Predictable Success in Restoring a Fractured Tooth for a ...

40 Spring 2018 • Volume 34 • Number 1

AbstractThe restoration of a Class IV fracture is a very common procedure in a dental practice. A predictable method to restore this condition is useful to any restorative dentist. This article will demonstrate a simple technique to restore a fractured anterior tooth in a young patient so that it appears as if the fracture had never occurred. Shade selection, composite layering, anatomical buildup, and finishing and polishing will be discussed and demonstrated with clinical photographs and color maps.

Key Words: conservative, reasonable longevity, polychromatic, intraoral mock-up, long facial bevel, predictable

Restoring a Fractured Tooth for a Young Patient

James H. Peyton, DDS, FAACD

Predictable Success in

41 Journal of Cosmetic Dentistry

Peyton


IntroductionA Class IV composite resin is used when there is a frac-ture involving the incisal edge of an anterior tooth. Conservation of tooth structure with a limited Class IV fracture repair is in the best interest of the patient and the ethical treatment of choice for the restoring dentist. There is no need to aggressively grind down the tooth structure for an indirect restoration when the dentist can place a conservative composite resin. This is especially true with younger patients, who are more likely to sustain traumatic tooth damage due to accidents. A young patient has a much more vulner-able pulp, and the coronal aspect of the tooth has not erupted fully. An indirect restoration could influence the health of the pulp and eventually require repair or replacement, necessitating additional preparation and loss of tooth structure. A properly restored composite resin should provide reasonable longevity and excel-lent esthetics.1-3

In the recreation of the incisal edge, it is important for the composite material to withstand the forces of occlusion that are necessary for its function. In areas of functional high risk, it is beneficial to choose a hybrid, microhybrid, or a supranano filled composite materi-al that has the necessary strength. Preparation designs also can influence the retention and appearance of these direct restorations. A lingual chamfer provides a bulk of material to help withstand the stresses of func-tion, and a long facial bevel allows added retention as well as a much nicer color blend.4-6

When managing a fractured tooth, the clinician ide-ally should obtain a diagnostic model and complete a diagnostic wax-up; this will allow for the fabrication of a putty matrix to help facilitate the placement of the restorative material. The clinician can insert the putty matrix into the patient’s mouth, facilitating a very ac-curate fabrication of the lingual contour and incisal edge position. This technique saves time, is efficient, and will help the operator to create a predictable res-toration.7-9

A properly restored composite resin should provide reasonable longevity and excellent esthetics.

Clinical Case Description

Patient Complaint and FindingsThe patient, an eight-year-old girl, had fallen and fractured the mesial incisal edge of tooth #8. Other than being sharp at the edges of the fracture the tooth was asymptomatic and there was no damage to any other teeth (Figs 1 & 2). The patient and her parents wanted the tooth to be restored in a conservative manner. They also wanted it repaired immediately, at the first (and only) appointment.

Figure 1: Preoperative smile, fractured #8.

Figure 2: Preoperative view (1:1) shows that there is minimal and diffuse incisal translucency.


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Figure 3: Side view color map showing the layers of composite material used in this polychromatic restoration. (Illustration by the author)

Figure 4: Frontal view color map showing the shape and position of the dentin lobes and the position of the shade BL1 on the mesial marginal ridge. (Illustration by the author)

Figure 5: Custom shade tab made of the composite material itself.

TreatmentComposite properties: The shade was selected at the beginning of the appointment using a custom-ized shade guide (Tokuyama Dental America; En-cinitas, CA) made of the actual composite material (Figs 3-5). A high-quality anterior composite should have the following properties: It should be polychro-matic, have high strength, handle well, be able to achieve a high polish, and be simple to use. Estelite Omega (Tokuyama), a polychromatic supranano spherically filled universal composite was chosen for this case because it has an easy-to-use basic composite restorative kit. The dentin shades have just the right opacity to block out a fracture area and the enamel shades blend well into the natural tooth enamel. The high polish that can be obtained is similar to that of a microfill, and it keeps its luster over time. This com-posite’s spherical filler provides a more uniform dif-fusion of light, allowing for a better blending of the composite with the natural tooth structure.


