Dentaltown December 2020 - 28

Fig. 13

Case 2
Fig. 14

Fig. 15

Fig. 16

Fig. 17

Fig. 18

Fig. 19

28

The second clinical case features a
55-year-old patient who also had several
noncarious cervical defects on #11-13.
Tooth 12 had a previously treated Class V
composite that needed to be replaced. A
history of bruxism was evident by the wear
of the incisal edges of his teeth. The patient
admitted to a reluctance to wear his night
guard (Fig. 13). The patient was encouraged
to wear the night guard to decrease the
incisal wear as well as preventing the cervical
erosion/abfraction lesions.
The teeth were anesthetized with 1.7ml
(one carpule) of Lidocaine HCl 2% with
1:100,00 epinephrine. Packing cord (00
Ultrapak, Ultradent) was placed below
the gingival margin of the teeth to provide
retraction of the gingival tissue and some
moisture control at the gingival tissue
margin. Once the composite is cured, the
cord also acts as a landmark to locate the
gingival margin.
The facial margins on the teeth were
beveled to increase the enamel bond and
to help blend the color of the composite
material seamlessly into the enamel of
the tooth. The old restoration on #12 was
completely removed to ensure the greatest
bond to the tooth. A slow-speed round bur
was then used to remove the surface dentin
layer from #11 and #13. The teeth were
then acid-etched, rinsed and dried before
the bonding agent (Bond Force, Tokuyama
Dental) was applied to all three teeth and
light-cured. Omnichroma was applied in a
single layer one tooth at a time and evenly
spread out with a thin IPC sculpted, taking
time to make sure the gingival margin
is sealed. A #3 brush is helpful to evenly
spread out the composite; there is no need
to rush because the composite material is
very sculptable and holds its shape. Next,
the composite was light-cured (Fig. 14).

As with the first clinical case, a flame tip
diamond bur on a high-speed handpiece was
used to contour the gingival margin area. If
there is a large excess of composite material,
then the diamond bur can be used to reduce
the composite close to the final contour. The
final contour is best done with a thin, coarse
disc (e.g., Soflex-XT, 3M) to achieve a smooth
and uniform contour (Fig. 15). Once this
contour has been achieved, a higher polish
can be accomplished with a medium and then
a fine rubber cup polisher (e.g., Blue & Pink
Flexicups, Cosmedent, Fig. 16). To achieve
an even higher polish, use a Jiffy brush or
a felt buff wheel (FlexiBuff, Cosmedent).
If there is still an over-contoured gingival
margin, a #12 Bard Parker scalpel can also
be used to trim the excess composite (Fig. 17,
demonstrated here on a Typodont). A high
polish is always desirable, but it is more
important to achieve an even and smooth
surface with a nicely sealed gingival margin.
Fig. 18 shows an immediate postprocedure
result; Fig. 19 was taken after 11 months.

Conclusion
Postoperative photos taken at 8-, 10- and
12-month follow-up appointments show
that these restorations can hold polish and
color. For direct veneers and large Class IV
restorations with a high polish, it is advised to
have the hygienist either skip these surfaces
when using a coarse prophy paste or use fine
polishing paste. n

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