Written by Jeff T. Blank, DMD Thursday, 31 May 2007 19:00
The art and science of aesthetic dentistry is the most exciting development in the history of modern dentistry. Simply stated, replacing or repairing natural tooth structure conservatively and beautifully is the future of dentistry.
Today, the term cosmetic dentistry has become vernacular across the globe. Regardless of inherent differences in the interpretation of beauty, the restoration or improvement of natural tooth structure with materials and techniques that mimic the polychromatic subtleties of vital teeth transcends cultural boundaries. The human smile is universal, the beauty of which is a common thread that binds us all in the purest sense.
Almost overnight, the general public embraced the concept of “invisible” dentistry and, with time, began to demand it. When given the choice, the general population will choose to restore not only the health of their teeth, but the beauty as well.
THE ROLE OF DIRECT COMPOSITE VENEERS IN THE MODERN DENTAL PRACTICE
Indirect crowns, veneers, inlays, and onlays have their place in modern dentistry. But indiscriminately defaulting to indirect restorations for all cosmetic cases demonstrates a reckless disregard for tooth structure, economics, and time management. Further, by routinely delegating aesthetics to lab technicians, the dentist loses his or her eye for color and form, and misses out on the enjoyment of being the artist.
Though direct composite veneers may have a shorter lifespan than some indirect restorations, they do possess certain key advantages:
- More conservative preparations; sometimes no preparation is required.
- When a simplified technique is utilized, polychromatic direct composite veneers can be placed in a single appointment with no lab fees.
- Once the practitioner is proficient in this simplified technique, highly aesthetic results can be delivered to the patient at a fraction of the cost of indirect restorations.
- This lower cost to the patient leads to greater case acceptance by those patients who find that indirect restorations do not fit their budget.
- By utilizing a fast, simplified technique as outlined in this article, both the master and novice can increase the volume of cosmetic cases the office produces.
DIRECT COMPOSITE VENEERS: WHY DENTIST’S DON’T LIKE TO DO THEM
Dentists’ primary obstacle to offering patients direct composite veneers is the lack of a simplified, well-designed technique for consistent delivery of layered restorations. Though numerous composite materials exist on the market today, few are designed around a specific technique that is easy to understand and apply in the general dental setting. To confuse matters further, the nomenclature used to describe the various shades and opacities can be confusing. Elaborate shade charts and guides are available to ease shade and opacity selection, but without a detailed guide for layering these materials, success may depend on trial and error and chairside improvisation.
The secondary obstacle to offering direct composite veneers as a cosmetic option is the time it takes to place each layered restoration. Simply stated, spending 40 minutes to an hour per tooth may exceed the tolerance of many busy practitioners and can make the service less profitable.
These obstacles may be overcome by the availability of a quick, easy, and dependable material formulated to be used with a simplified technique.
THE ANSWER: A SIMPLIFIED HISTOLOGICAL APPROACH TO LAYERING
The art of placing “layers” or increments of various shades and opacities is not new to dentistry. Perfected by laboratories in ceramic restorations many years ago, the concept of replacing the layers of missing tooth structure with direct composite materials that optically match the layer being replaced is still foreign to many dentists today.
The concept of direct composite layering is simple. The natural tooth contains 3 optically distinct “layers” (Figure 1). Viewing natural teeth from a histological perspective, dentin imparts the most significant amount of a tooth’s overall hue or color. Though we may have been taught in dental school to apply A3 in the gingival one third, then A2 in the middle one third, and A1 in the incisal one third, this is not a histological representation of how color is imparted in natural teeth.
What gives the varying degree of saturation from the cervical to the incisal aspects of a natural tooth is the thickness and “tint” of overlying translucent enamel. Optically, enamel is basically colorless, largely serving to modulate value with only slight hue variation.