Figure 6: Intraoral mock-up used to approximate the correct anatomical contour.

Figure 7: Putty matrix made from the intraoral mock-up.

Figure 8: Bonding agent added to the prepared and etched tooth surface.

Mock-up and matrix: An intraoral composite mock-up was used to simulate the anatomical form of the final restoration (Fig 6) and to help in creat-ing a putty matrix. This was fabricated using a rig-id material (Blu-Mousse, Parkell; Edgewood, NY) that was placed on the lingual of the anterior teeth (Fig 7). The purpose of the putty matrix was to provide the anatomical framework of the lingual incisal edge and the proximal contact area. When this technique is used properly, there should be little adjustment of the lingual surface needed at the end of the appointment. Ideally, the clinician would make the putty matrix in advance of the restorative appointment. However, in this case, the patient’s parents wished to have the res-toration performed immediately. Fortunately, there was sufficient time to completely restore the fractured tooth there and then at the initial appointment.

The fit of the putty matrix was verified. The facial margin of the tooth was prepared with a long (1.5 mm from the fracture line) and deep bevel. The lin-gual margin requires a small chamfer (0.5 to 0.75 mm). The tooth was acid-etched (Ultra-Etch, Ultra-dent Products; South Jordan, UT), bonded (Prime & Bond NT, Dentsply Caulk; Milford, DE) (Fig 8), and light-cured10 with a light-emitting diode curing light (Valo, Ultradent).

Layering: Using the putty matrix, a thin layer (0.3 mm) of effects shade Milky White (MW) was added, making sure the composite on the matrix touched the tooth (Fig 9). The restoration was light-cured for 20 seconds. When the MW is layered very thinly it be-comes translucent and leaves a nice milky white halo at the incisal edge. The next layer to be placed was the dentin shade (DA1). The dentin shade occupies the same physical space where the tooth’s natural dentin had been. Care should be taken to create the dentin lobes in the incisal area to match those of the adjacent central incisor and the remaining section of the frac-tured tooth (Fig 10). The dentin layer was then light-cured. White tint was placed near the incisal edge to create diffuse white opacities, to better match tooth #9. A clear composite (Trans) was layered between the dentin lobes to impart incisal translucency and then light-cured. A layer of bleach shade (BL1) was add-ed to the mesial marginal ridge to impart an area of slightly higher value to mimic the contralateral #9 and then light-cured (Fig 11). The final layer of composite placed was an enamel shade (EA1) to simulate the ac-tual enamel. When a lot of translucency is needed in the incisal edge, it is necessary to cut back the enamel and place a more translucent shade of composite. There was not a lot of translucency in this clinical case, so this process was not necessary. After light-curing the final layer of composite, the tooth was shaped into the proper anatomical form (Fig 12).


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Figure 9: First layer of composite material (lingual shelf) formed from the putty matrix.

Figure 10: Layer of dentin composite added to simulate the natural tooth dentin and to create the dentin lobes.

Figure 11: White tint used to simulate small and diffuse white opacities near the surface.

Figure 12: Final layer of enamel placed, and the full contour of the restoration established.

Contouring: The first step in the contouring process was to shape the incisal edge and create the facial-incisal line angle. Pencil lines were drawn on the facial-incisal line angle and on the proximal line angles. Sof-Lex XT discs (3M ESPE; St. Paul, MN) were used for this case. The restoration was contoured with a red coarse disc to obtain the primary anatomical form. A digi-tal caliper (Absolute Digimatic, Mitutoyo; Kawasaki, Japan) was used to verify that the widths of #8 and #9 were the same. It was essential to examine #8 from the incisal, facial, and side views to verify that it had the proper anatomical form. The putty ma-trix can be tried back on the teeth to make sure that the mesial and incisal contours are correct. Fine and superfine discs were used to obtain a progressively higher polish (Figs 13 & 14).11,12

The restored tooth should look like the accident never happened.


