Fractured teeth: an aesthetic challenge?

ATTRACTIVE faces are considered to be more socially established, more appealing and more honest than faces presenting a disfigurement (Bull and David, 1986). When looked at, faces, the eyes, nose and mouth are in the focus of gaze (Mertens et al., 1993). After the eyes, the teeth are the point on which another person’s gaze will fix most intensely during communication (Burkard, 2008). Teeth, as a result of their strategic location on the face, are our “calling card towards others”. The smile is responsible for 60 per cent to 70 per cent of the aesthetics of the face (Dalloca and Brambilla, 2009).

Tooth fractures can be classified into root fractures (horizontal, oblique or vertical), crown fractures and cervical fractures. Crown fractures vary, from chipping fractures in the enamel to more complex enamel-dentine fractures, with and without pulp exposure. The treatment is dependent on this classification and ranges from extraction of vertically fractured teeth to minimally invasive approaches, like reattachment of a tooth fragment.

Patients prefer fast and natural reconstruction of fractured teeth.

In cases of a crown fracture without pulp participation, minimally invasive, direct composite restorations are preferred over more invasive indirect restorations, as performed in cases of lost or non-replaceable fragments. In particular, direct restoration should be aspired to in young teeth with extensive pulp dimensions (Krastl et al., 2011).

A prerequisite to achieve a highly aesthetic result in those cases is a composite shade system which enables the imitation of the lost natural tooth structure. Furthermore, this shade system should be easily comprehensible to achieve predictable results.

A new composite materialVenus Pearl is a nano-hybrid composite

for universal indications. That means it can be used for the restoration of anterior and posterior teeth. It is a radiopaque, low shrinkage composite with high aesthetic characteristics and optimised handling features. It is based on the same new matrix chemistry as the well-proven Venus Diamond (also Heraeus Kulzer), TCD-urethane.

This new matrix system allows a high resistance to mastication forces combined with low shrinkage stress. As caries and fracture of restorations are still the main reasons for failure of restorations, this combination can help to reduce the risk of both.

The filler system consists of aluminium-barium-fluoride glass, nanoparticles and pre-polymerised fillers. The interplay of these fillers leads to a soft and creamy consistency.

The shade system of Venus Pearl is, like Venus Diamond, based on three levels of translucency: opaque dentine chromatic shades, which show the lowest translucency to imitate dentine; universal shades with a medium translucency; and incisal shades, which possess the highest translucency needed in incisal areas.

Case reportThe aim of this case report was to evaluate the aesthetic performance of the new resin composite, Venus Pearl (Heraeus Kulzer).

The clinical case presented is a 15-year-old female patient who exhibits a good health status. She was not satisfied with the cosmetic appearance of the composite restoration of tooth 11.

An aesthetic analysis of the restoration revealed impairments in the restoration shape and size, hue, chroma, value und translucency, which could be improved.

Against this background, the dental practitioner needs to keep in mind that adolescents generally are often not satisfied with their dental appearance and tooth colour.

They are more concerned about the tooth shape than their parents (Kavand et al., 2012).

During the first visit, dental photographs of the patient’s smile and a frontal view in intercuspidation with retracted lips were taken for the aesthetic analysis (Figures 1 and 2). Furthermore, a photograph showing the inter-incisal relationship was taken. This was especially helpful to evaluate translucency and incisal edge effects (Figure 3).

For model analysis, alginate impressions were taken and a wax-up with an ideal restoration shape and size was done to plan the new restoration. The wax-up was used to produce a silicone index, which served as guidance for the reconstruction of the palatal restoration surface. It is, furthermore, a useful tool to check the contours and the entire restoration visually.

During the next appointment, the tooth shade and incisal translucency was measured. The situation in-situ was compared to the photographs taken. This resulted in mapping of the tooth shades (Figure 4).

The next step was the removal of the old restoration and redefinition of the old bevel. There are many types of margin bevels for anterior restorations described. Advances in materials and techniques even allow margin bevels to be omitted (Barateri, Ritter, 2005).

The treatment was preceded with the application of rubber dam (Figure 5).

Palatal wall reconstruction was performed with the help of a silicon index based on the wax-up, as described earlier. The shade of Venus Pearl used was CL (Clear) (Figure 6). Proximal wall construction was performed with the aid of wedge and a transparent matrix, also with the CL shade.

The incisal halo can be imitated using a high value and slightly translucent composite. (Duarte et al., 2003).

Therefore, the universal shade, BXL (Bleach Xtra Light), representing a high value was selected (Figure 7).

The next step was the placement of the dentine mass. In this case, the opaque dentine shade, OLC (Opaque Light Chromatic), was utilised (Figure 8).

Visual examination led to the selection of an amber area in the incisal half. AM (Amber)

shade was placed on the dentine mass OLC (Figure 9).

In the course of treatment, the vestibular enamel was then placed using the universal shades A1 and CL (Figure 10). In doing so, it needed to be considered that increasing the thickness of the enamel layer results in increased chroma and decreased value. Enamel layers should hence be restricted to a maximum thickness of 1mm (Duarte, 2011). The thickness of the restorative material is crucial for a natural result (Duarte, 2003).

Figures 11, 12 and 13 demonstrate the final result after finishing and polishing.

ConclusionIn this case, the minimally invasive approach using the direct composite restoration technique led to a natural looking result, with a good prognosis regarding long-term preservation of the sound tooth structure.

The new composite system, Venus Pearl, was easy to handle and allowed a good aesthetic outcome due to its optimised and easily understandable shade system.

The composite, Venus Pearl, has proved its suitability to carry out highly aesthetic treatments. n

Reader enquiry: References are available on request.

DR ANTONIO ROS LLUCH presents a case report, which aimed to evaluate the aesthetic performance of the new resin composite, Venus Pearl, from Heraeus Kulzer...

About the authorDr Antonio Ros Lluch DDS (2002), master in operative and aesthetic dentistry (Universidad Internacional de Cataluña, Barcelona, Spain, 2003-2005).

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The Probe | May 13 dentalrepublic.co.uk

Figure 1: Pre-operative smile Figure 2: Aesthetically dissatisfactory restoration of tooth 11

Figure 3: Inter-incisal relationship during protrusion

Figure 5: Isolation with rubber dam

Figure 6: Palatal wall Figure 7: Proximal wall and reconstruction of the halo

Figure 8: Application of dentin mass Figure 9: Notice the placement of the AM shade on the central lobe

Figure 10: Imitation of vestibular enamel using A1 and CL

Figure 11: Smile photo. Final result Figure 12: Frontal view with retracted soft tissue. Final result

Figure 13: Inter-incisal contact photo. Final result

Figure 4: Colour map