Full-Mouth Reconstruction of Bulimic-Ravaged Teeth Using Direct Composites: A Case Presentation

A female patient, “Mary”, over 50-years-old, in declared good health except for body weight, presented stating that she has been bulimic for more than a decade. Her wish was to get medical help for her eating disorder and to preserve her teeth, keeping her financial capabilities in mind. At the initial consultation visit, records were gathered including, full-arch study models, a face-bow transfer, full-mouth radiographs, and a thorough medical history.
The patient agreed to let our office contact her primary care physician should there be any interhealthcare decisions needed. The patient also conveyed a true sense understanding regarding the situation that she had found herself in, telling us that she had a desire to speak-out to young people hoping to help them prevent a similar condition in their lives. Therefore, the patient granted written permission to share her photographs and any case information required in helping others who may have experienced a similar situation.

TREATMENT PLANNING: PATIENT CONSULTATION

During the next consultation visit, 2 treatment plans were outlined with the patient. These plans included the possibility of nonvitality in certain premolars based on radiographs and clinical examination. With standard practice techniques it was determined that the questionable teeth were in fact demonstrating vital responses.
(Note: At this point in the article, the author would ask each dental care professional to view the preoperative photos and reflect asking, “If I were treating this patient, what would I do?”)
The first and most desirable treatment plan (from the author’s perspective) would include the restoration of all teeth with direct, acid-etched, resin-based direct composites. This would be the most conservative approach due to the minimal amount of tooth structure removal required for placement of these materials. The creation of direct placement composite crowns could only be accomplished through the use of a contoured matrix band especially for direct composite placement.
The second treatment plan possibility included the endodontic treatment of all questionable teeth, and/or the extraction of the upper left premolars with implant replacement therapy in those areas. Then, the restorative phase would include full and partial coverage laboratory-fabricated restorations on all teeth in the maxillary arch, and the majority of the mandibular arch. It was pointed out that the trauma caused by more extensive preparations, the length of time for the implant osseointegration, and the time of wearing provisional systems, would all add to the possibility of future negative response from pulp tissue.
Using “Mary’s” case as an example, the confidence factor in both the patient and the dentist must be positive. As many of us have seen in our practicing history, the outcome of any case cannot be 100% predictable. The ability to care for the patient in follow-up situations is paramount. The fee structure (when based on chair time and the additional fees related to indirect laboratory-fabricated restorations) and insurance ramifications can certainly be influential in the patient’s ability to improve their life, and which treatment plan is chosen as best-suited for a particular patient.

ADVANTAGES OF DIRECT COMPOSITES: TECHNICAL CONSIDERATIONS

Experience has shown that the limitation of “preparation trauma” is not a predictable event, so a more minimally invasive approach is usually a prudent choice whenever possible. Direct composites can be the most conservative choice in materials that we have in dentistry. A dentist working with these materials also has total control over shade, shape, and function. After placing and curing the composite material, if the shade is not acceptable, it is easily removed and altered to satisfy the specific aesthetic demands of the case. Because of this, the ability to control the shade at the chair with direct composites makes the restorative phase less complicated and less time consuming than what would otherwise be involved in accomplishing the task with indirectly fabricated restorations. In addition, resin-based composite restorations can be easily repaired if the need arises, whereas fractured porcelain can only be corrected by redoing the restoration.
The conservation of tooth structure in this patient’s situation was paramount. However, there are certain technical challenges in placing excellent direct composite restorations. To help overcome issues regarding contour and the overall quality of the final restorations, there are excellent matrix systems available that can be placed to insure excellent gingival margins and contours. This case will demonstrate the use of one such matrix (Contour-Strip [Ivoclar Vivadent]) that, when properly shaped and placed, becomes a perfect “gingival margin-forming mold.”

Figure 1. The clear matrix strip (Contour-Strip [Ivoclar Vivadent]) (CS) is used to “mold” the direct composite, allowing the creation of full coverage for the conservative salvation of dentition.

