Onur Alp Yünük

Case af Dr. Onur Alp Yünük

Flotte tænder; et strålende, perfekt smil: Det kan være udfordrende at imødekomme de æstetiske krav fra patienter, der ønsker plastfacader. Mens nogle patienter deler konkrete ideer til, hvordan deres nye tænder skal se ud, er det sværere for andre at udtrykke deres forventninger. I sådanne tilfælde er det vigtigt at vælge en behandling med mulighed for justeringer – om det er i form af en udvidet planlægningsfase med et digitalt smile design eller ved at lave plastfyldninger, som nemt kan justeres intraoralt.

Den sidstnævnte tilgang blev valgt til en ung kvindelig patient som henvendte sig til vores klinik, da hun var utilfreds med sine plastfacader på overkæbeincisiverne (Fig. 1 til 4). Ved den intraorale undersøgelse viste det sig, at de eksisterende fyldninger på hendes overkæbeincisiver og -hjørnetænder havde ujævne, ru overflader, kantmisfarvninger og kompromitteret strukturel integritet af plastmaterialet. I overensstemmelse med disse fund blev det planlagt at fjerne de eksisterende fyldninger i overkæbefronten og genskabe optimal æstetik og funktionel integritet med nye plastfyldninger (3+ til +3 ad modus Haderup). Patienten udtrykte, at hun godt kunne tænke sig, at vi tilføjede mere individualitet og karakter til hendes tænder samt at hun ønskede at få et mere strålende smil, end hun havde med de eksisterende fyldninger.

Fig. 1: Plastfacader på overkæbeincisiver med mangelfuld æstetik og funktionel integritet.

Fig. 2: Overkæbefronten okklusalt med synlige defekter i plastfacaderne.

Fig. 3: Lateral visning fra højre side, der afslører overfladeujævnheder.

Fig. 4: Lateral visning fra venstre side, der afslører et stort debonded og afskallet område.

UDSKIFTNING AF PLASTFACADERNE

For at genskabe de naturlige tænders karakteristiske translucens og opfylde patientens æstetiske krav, blev det planlagt at anvende et polykromatisk lagdelingssystem og en tolagsteknik. Dette muliggør et flot sammenspil af de forskellige translucenser i fronten.

Under farvevalgsfasen blev Bilaminar Shade Assessment Technique (BSAT), som er baseret på farvekombinationen af dentin- og emaljeplast, anvendt. Med denne teknik blev den tilsigtede emaljefarve lagt i lag over den ønskede dentinfarve for at vurdere den resulterende farve skabt af de to plastfarver. Plasten blev polymeriseret på tandoverfladen uden adhæsiv. Således blev det bekræftet, at den kumulative farveopfattelse, som stammer fra lagdelingen fremfor de individuelle plastfarver, var i harmoni med den naturlige tandsubstans ved behandlingsstart. Fotos blev taget med et kamera udstyret med et krydspolariseringsfilter (Fig. 5). Herefter blev den faste retainer samt de eksisterende plastfacader fjernet. For at bevare så meget af den underliggende, sunde tandsubstans som muligt, blev proceduren lavet under forstørrelse samt brug af orange lys. De valgte instrumenter var røde og gule diamantbor samt hårdmetalbor. Figur 6. viser resultatet efter proceduren.

Fig. 5: Farvevalg – billede taget ved hjælp af et krydspolariseringsfilter, som eliminerer refleksioner.

Fig. 6: Tænderne efter fjernelse af de insufficiente plastfacader.

Tænderne blev isoleret med kofferdam fastgjort med tandtråd cervikalt. Herefter blev fyldningsproceduren påbegyndt.  Efter emaljeætsning og påføring af en selvætsende adhæsiv (CLEARFIL™ SE Bond 2, Kuraray Noritake Dental Inc.), blev CLEARFIL MAJESTY™ ES-2 Premium (Kuraray Noritake Dental Inc.) påført. Dentinkernen, med dens fremtrædende mameloner, blev formet i farven A1D. Incisalkanterne og mamelonerne blev fremhævet pletvist med hvid karakteriseringsfarve. For at skabe opalescens blev et tyndt lag af den translucente farve Blue påført ovenpå, mens emaljedelen blev opbygget med emaljefarven WE. Eftersom den faste retainer var blevet fjernet, blev en aftagelig gennemsigtig retainer fremstillet og udleveret til patienten i slutningen af seancen til brug indtil den efterfølgende aftale.