Histologically, enamel is thinnest in the cervical one third of the natural tooth, thus allowing the darker dentin color to shine through. This is why the cervical aspects of natural teeth appear more saturated or darker, not because the enamel is darker. As enamel approaches the middle one third of the natural tooth, it gradually thickens as the underlying dentin begins to taper back toward the lingual. Thus, the influence of the single dentin hue is reduced, and the value of the dentin becomes lower. In the incisal one third of the tooth, dentin stops short of the incisal edge. The majority of the incisal one third of the natural tooth is devoid of dentin altogether; it is composed only of enamel. Free from the influence of the underlying hue of dentin, incisal enamel takes on a myriad of optical and color diversity, often allowing the darker oral cavity behind the lingual of the tooth to show through the undulations of the dentin mammelons and through the translucent incisal enamel. In this zone, dramatic “edge effects” are often visualized in natural teeth.
A SIMPLIFIED TECHNIQUE AND MATERIAL FOR UTILIZING A HISTOLOGICAL APPROACH TO LAYERING
Figure 1. The natural tooth contains 3 optically distinct “layers.”
Many excellent direct composite materials on the market each possess unique qualities and are suited for a variety of applications (eg, Filtek Supreme [3M ESPE]; Esthet-X [DENTSPLY Caulk]). One recently introduced product, Artiste Nano Composite (Pentron Clinical Technologies), is marketed as a simplified system designed around a simplified anatomic/histological technique. Though Artiste Nano Composite can be adapted to nearly any existing technique, the beauty of this system is that the shades and opacities are perfectly co-ordinated and easy to understand, making them easy to select and place. The end result is quick decisions chairside, no guesswork, and truly beautiful restorations without a significant time investment.
As stated in Figure 1, the primary determinant for the overall appearance of natural teeth is intermediate dentin. This layer is typically uniform in color unless developmental disturbances or in-trinsic staining exist. Based on this concept, the most important “layer” of a direct composite veneer will be the dentin/body layer, onto which the enamel material is layered.
OVERVIEW OF THE SIMPLIFIED ARTISTE LAYERING TECHNIQUE AND MATERIAL
The simplified Artiste Nano Composite technique is a 2-opacity (dentin/body and enamel) system with shading based on the Vita Classic Shade Guide (A, B, C, D). It uses the Vita 3-D Bleach Shade Guide (OM3, OM2, OM1) for the bleached shades.
Note that expanded shades, opaque shades, and internal tints are available for “master level” cases. Also, an additional bleach shade, Movie Star White, is available.
- Use the Vita Classic or Vita 3-D Bleach shade tabs to select the desired overall shade of the final restoration.
- Choose the Artiste dentin/body shade that corresponds to the desired shade selected.
- Select one of the 5 Artiste enamel shades (A, B, C, D, Bleach) that corresponds to dentin/body Vita class. For instance if A1 is selected, then use the universal Artiste A Enamel. If a dentin/body Bleach shade is selected, then select the Artiste Bleach Enamel. Each of the 5 enamels are designed to work with each subcategory of the corresponding Vita class.
- Place the selected dentin/body in a thin layer across the veneer preparation, allowing it to come to full facial contour in the gingival one third to permit full saturation.
- Taper this layer toward the gingival in the incisal two thirds to leave room for the enamel layer.
- Create dentin mammel-ons if incisal translucency is desired. Light-cure.
- Overlay the incisal two thirds with the corresponding Artiste enamel shade. Adapt into dentin mammelons. Shape primary and secondary anatomy and light-cure.
- Optional: if an incisal halo is desired (semitranslucent white edge), adapt a thin ribbon of Artiste Milky White material on the incisal edge and light-cure.
Case Presentation Using the Simplified Artiste Technique and Material
|Figures 2 to 4. Options were discussed, and the patient elected to have 8 direct composite veneers placed on teeth Nos. 5 to 12.|
A 37-year-old female presented for improvement of her smile color, alignment, incisal edge position, and midline correction (Figures 2 to 4). Options were discussed, and the patient elected to have 8 direct composite veneers placed on teeth Nos. 5 to 12.
The desired overall shade was selected by holding the Vita shade tab in the middle third of the tooth prior to dessication. In this case, the Artiste dentin/body shade Super Bleach (OM1) was selected as the desired base shade for the direct veneers. The corresponding universal Artiste enamel, Bleach Enamel, was selected.
|Figure 5. All preparations remained in enamel, and a light chamfer finish line was used on each tooth.||Figure 6. Each tooth was etched, and a fifth-generation, single-bottled primer/adhesive was applied and light-cured.|
The teeth were prepared using a silicone prep guide based on a diagnostic wax-up to ensure proper tooth reduction, permit correction of the canted midline, and accommodate the new smile line. All preparations remained in enamel, and a light chamfer finish line was used on each tooth (Figure 5).