Figure 2. The CS matrix is rapidly manipulated via finger pressure to custom shape it for the specific situation at hand.

Figure 3. The custom-shaped CS (shaped by rolling in the fingertips) is ready for placement around a prepared tooth.

Figure 4. In vitro demonstration illustrating the positioning of the shaped CS, held in the gingival sulcus with a light-cured application of a low-viscosity light-cured resin (Heliobond [Ivoclar Vivadent]).

Figure 5. In vivo clinical placement of a CS around a prepared premolar, ready for direct composite placement.

Figure 6. The bulk placement of a microfilled hybrid composite (4 Seasons [Ivoclar Vivadent] ready for light polymerization.

Figure 7. Clinical image of the completed buccal aspect of a conservative direct composite restoration utilizing CS matrices for the “molding” of the entire restoration.

Preventing oral fluid contamination and resin flash beyond the margins during these restorative procedures is also critical for success of the case. The use of clear mylar matrix strips held in place with light-cured liquid resin one of the best techniques available. In many instances, mechanical wedges will distort the matrix. However, by using a light-cured bonding liquid and allowing it to flow into the interproximal spaces, one can create a “liquid wedge” once it is cured.
Figures 1 to 4 demonstrate how the author uses the Contour-Strip (CS) (Contour-Strip [Ivoclar Vivadent]). First, it is custom shaped in approximately 30 seconds by the doctor (or the assistant). To be properly placed, the sulcular edge of the CS should be intimately touching the tooth surfaces in the gingival sulcus, and held in place with finger pressure. A BisGMA light-curable resin liquid (Heliobond [Ivoclar Vivadent]) is then placed onto the gingival tissue outside of the matrix and light cured (while holding the CS firmly in place in the sulcus to prevent the Heliobond from flowing under the edge before curing), forming a fixed “mold.”
Figures 5 to 7 demonstrate the clinical positioning for the conservative restoration of a premolar. Restoring both the buccal and the lingual surfaces requires placing a CS on one side first (ie, starting on the buccal, placing the matrix, and “fixing” it with Heliobond); next cleaning and etching the prepared tooth; injecting and light curing the composite; and then removing the CS from the buccal and placing a new one from the lingual to finish the “around-the-tooth” addition. These steps were carried out in all teeth from premolar to premolar in “Mary’s” case. In the molar area, the CS was positioned only where tooth structure was missing.


Figure 8. The clinical image of a bulimic-ravaged dentition. Note the loss of vertical dimension of occlusion (VDO).

Figure 9. Palatal view of maxillary arch. Note the amalgam restorations which are maintaining the VDO.

Figure 10. Mandibular arch: Note the amalgam “stops” created by these metallic restorations which were used in determining the occlusal positions when placing the direct composites.


TREATMENT BEGINS

After the analysis of the articulated study models, radiographs, and the clinical examination of both maxillary and mandibular arches (Figures 8 to 10), the first step was to decide if a replacement of lost vertical dimension of occlusion (VDO) would be necessary. Using the amalgam restorations as “vertical guides,” the occlusal surfaces that needed restoration would be restored with a sufficient amount of flat-plane bulk added to allow for the cutting of final occlusal anatomy into these “flat planes.” An anterior interarch jig registering the preoperative VDO was created. This would then allow us to keep the same VDO that was in function when the patient first presented. (Note: No splint therapy was indicated in this case.)
The restorative treatment began with the restoration of the posterior teeth in the maxillary arch at the first appointment. The aesthetic positions of the premolars (considering both length and the width of the buccal corridor) would be made aesthetically acceptable. The use of minimally invasive techniques requires the dentist to utilize any mechanical retentive shapes already present, and to also thoughtfully prepare appropriate retention with the rotary diamond. The author uses a fine grit (40 to 50 µm abrasive) 8862-010 (red-banded) flame-shaped finishing diamond (Brasseler USA).

Figure 11. Right sagittal view. Note the loss of tooth structure loss in the mandibular and maxillary arches.

