Dental Asia March/April 2022

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USER REPORT On the day of treatment, complete anterior isolation was then performed using a heavy gauge latex rubber dam, with W2A clamps attached to the premolars to secure the dam. Floss ligatures were placed and tightened around both central incisors to further retract the dam into the gingival sulcus with the benefit of suppressing the papilla, which is extremely useful when closing diastemas with direct composite bonding (Fig. 4). Fig. 4 Fig. 6 Fig. 5 Fig. 7 The teeth were cleaned with an Enhance polishing cone, followed by air abrasion using a Rønvig sandblaster with 30-micron aluminium oxide particles. The teeth were then etched, followed by thorough rinsing, drying and application of a bonding agent that was carefully air dispersed. Fig. 8 Fig. 9 A pre-rolled composite increment was first applied to the UR1 and adapted freehand from all directions to achieve the ideal initial starting proportions. Care was taken to adapt the gingival portion to avoid gross overhangs. Good isolation made this much easier (Fig. 5). This increment was then cured and refined using interproximal strips to remove gingival excess (Fig. 6) and a Sof-Lex disc to gently contour the contact point to a smooth convex profile (Fig. 7). Polytetrafluoroethylene (PTFE) tape was then placed over the UR1 and the process was repeated on the UL1. For optimal adaption of composite placement and smooth transitional junctions from composite to the tooth, a GC Fig. 10 Fig. 12 sculpting brush (Fig. 8) and Optrasculpt (Fig. 9) modelling instruments were employed to eliminate instrument indentations from being introduced into the composite increments (Fig. 10). Following final curing, the palatal aspect was re-checked (Fig. 11) and a small overhang was removed by using an ultra-thin metal polishing strip passed under the interproximal contact (Fig. 12). Fig. 11 Fig. 13 Once again, effective isolation made this possible and is almost mandatory when attempting such cases freehand. Following rubber dam removal, the primary form was lightly adjusted using a coarse Sof-Lex disc. An Enhance polishing cone was used to reductively polish the marginal junctions. A medium grit flame bur was used in an electric handpiece in a light feathering motion to introduce tertiary anatomy into the restorations (Fig. 13). 50 DENTAL ASIA MARCH / APRIL <strong>2022</strong>
USER REPORT Fig. 14 Fig. 15 Fig. 16 Fig. 17 Fig. 18 ABOUT THE AUTHOR Fig. 19 The two-step Diatech polishing wheels from Coltene (Fig. 14) were then used on all surfaces of the restorations until a final high lustre was established (Fig. 15). Occlusal checks were performed as standard, to ensure the new restorations conformed to the existing occlusion. The close palatal inspection was performed under high magnification to ensure a smooth, ledge-free transition of restorative material towards the gingiva to respect the soft tissues (Fig. 16). FINAL APPRAISAL Following two-and-a-half weeks of healing, the patient was reviewed and the papilla had reestablished to confirm a hygienic result that blended well with the existing anatomy and soft tissues. The patient has since been seen for a one-year recall visit where the restorations have demonstrated excellent retention of polish (Fig. 17) and an extremely healthy soft tissue outcome (Figs. 18-19). TOP TIPS 1. Use a mock-up. Place composite without etch and bond, and shape roughly to determine the outcome and ensure it fits within the natural envelope of function. Check excursions and guidance at this stage. This is increasingly important when lengthening teeth or broadening and elongating lateral incisors which may incur a lateral interference in some cases, causing early failure. A mock-up also allows clinicians to assess and control patient expectations and is an excellent tool to choose the final restorative method and shade, and aid in informed consent. 2. Isolate like a pro. For diastema closures, use a medium or heavy dam secured with self-tightening floss ligatures. This will ensure the dam is retracted to the soft tissue junction and suppress the papilla, which is useful for median diastemas. Expect the papilla to rebound within a few weeks. 3. Sculpt like an artist. Use the correct instruments for labial increments. The final appearance and polish are determined earlier on during placement and a good polish is an outcome of great finishing. Use a broad, softer instrument to adapt the final labial increment to the tooth to ensure seamless margination and a final layer free of instrument indentations and irregularities. 4. Use the light. Following initial placement and gross finishing, take a photo of the direct anterior restorations. Schedule a second appointment for final refinements and high-gloss polishing two weeks later. Assess this photo in the meantime and the way the light hits the line angles of the restorations, as well as the axial inclination of the restorations. Aim to see even, straight-line light reflections on the mesial and distal line angles, as well as an axial inclination pointing down and towards the naval. Plan the refinements to achieve these optical properties at the next visit. A twin flash system is recommended for anterior work. DA ABOUT THE AUTHOR DENTAL ASIA MARCH / APRIL <strong>2022</strong> 51
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Dental Asia March/April 2022

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