April 2, 2018
by Luc Vandenborght, LTH
Dentists are often faced with conflicting demands between function and aesthetics. Patients demand from their dentists an improved smile at a reasonable fee. Dentists want to not only meet the patients wants but also want to do that in a durable and evidence-based way.
Thanks to the well-known improvements of enamel and dentin bonding, it is now possible to bond dental composites and ceramics in a durable way. The adhesive bond is very long-lasting and can provide retention of a restoration for years.
When considering a reasonable fee, dental composites immediately come to mind. Present microhybrid and nanofilled composite materials are not as fracture prone as the former microfills because they have particle sizes that allow them to be more fracture and wear resistant. This makes the present composites a good choice for the treatment of the eroded dentition.
The term transitional bonding is used to describe its relation to ultimate aesthetic bonding and ceramic restorations. The transitional bonding is done in one single shade. Afterwards, it can be upgraded with artistic composite layering with the cutback technique very similar to the cutback technique that is done with ceramic restorations to make them multi-layered. Although this is an option, the aesthetic result of transitional bonding several teeth at a time will be 80% of the technique that uses artistic composite layering. If wanted, the transitional bonded restorations can also always be upgraded to ceramic restoration. The composite build-ups can then be used as a core build-up.
Case Study: Before
A 34-year-old female consulted me with extremely worn front teeth in the upper jaw. A canine deciduous canine was still present. The permanent canine was present but horizontally included. The lower front teeth were crowded (Figs. 1-5).
At the initial consultation, it was agreed to make X-rays, models and to take bites in maximum occlusion (MO) and in centric relation (CR) together with a facebow (KOIS) registration. The models were put in the Panadent articulator and a study was done. The study revealed that in MO, there was no lingual space to provide for the lingual build-up. In CR, it was noticed that there was enough space to build-up the composite on the lingual surfaces (Figs. 6 & 7).
Treatment plans were discussed with the patient. The goal of the treatment would be to restore the concerning teeth in aesthetics and function. It was decided to extract the deciduous canine but leave the permanent one included. The front teeth together with the first premolars would be treated with dental composites and we would make a fiber-reinforced bridge to close the gap that would be created after extracting the deciduous tooth.
The first step was to make mock-up. I do this before the dental lab makes the Smile Design. First, I draw the ideal teeth on two photos; one intraoral and one extraoral. It’s the same as the Digital Smile Design but in an analog way. Then, I create a rough free hand composite mock-up in the mouth and I show it to the patient (Fig. 8). I am told that the Uveneer templates would make this even easier but I have not tried that as of yet. On the basis of the mock-up and my drawings on the photos, a real Smile Design was made (for this patient the Smile Design was made by Nulife Long Island – by Mark Marinbach, accredited member of the American Society for Dental Aesthetics (ASDA) – www.asdatoday.com). Mark made a functional wax-up so that function was restored as well. The present length of the two central teeth was 5 mm. With the Smile Design, a length was created of 9 mm (Figs. 9 & 10). From the Smile Design, I made a putty guide of ridged translucent VPS. I didn’t have to test-drive the Smile Design first, which is advocated when using the Digital Smile Design. Through the mock-up and my drawings, I know that my Smile Design is fool-proof and that my patient agrees.
The treatment started with a gum lift of teeth #12 and 21 and the extraction of the deciduous canine. For the build-ups, very little preparation was needed. After preparation, all surfaces were cleaned with fine pumice (Consepsis Scrub- Ultradent) and separated each tooth after another with teflon tape, which I buy in a do-it-yourself store (Fig. 11). In this case, I especially like to work with Teflon tape because it permits me to use the translucent putty guide to build-up the lingual part. The enamel was etched with etch gel 40% from Henry Schein. I don’t believe there is any difference between etch gels, so I chose a cheap one. Afterwards, I used All-Bond Universal from Bisco.
I filled the incisal and lingual part of the putty guide with heated dental composite so that it has a good flow (composite: Filtek Supreme – 3MEspe/composite heater: Calset AdDent). Transparent guides are my materials of choice for the guides in these cases. It is very important to not press too hard on the VPS guide because it can distort the guide. After the lingual and incisal part the buccal part was created by hand-free. I did every build up one at a time (Fig. 12).
Before making the build-ups for teeth #12 and #14, the structure for the fibre-reinforced bridge for the replacement of tooth #13 was made. All other teeth at the time were already built-up with composite so that I could have a good support for the VPS guide. This was done with everStick C&B from GC. After the structure, the gums were isolated with Teflon tape and again the procedure was repeated (Figs. 13 & 14).
Now that all build-ups were made, I checked the occlusion and the articulation. Before polish I did an oxygen free final cure. When doing this, the composite will be less prone to discoloration and will polish better. For polishing, I use the discs from 3MEspe. Then I use the enamel polisher from Cosmedent for the final luster. After 14 days, I saw the happy patient and gave her the already made night guard (Figs. 15 & 17).
One minor property of composites is that they will lose their luster over time. They need to be polished regularly so that their luster comes back.
It is very well accepted that composite is an evidence-based material for this kind of treatments. Composites wear at a similar rate as enamel and have a fracture resistance similar of that of enamel. In case something goes wrong, the advantage of a composite is that it can always be restored as an invisible. Dental composite is considered as a material of second rate. There are questions if composite restorations of this size will hold up during many years, though for many patients, the transitional bonding procedure can be the only payable solution. OH
Oral Health welcomes this original article.
The author would like to acknowledge the late Dr. Irwin Smigel, the late Dr. Paul Belvedere and Dr. Elliot Mechanic from the ASDA for their education and mentorship. (ASDA: American Society for Dental Aesthetics – www.asdatoday.com). This year the ASDA holds its annual meeting in Nashville.
About the Author
Mr. Luc Vandenborght, LTH, maintains his private practice in Belgium. He graduated as a dentist at the Free University of Brussels. He is an accredited member of the American Society for Dental Aesthetics (ASDA), a member the European Society of Cosmetic Dentistry (ESCD), a member of the Dutch Academy of Esthetic Dentistry (DAED) and a participating member of the American Academy of Cosmetic Dentistry (AACD). He has a Fellowship of the American Society for Dental Aesthetics (ASDA), a Fellowship of the International Academy of Dental Facial Esthetics (IADFE) and a Fellowship of the International Congress of Oral Implantologists (ICOI).