Dental Asia November/December 2022

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CLINICAL FEATURE Augmented aesthetics in direct composite layering Presenting a tedious but effective technique, Dr John Rundell Paredes details the use of modifying stains in conjunction with a mono-shade composite system to fabricate natural-looking restorations. Translucency in composites and other dental restoratives are ever present. The effects of translucency largely affects the final restoration, the thickness and type of this layer will dictate corresponding optical effects, especially on composites (Fig. 1). Thickness of the translucency layer reduces the chroma or the intensity of the shade (Figs. 2-3). It also reduces the value, or the overall brightness of the shade. Differences in the type of translucency layers is also important, as higher value translucencies, in which being a brighter, milky-white layer, increases the value of the restoration while also decreasing chroma in increasing its thickness (Fig. 4). Lower value translucency layers in contrast, darkens the restoration and produces an amber shade to the restoration. It is worth noting that some types of translucencies vary in its translucency itself. Translucency in general lessens the definition of the layers and colours underneath it, like stains for example, but highly translucent, almost transparent/ achromatic composite variants also exist, for those cases in which patterns and shades on the underlying layer should be better observed. The knowledgeable use of these types of layers can be an indispensable tool in creating high level aesthetics in anterior restorations. Typically found in multi shade system composites, mono shade systems can also have a translucency layer available to it, typically labelled as Incisal. CASE STUDY A 30-year-old female patient has undergone a class III non-extraction, compensated orthodontic treatment; the previous situation was a severe crowding on the anterior teeth with crossbite. The orthodontic treatment was done in the concept of using an accentuated curve of Spee to accommodate the spacing needed for the anterior teeth, without extraction of the lower premolar teeth to avoid resulting in an excessive retraction of the mandibular teeth. A disadvantage of this technique is the overinclination of the anterior teeth facially, but with the advantage of being less invasive due avoidance of extraction (Figs. 5-7) The patient wanted a better smile, but is not amenable to indirect restorations due Fig. 1: One type of translucency layer; TN- Translucent Neutral, Amaris, Voco Figs. 2-3: Note the thickness differences and its effect on the underlying layer Fig. 4: TL-Translucent Light; Amaris, Voco Figs. 5-7: Pre-operative pictures 28 DENTAL ASIA NOVEMBER / DECEMBER <strong>2022</strong>
CLINICAL FEATURE Figs. 8-9 Fig. 10 Figs. 11-12 Fig. 13 Figs. 14-15 Figs. 16-17 to the preference of minimising tooth reduction. So, the treatment plan was to first lengthen the anterior teeth in an attempt to “test out” the function and phonetics of the proposed new length of the anterior teeth, keeping in mind minimising or possibly avoiding tooth reduction as per patient’s request. The patient also wanted to try out a brighter shade during this phase. Harmony is not yet a concern initially because of the prevailing COVID-19 restrictions of using a mask, the patient was more than willing to do this phase. Subsequent proposed procedures would be an in-office bleaching appointment, then a minimally invasive direct veneering or bonding smile makeover to recreate the smile with the least tooth reduction possible. Direct composite restorations also have the advantage of easy adjustments, considering that the patient had a crossbite and may not adjust to the new anterior design easily, while also enabling the us to layer a more natural looking restoration, as compared to a monolithic composite injection technique. A final, more durable, indirect restoration was also proposed, after a three-month period following the final direct restoration, if the patient would want to change it and would be amenable to tooth reduction. PRE-PROCEDURAL PREPARATION Direct addition of composite material was added to the tooth to simulate the new length of the anterior teeth, using a direct ormocer composite, Admira Fusion from VOCO; shade B1 and Incisal are layered in using a freehand technique. This phase was supposedly only for two-three weeks, but the patient wanted to delay the final treatment (Figs. 8-9). Patient came back for the definitive treatment citing the different adjustments she wanted for the teeth. The planned inoffice bleaching was done after reduction of the existing layered composite. Initial shade was at VITA Classical A4 (Fig. 10), noting the strong chroma and low value of the existing natural teeth, the patient was made to understand that a high value and target shade of B1 may not be achieved. This was understood and accepted by the patient before we continued with our bleaching procedure after impression and removal of the existing composite material (Figs. 11-12). A request of bonded temporaries was made by the patient during this time, as she is already accustomed to the new shape of her teeth. It was planned that we will be fabricating a direct temporary and mock up of the planned makeover for her to wear after a week from the bleaching procedure, to minimise possible discolouration of the natural teeth due to the possible effects of the bonding agent. A combination of A1 and B2 shades were achieved after the bleaching procedure (Figs.13-15), the patient was appointed a week after for her bonded temporaries. An appointment after two weeks was also set for the definitive composite restorations. The shade is still consistent after a week the bleaching procedure (Figs. 16-17). DENTAL ASIA NOVEMBER/ DECEMBER <strong>2022</strong> 29
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Dental Asia November/December 2022

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