Figure 12. Left sagittal view. Note the occlusal positioning prior to any preparation changes. Clinical “sight memory” is a useful aid in occlusal plane reconstruction. Coupled with any form of fixed vertical-dimension jigs helps the operator determine the future occlusal height position and in the creation of functional anatomy.

In Figures 11 and 12, visualize the areas of the enamel that could have 0.75-1.0 mm conservatively removed on the buccal and lingual surfaces; so that the added composite will have sufficient thickness to hide the underlying tooth structure and still cover these areas. Next, axial (nonparallel) grooves are placed using an 863-010 bur (Brasseler USA) at the proximal surfaces. This serves to mechanically lock the composite into place. (Depending only on an acid-etched surface for retention can be questionable.) Also, all other smooth-enamel surfaces are cleaned with a fine grit 8862-010 diamond (Brasseler USA), not just pumice.
The dentin surface dictates a more aggressive mechanical consideration. In the mid-1970’s, Dr. Ralph Phillips, in a lecture he gave discussing the ability to restore Class V defects, taught us that using a one-half round bur was the best way to gain optimal retention. In all direct composite cases such as this one, the author continues to follow that teaching by placing conservative mechanically retentive shapes in the root surfaces, on both the buccal and lingual.
The mandibular posterior teeth were then restored at the next appointment again with the same flat occlusal anatomy to meet the created upper flat plane dentition. Using the flat-plane approach also allows the occlusal function to be less traumatic during the early stages of rehabilitation. (Note: At a later date the final occlusal anatomy was created.) The occlusal anatomy was developed by cutting into the flat plane surfaces with a spiral-bladed finishing bur, an H379-023, a football-shaped bur (Brasseler USA). The flat surfaces on buccal and lingual then would were shaped with another spiral-bladed bur, an H48L-010 (Brasseler USA), and the final polish was created using the Astropol (Ivoclar Vivadent) finishing and polishing system as directed.
The next challenge was the restoration of the maxillary anterior teeth. As the 2 central incisors were previously restored with PFM crowns, the method of restoring these became yet another decision to make. With the ability to create full crowns through the use of direct resin composite and the CS matrices, it was concluded that this was the restorative method of choice in this case because the operator has full control over position, shape, and shade. The PFM crowns were removed from the 2 central incisors and replaced with direct composite crowns using CS matrix technique (Figures 13 and 14). Next, the laterals and cuspids were restored (Figures 15 and 16) in the same fashion utilizing the CS matrices, thus completing the restorations in the maxillary arch.

Figure 13. After removal of old PFM crowns from the 2 maxillary central incisors, a CS is positioned from the labial aspect, held in position with cotton saturated with Heliobond and light cured.

Figure 14. After completing the labial aspect of one central, the CS matrix is removed from the labial. A new CS is placed on the lingual to finish the creation of the direct composite (full) crown.

Figure 15. Maxillary right quadrant of the finished full-coverage, direct composite restorations. Note the excellent gingival tissue health and surface polish of the composite restorations.

Figure 16. Maxillary left quadrant. (Refer to Figure 12 for the condition of these teeth prior to restoring.) The teeth tested positive to normal pulp testing procedures, and composite was used directly with no additional pulp capping materials. Full crown preparations could have jeopardized the vitality of these teeth.

Figure 17. Maxillary arch after being in function for a brief period of time.

Figure 18. Full-arch views of the functional surfaces placed into the cured direct composite (4 Seasons [Ivoclar Vivadent]) full-mouth reconstruction.

Figure 19. Full-arch photos of the finished, minimally invasive restorative work utilizing direct composites.

Figure 20. The finished definitive reconstruction (accomplished in four, 4-hour appointments). Note the high gloss surfaces reflecting light as human enamel does.

After seeing the excellent aesthetic and shade-changing results accomplished on all of the damaged teeth, the patient and the author decided to create aesthetic direct composite labial veneers on the 4 mandibular anterior teeth (Figures 17 to 20). At the same time, we were also able to bring them forward in a labial direction, thus enhancing the Class I relationship of the anterior teeth.

