Superior Aesthetics Composite Layering vs Composite Veneers

Munther Sulieman

Aesthetic Treatments

• • • • • • • Smile analysis Recontouring Whitening Micro/macro-abrasion Composite bonding Veneers Crowns

Factors affecting tooth shade

• • • • • • • Degree of polish Thickness of enamel Enamel morphology Fluorescence and translucency Dehydration Recession and dentinal exposure Intrinsic, extrinsic or internalised stain

Causes of Tooth Discolouration

• • • Intrinsic Discolouration Extrinsic Discolouration Internalised Discolouration

Intrinsic tooth staining causes

• • • • • • METABOLIC Alkaptonuria Congenital erythropoietic porphyria Congenital hyperbilirubinaemia Rickets, Ehlers- Danlos syndrome etc.

Intrinsic tooth staining causes

• INHERITED • • • Amelogenesis imperfecta Dentinogenesis imperfecta Dentinal dysplasias

Intrinsic tooth staining causes

• • • IATROGENIC Tetracycline stains Fluorosis

Fluorosis Staining

 Caused by an interference with the calcification process of the enamel matrix which results in incomplete maturation accompanied with opacity and or porosity  Wide range of severity: mottled teeth- minor (intermittent white flecking or spots) to severe manifestation that involves pitting and brownish surface stains  Only affects superficial enamel thickness usually

Intrinsic tooth staining causes

• • • • TRAUMATIC Enamel hypoplasia Pulpal haemorrhage products Root resorption • • AGEING Teeth become darker, more yellow and slightly more red

Haemorrhagic discoloration

 Rupture of blood vessels and extravasation of erythrocytes into the dentinal tubules which gives the tooth a pink hue but the tooth may still remain vital  Majority of post endo discoloration is caused by failure to completely remove blood or other organic material from the pulp chamber.

 Pastes/ restorations: corrosion products from silver amalgam in dentinal tubules, silver in sealing pastes or zinc oxide eugenol- blue grey discoloration at cervical area

Enamel Hypomineralisation

 Developmental disturbance in the formation of the inorganic component of enamel during amelogenesis- results in brown enamel, white opacities or enamel coloration defects of various hues.

 Defects can be localised to one section or an entire surface of the tooth with coloured streaks, multiple spots or other patterns

Intrinsic tooth staining causes

• • Idiopathic MIH: Molar Incisor Hypomineralisation

Root Resorption

Extrinsic tooth staining-direct

• • • • • • Tobacco products Tea, coffee and red wine Spices Vegetables Medicines Plaque

Extrinsic tooth staining-indirect

• • • • • CATIONIC ANTISEPTICS Chlorhexidine CPC Hexetidine OTHERS eg. Listerine

Internalised stains

• • • • TRAUMA cracks loss of enamel recession • • CARIES RESTORATIONS

Enamel Decalcification

 Lesions are acquired: occur when dental plaque persists undisturbed on enamel surface producing organic acids that etch the mineral content out of the enamel surface  Left undisturbed further leads to dental decay  If intercepted early, there is no need for restorations  Common sites for these lesions are cervical margins of teeth or around orthodontic brackets with poor OH.

Tooth discolouration

• Regardless of the nature of the discolouration  Must decide whether the discolouration is confined to the superficial enamel thickness or in the deep dentine layers  This determines the complexity and extent of treatment as well as the absolute choice of treatment

Tooth discolouration

Treatment Options

1. Bleaching: Vital and Non-vital 2.

Enamel microabrasion 3. Direct composite veneers 4.

Indirect veneers (Porcelain/ Composite) 5.

Bleaching with indirect or direct veneers

Bleaching Options

• •  •   •  •  Vital Home CP / HP -trays In-surgery 15-50% HP ± activation heat / light 35% CP waiting room OTC Strips / Paint-on Other Toothpaste Mouthrinse Chewing gum • Non-Vital  Walking  HP,Perborate/HP, CP  Inside / Outside  CP  In-surgery  35% HP

Bleaching Indications

• • • • • • • Generalised staining Ageing Smoking and dietary stains Fluorosis Tetracycline staining Traumatic pulpal changes Aesthetics pre or post restorative

Bleaching Contraindications

        Patients high expectations Decay and periapical lesions Patient can’t tolerate taste Pre existing Conditions Crowns Extensive restorative dentistry: Composite and porcelain restorations Major cracks Exposed dentine      Pre existing problem sensitivity Highly translucent tooth Pregnancy No scientific evidence against bleaching but there may be a psychological effect on mother Bleaching may exacerbate pregnancy gingivitis

Treatment of White Fluorosis

 Intensity, Location and Depth of lesion will determine Tx  Bleaching of background (reduce contrast between white spot and rest of tooth)  Micro-abrasion of foreground with or without bleaching  Bleaching/abrasion and composites  Composite Veneers

Where Why and When Does Composite Work?