Finishing and polishing: Tooth #8 was wetted with water to verify that its light-reflective surfaces were symmetrical with those of #9. A red coarse disc was used to make any minor cor-rections and to smooth the surface of the restoration. A slight developmental depression was created on the mesial surface of #8 with a flame carbide (7901, Brasseler USA; Savannah, GA). Care was taken to create a shallow and smooth depression area, not a deep notch. Next, blue (medium) finishing and pink (su-perfine) rubber polishing cups (FlexiCups, Cosmedent; Chicago, IL) were used to polish the restoration. If surface texture (periky-mata) is required to match the adjacent teeth the clinician can create this effect by using a diamond bur. The final polish was achieved with FlexiBuff and Enamelize (Cosmedent).13,14 The FlexiBuff kept the surface texture and imparted a beautiful shine.

SummaryA Class IV fracture repair is a very commonly indicated restora-tion and should be a valuable tool of everyday dental practice. When properly restored with the correct shades, proper prepara-tion, and correct anatomical form, the repair can blend in im-perceptibly with the natural tooth.

The patient and her parents were very happy with the result of the new composite filling (Fig 15). Their reaction, “I can’t even see where the filling is,” is the best compliment a patient can give. It should be noted that, although this patient also had a slight diastema and a slight rotation of the central incisors, these conditions deliberately were not treated at this time and should not be corrected with the composite restoration. The restored tooth should look like the accident never happened. When the patient needs orthodontic treatment in the future, the teeth can be aligned perfectly because the anatomical form of the tooth was maintained with the composite filling. Once clinicians be-come proficient in restoring Class IV fractures they should share their knowledge with colleagues, thereby helping not only their fellow restorative dentists but their patients as well.

Figure 15: Postoperative portrait view of a very happy patient.

Figure 13: Postoperative smile view showing the completed restoration.

Figure 14: Postoperative view (1:1) showing the final restoration's excellent color, contour, and polish.


Dr. Peyton is an AACD Accredited Fellow and has been an AACD Accreditation Examiner since 2000. A part-time instructor at the UCLA School of Dentistry, he practices in Bakersfield, California.

Disclosure: The author receives an honorarium from Tokuyama Dental America.

References

1. Fahl N Jr. Mastering composite artistry to create anterior master-

pieces—part 1. J Cosmetic Dent. 2010 Fall;26(3):56-68.

2. Crispin BJ. Contemporary esthetic dentistry: practice fundamen-

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creditation: hands-on typodont exercise. J Cosmetic Dent. 2008

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Montage Media; 2004. p. 106-14.

10. Baratieri LN, Berry TG. Esthetics: direct adhesive restoration on

fractured anterior teeth. Hanover Park (IL): Quintessence Pub.;

1998. p. 209-58.

11. Peyton JH. Finishing and polishing techniques: direct com-

posite resin restorations. Pract Proced Aesthet Dent. 2004

May;16(4):293-8; quiz 300.

12. Manauta J, Salat A. Layers: an atlas of composite resin stratifica-

tion. Hanover Park (IL): Quintessence; 2012. Chapter 10, Surface

and polishing; p. 349-84.

13. Strain R. Class IV composite repair. J Cosmetic Dent. 2014

Spring;30(1):14-9.

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Aesthet Dent. 1996 Jan-Feb;8(1):17-31. jCD

Dr. Peyton's ObservationsThis clinical case came out very nicely. Of course, this does not always occur. One of my most common challenges is obtaining the correct value. The key is to get the value as close as possible so the correction is minor and can be done with less effort.

To get the correct value (as well as hue and chroma):

• take the shade at the very beginning of the appointment

• use a composite shade tab made of the material itself

• place the composite material itself on the tooth and light-cure the composite.

This should result in a very close shade match.

If the value of the finished restoration is slightly too low:

• reduce the facial surface in a thin layer • add some white tint or Milky White incisal

shade.

If the value is too high:

• reduce the facial • add some gray or violet tint and cover with a

clear incisal shade.

Peyton

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