DISCUSSION: TECHNIQUE DETAILS

Chemical Preparation of the Teeth 

With the CS held firmly in place on the first surface, the tooth surface was “scrubbed” using a small stiff bristle brush with an organic solvent. This will remove all organic debris, such as the smear layer, and/or minute amounts of plaque that may be present in the gingival sulcus. Ethylenediaminetetraacetic acid (or 5% sodium hypochlorite) can be used for this with the same understanding that dentistry has used these chemicals in endodontic therapy. Then, rinse the tooth thoroughly, dry, and apply an etchant. For the etching process, the author prefers Email Preparator (Ivoclar Vivadent) or UniEtch (Bisco) because of ideal viscosity, similar to that of saliva. Capillary action aids in dispersion with the previously described viscosity insuring that all minute sulcular areas are truly etched. Having used the 8862-010 (red-banded) flame-shaped finishing diamond (Brasseler USA) to clean (rather than a slurry of pumice), 15 seconds of etch activity is sufficient.
Thoroughly rinse the etchant and remove visible standing water before applying a dentin/enamel adhesive system. The author finds the 4th generation technique (a total etch followed by the use of an acetone-based dentin primer/adhesive system such as Prime & Bond NT [DENTSPLY/Caulk]) still the fastest, while granting the most restorative confidence.

COMPOSITE PLACEMENT

In this case, the direct composite placement was accomplished through the use of single-unit doses of 4 Seasons (Ivoclar Vivadent). It is one example of a microfilled hybrid composite that has excellent aesthetic, strength, and polishing properties. (Note: With regard to strength and longevity; the zone of function with resin-based composite placed on the occlusal surfaces must be greater than 0.5mm, with 2.0 mm being the standard thickness that experience has shown to withstand the forces of occlusion.)
It is injected inside of the CS matrix and the hydraulic pressure created during the injection process physically forces the resins into the mechanical retentions created in the preparation phase. Shaping is accomplished with any of a variety of instruments and devices. The author relies heavily on a ceramist’s brush (G-2 [Ivoclar Vivadent]) and a soft-tipped cuticle pusher.

 

POLYMERIZATION

Each dentist must follow their own polymerization methods, whether using layering or bulk placement techniques. The author has been using bulk placement since 1985 with excellent results. Using bulk placement requires a light intensity of at least 1,200 mW/cm2. The Demi or LED II (Kerr Corporation) fulfills this requirement. The operator must also have a thorough understanding of the bulk technique in order to use it successfully.

CONCLUSION

The author’s clinical success over the past 25 years in placing direct composite restorations in challenging situations such as this, and witnessing the clinical results over time, supports this method of restoring a patient when indicated. The case presented in this article has been in function with no changes for over 2 years now. Having clinical confidence and seeing years of functional success in resin-based composite can add a new dimension to any dental practice.


Dr. Belvedere is a pioneer in the placement of direct composite dentistry. Dr. Belvedere graduated from Loyola Dental School, Chicago, in 1955, and is co-director of the Postgraduate Program in Esthetics and Contemporary Dentistry, is an adjunct professor at the University of Minnesota School of Dentistry, and an associate professor at State University of New York at Buffalo, NY. He has published many papers, and chapters in aesthetic-oriented books. He is the aesthetics editor for The Year-book of Dentistry and teaches through a multimedia presentation. He is the featured lecturer and workshop mentor to state dental societies, study groups, and dental schools at home and abroad. He concentrates on direct composite dentistry and teaches using demonstrations of step-by-step techniques, on closed circuit TV teaching practical, time saving procedures. His workshops in direct composite dentistry using the contour strip can be found at state and dental school venues. He can be reached at (952) 941-3397 and at velvytooth@aol.com.

Disclosure: Dr. Belvedere receives no compensation from the manufacturers of any the products mentioned in this article.



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