IV had fractured off when he bit into a chicken wing. This is how he presented to me.

Fig. 1b

Fig. 2: I generally do a mock-up for two reasons: First, to test my shade choice on the actual tooth, and second to allow fabrication of a putty matrix. To do this, I add a little dentin and enamel of the selected shade (A2, in this case), quickly layer it on the tooth and cure it for five seconds. Then, I create a putty (typically Aquasil EasyMix from Dentsply) to duplicate the lingual surface all the way to, and overlapping, the incisal edge. I find that for me, the time it takes to do this step is easily made up during the composite placement and finishing portion of the procedure. In this case, the patient still had the matrix from the previous placement of this restoration, which we used.

Fig. 3a: Beveling is important because it creates all the restoration’s retention. This is also important for the final aesthetics. I generally place two bevels, with the first being short and steep and on the buccal and lingual of the tooth. This allows room for layering different composite opacities in such a way that hides the fracture line and makes the final restoration mimic a natural tooth. The second is longer and shallower, and its sole purpose is additional enamel for retention.

Fig. 3b: The first increment is a thin layer of the enamel shade placed with the putty in place. I will make this as thin as I can get it and bring it all the way to the incisal edge. I want this increment to be the outline for the final shape of the tooth. All composite is initially placed with a Cosmedent IPCT instrument. The thin, flexible nature of this instrument allows for easier manipulation of interproximal contours.

Fig. 4: I use the flowable version of Trans Opal from Ivoclar Vivadent to accentuate any incisal translucency that exists in the tooth. I find that just a little is required, and generally place it just gingival of the incisal edge. Knowing the final position of the incisal edge is important when layering composite, in addition to the putty showing the final shape of the tooth.

Fig. 5: Dentin shade composite (A2) is placed to cover the fracture line. I generally place it one-third of the way down the first bevel and extend it to just gingival of the incisal edge. If incisal translucency is not required, I extend it all the way to the incisal edge. It is important to evaluate your tooth after this increment is cured to ensure that you can no longer make out the fracture line. Not using a more opaque, or dentin, shade composite is one of the most common errors I see when patients are unhappy with their existing Class IV composites.

Fig. 6: One more increment of enamel shade composite (A2) is placed. Because this layer will make up the facial surface, it is very important to smooth it once the desired shape has been created. I use the OptraSculpt pad from Ivoclar Vivadent, and have found it to be a game-changer. If a composite is to disappear on a tooth, it must match the luster of natural enamel. For this to occur, the composite cannot have any seams, voids or gouges. When using multiple increments of composite, it’s imperative to not create seams or integrate air bubbles into the restoration that can be unearthed during the finishing process. For me, the OptraSculpt pad is the first step of the finishing process. It enables me to create a flat surface on the facial of the tooth, smooths seams between increments and minimizes the risk of bubble formation. I find this to be more predictable and efficient than a sable hair paint brush and modeling resin, which is what I used before. My technique is to get the shape of the composite as close to perfect as I can before curing it—the less I need to finish, the better I think the composite will look in the end.

Fig. 7: This photo was taken after finishing with a superfine diamond and sandpaper discs and before checking the patient’s occlusion. For laterals that include the incisal edge, I always carefully check to see where that edge hits when the patient goes into lateral excursive movements. In this case, he was bumping our restoration, and I adjusted to make sure that it cleared. This will certainly help the longevity of the restoration.

Figs. 8a–8d: Final restoration, taken with different flash settings. (Fig. 8a above)

Fig. 8b

Fig. 8c

Fig. 8d

 

You can see in some versions of the final where I may have overdone my use of the Trans Opal. This accentuated incisal translucency is quite powerful and it should be used carefully. I take final photos with different flash settings and angles to allow me to scrutinize my work at a macro level. I believe this has helped me improve the quality of the aesthetic restorations that I’ve placed over the years.