Each tooth was completed using the simplified Artiste technique. Dead-Soft foil (Den-Mat) was used to isolate the tooth to be veneered from the adjacent teeth. Each tooth was etched, and a fifth-generation, single-bottled primer/adhesive (Bond-1 [Pentron Clinical Technologies]) was applied and light-cured (Figure 6). The foil was removed, and each restoration was built to full contour and contact with the adjacent teeth.
|Figure 7. Using the simplified Artiste technique, this layer was sculpted to full facial contour in the gingival one third, then tapered back to the lingual in the incisal two thirds to leave room for the enamel layer.||
Figure 8. Prior to light-curing, dentin mammelons were sculpted using a thin composite instrument and adapted to the lingual finish line. The dentin/body layer was then light-cured for 20 seconds.
|Figure 9. The corresponding Artiste enamel material (Bleach Enamel) was applied only to the incisal two thirds.|
The Artiste dentin/body shade Super Bleach was applied to the facial surface of the tooth. Using a clean, dry, gloved finger, the dentin/body material was spread across the entire tooth surface. U-sing the simplified Artiste technique, this layer was sculpted to full facial contour in the gingival one third, then tapered back to the lingual in the incisal two thirds to leave room for the enamel layer (Figure 7). Prior to light-curing, dentin mammelons were sculpted using a thin composite instrument (CCIB [Hu-Friedy]) and adapted to the lingual finish line (Figure 8). The dentin/body layer was then light-cured for 20 seconds. The corresponding Artiste enamel material (Bleach Enamel) was applied only to the incisal two thirds (Figure 9).
|Figure 10. The enamel layer was sculpted with a silicone-tipped composite placement instrument.|
By allowing the dentin/ body shade to come to full contour in the gingival one third and not be covered by the translucent enamel, the increase in saturation of color found in natural teeth was replicated. The enamel layer was then adapted into the dentin mammelons all the way through to the lingual contour without adding length to the tooth. Since the dentin/body layer was sculpted progressively toward the lingual as it approached the incisal edge, the increasing thickness of the translucent enamel layer replicated the natural desaturation found in the incisal two thirds of natural teeth. The enamel layer was sculpted with a silicone-tipped composite placement instrument (Figure 10).
Figure 11. A thin ribbon of Artiste shade Milky White was applied directly to the incisal edge and adapted to replicate the thin, glowing edge found on some natural teeth.
Figure 12. Each restoration was finished and polished using various grits of sandpaper discs and silicone polishing points, and a final luster was achieved with a finishing paste and felt wheel.
Figures 13 to 15. The final postoperative views. Note the dramatic smile transformation and lifelike edge effects achievable using this simplified technique and material.
In this case, an optional incisal halo, or thin, milky white edge was desired. A thin ribbon of Artiste shade Milky White was applied directly to the incisal edge and adapted to replicate the thin, glowing edge found on some natural teeth (Figure 11). Each restoration was finished and polished using various grits of sandpaper discs and silicone polishing points, and a final luster was achieved with a finishing paste and felt wheel (FlexiDiscs and FlexiCups [Cosmedent]; Figure 12).
The final postoperative views are seen in Figures 13 to 15. Note the dramatic smile transformation and lifelike edge effects achievable using this simplified technique and material.
Though numerous composite materials and techniques are available to practitioners today, a simplified composite material and technique remains desirable. The Artiste Nano Composite material and technique not only reduces the number of layers and shades required to replicate natural teeth, but it offers a simplified layering system that saves time and effort.
Dr. Blank maintains a private practice in Rock Hill, SC, where he emphasizes comprehensive restorative and cosmetic reconstruction. Dr. Blank is an adjunct professor of general dentistry at the Medical University of South Carolina, and a guest lecturer for graduate and undergraduate studies. He has consulted with dental manufacturers and lectured throughout the United States on the recent advances in adhesion technology and the benefits of various cosmetic techniques. He can be reached at (803) 327-3240 or by visiting the Web site carolinasmilecenter.com.
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