Superior AestheticsComposite Layering vs Composite

VeneersMunther 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 Options1. Bleaching: Vital and Non-vital 2. Enamel microabrasion3. 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± heat / light activation 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

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• Stickiness

• Surface wetting

• Surface smoothness

• Homogeneity

• Adaptation

• Individualization of texture and shape

• Internal air bubbles and wetting defects

Main problems in handling composite

© Mario Besek

• Aesthetic impression/expression

• Anatomical form

• Modelling incisal edges

• Surface texture

• Mammelons

• Ridgeline contour

• Control thickness of enamel layer

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Freehand technique - problems

Direct Composite Veneers

Primary indications White spot lesions Severe fluorosis Severe hypoplasiaAll 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

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● 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

COMPONEER

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

● Ceramic veneers have a minimumthickness of 0.5 – 0.8 mm

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

Contour guide

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● High opalescence and natural blue effect of the enamel

● High flexure strength E-modulus similar to tooth

Properties & advantages

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Form - shape - texture - surface - gloss

© Mario Besek

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

Componeer erosion 2µm

Properties & advantages

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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

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Simple individualization

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● Optimized marginal quality - less polymerization stress

Properties & advantages

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• Extended indications

• Less objective & subjective limits

• Conservative Procedure

• Good Longevity /Repair

• Cost effectiveness

Advantages

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 BristolM.Sulieman@bris.ac.uk

2014