• • • • • Biocompatibility Adhesion to Enamel and Dentine Colour Perception Optical Effects Harmonious Blending with Tooth structure Multiple Uses 27

Main problems in handling composite • Stickiness • Surface wetting • Surface smoothness • Homogeneity • Adaptation • Individualization of texture and shape • Internal air bubbles and wetting defects 28

Freehand technique - problems • Aesthetic impression/expression • • Anatomical form 2 • • • • Surface texture 4 Mammelons 5 Ridgeline contour 6 Control thickness of enamel layer 1 7

7

4 5 3 2 1 6 © Mario Besek

Direct Composite Veneers

Primary indications

 White spot lesions  Severe fluorosis  Severe hypoplasia All these discolorations are usually confined entirely to the enamel thickness and never extend into the dentine  Heavily restored stained anterior teeth

Direct Composite Veneers

• • • • Advantages More conservative- no enamel removal!

One session no lab costs Easier shade match compared to single porcelain veneer involving a lab especially if mock-up is used

Direct Composite Veneers

 Only cut tooth tissue if absolutely necessary and then only into enamel  Consider air abrasion and bonding composite to reshape teeth  Mock-up may be needed to check contour and shade if patient agreement is deemed necessary  Shade match prior to tooth dehydration  Matching adjacent tooth roughness and texture greatly enhances appearance

Restoration of anterior teeth

• • For small class IV and III cavities- centripetal approach (build up from inside to outside) For large class IV and incisal build up- bucco lingual approach used in conjunction with silicone index

Natural Layering Technique “The Clinical Procedure” • • • • Finishing & Polishing- aim is to re-create texture and gloss. Surface re-contouring with fine diamonds while discs are best for plane and convex surfaces.

Smooth out concavities/uneven surfaces with fine diamonds or silicone points Fine shine best with hard polishing brushes

Polishing

• • • • • PC- Proximal contact BLP- Bucco-lingual profile TL- Transitional lines SM- Surface morphology IE- Incisal edge

COMPONEER

● are polymerized, prefabricated enamel shaded composite laminates ● is a direct Composite-Veneering-System ● simplify the freehand technique ● increases the quality of front teeth restorations ● is an economical system 36

Componeer thickness ● Minimal or no preparation due to the minimal thickness of composit laminates of 0.3 mm.

● Ceramic veneers have a minimum thickness of 0.5 – 0.8 mm

Contour guide ● Optimal form selection using the translucent, high-contrast contour guide 38

Properties & advantages ● High opalescence and natural blue effect of the enamel ● High flexure strength E-modulus similar to tooth 39

Form - shape - texture - surface - gloss 40

Properties & advantages ● Highest adhesion composite - composite, optimized by the microretentive surface (2 µm)

©

Componeer erosion 2µm © Mario Besek

Properties & advantages • Soaked for 1 week in water at 37 ° C • 240‘000 cycles, 49N • 600 x 5 ° / 55 ° • Cresylblue, 24h • 80 specimen • 74 showed no penetration • 6 showed some slight discoloration Prof.Dr. Ivo Krejci, University of Geneva

Simple individualization 43

Properties & advantages ● Optimized marginal quality - less polymerization stress 44

Advantages

• Extended indications • Less objective & subjective limits • Conservative Procedure • Good Longevity /Repair • Cost effectiveness 45

Componeer Clinical Procedure

• • • • • • Choose correct size Choose correct shade Isolation of teeth Preparation small shallow chamfer/interporoximal conditioning Re check size and adjust componeer with possible try in Etch Bond Cure tooth

Componeer Clinical Procedure

• • • • • Place and adapt composite on tooth Bond but don’t cure Componeer, place composite and adapt on Componeer Fit first Componeer on tooth and firmly push into position Clean excess before curing Trim and polish

Indirect Porcelain or Composite Veneers • • • • • Indicated for conservative treatment of anterior teeth that are; Relatively intact Worn Discoloured Misaligned Malformed

Indirect Porcelain or Composite Veneers • • • • • • Porcelain High aesthetics Excellent gingival tissue response Relatively minimal labial reduction Durable and fracture resistant Shine through problem (Blue grey) • • • • • • Composite High aesthetics Excellent gingival response More conservative Can be repaired if fractured Shine through problem (Blue grey)

Porcelain Veneers

 Types of preparation: depends on shade of discoloured tooth, its position and alignment and presence of restorations  Minimal: surface reduction just to bond to enamel  Conventional: 0.3mm reduction cervically, 0.5mm centrally within enamel and retain incisal edge or reduce by 1mm. Keep contacts!

 Deep: 0.6mm reduction into dentine and removal of contact points

© Munther Sulieman

University of Bristol [email protected]

2014