Fig. 7: Isolation med kofferdam til fyldning af de laterale incisiver samt hjørnetænderne.

Fig. 8: Tænderne påført det labiale emaljelag.

Fig. 9: Fyldningernes form og farve lavet i overensstemmelse med patientens forventninger.

Efter pudsning og polering med Twist DIA for composite blev patienten sendt hjem og en ny aftale oprettet til reevaluering samt endelige justeringer.

Til kontrollen bad patienten os mindske den incisale translucens og lyshed i sine overkæbeincisiver samt at ændre formen  af alle de fyldte tænder. Hun ønskede længere centrale overkæbeincisiver med blødere, mere afrundede overgange  (line angles) og en mere jævn incisal kontur. Kofferdam blev igen anlagt. Herefter blev den labiale overflade af plastfacaderne i overkæbeincisiverne reduceret en smule ved brug af røde og gule diamantbor. For at rugøre overfladen og øge topografien for optimal mikromekanisk låsning, blev plastoverfladen sandblæst med 50μm aluminiumoxidpartikler. Fosforsyre, silan og CLEARFIL™ SE Bond 2  blev derefter anvendt som en del af adhæsivprotokollen. Fyldningerne blev efterfølgende justeret med forlængelse, farvekorrektion med brug af CLEARFIL MAJESTY™ ES-2 Premium  i farverne A1D og A1E samt korrektion af de anatomiske konturer (Fig. 10 og 11). 

Fig. 10: Justering af fyldningerne på de centrale incisiver.

Fig. 11: Tilpasset smil med mere normale tandformer og -konturer og en mere naturlig tandfarve.

Under denne sidste aftale udtrykte patienten, at hun var meget glad for sit nye smil. Fyldningsoverfladerne blev genpolerede, en ny fast retainer fikseret og endelige fotos taget (Fig. 12 til 16).

Fig. 12: Endeligt behandlingsresultat –  frontal visning.

Fig. 13: Endeligt behandlingsresultat – okklusal visning.

Fig. 14: Endeligt behandlingsresultat –  lateral visning.

Fig. 15: Endeligt behandlingsresultat – patientens smil.

Fig. 16: Detaljeret visning af den indre farvestruktur – gjort synlig ved hjælp af et polariseringsfilter.

KONKLUSION

At tale med patienter om hver en detalje af behandlingen og at lytte opmærksomt til deres ideer, forventninger og krav, beskytter os ikke altid imod behovet for justeringer – simpelthen fordi patienterne har brug for at se, hvad de får for at kunne bedømme, om de kan lide det. Heldigvis kan valg af velegnede materialer og teknikker gøre det muligt for tandlæger at skabe nye smil, der kan justeres uden at skade sund tandsubstans. Således bliver dét, at gøre de mest krævende patienter glade, ikke længere er en udfordring.

Case by Dr. Onur Alp Yünük

Beautiful teeth, a bright, flawless smile: Meeting the aesthetic demands of patients asking for veneer treatment can be challenging. While some patients share concrete ideas on how their new teeth should look, it is more difficult for others to express their expectations. In this case, it is important to select a treatment approach that allows for modifications – be it in the form of an extended planning phase including digital smile design or by placing composite restorations that can be easily modified intraorally.

The latter approach was selected for a young female patient who presented to our clinic as she was dissatisfied with her composite veneers that had been placed on the upper incisors (Figs. 1 to 4). During intraoral examination, it became evident that the existing restorations on her maxillary incisors and canines had irregular, rough surfaces, discoloured margins and compromised structural integrity of the composite material. In accordance with these findings, removing the existing restorations at the maxillary anterior teeth and re-establishing optimal aesthetic and functional integrity with new direct composite restorations were planned (teeth between #13 - #23 according to the FDI notation). The patient stated that she would like us to add more individuality and character to her teeth and have a brighter smile than with her existing restorations.

Fig. 1. Composite veneers on the maxillary incisors showing aesthetic and functional integrity issues.

Fig. 2. Occlusal view of the maxillary anterior teeth with visible defects in the composite veneers.

Fig. 3. Lateral view from the right revealing surface irregularities.

Fig. 4. Lateral view from the left revealing a large debonded and chipped area.

REPLACEMENT OF THE COMPOSITE VENEERS

To reproduce the translucency characteristics of the patient’s natural teeth and fulfil her aesthetic demands, the use of a polychromatic layering system and a dual-layer technique was planned. This would allow for a nice play of translucencies in the anterior area.

During the shade selection phase, the Bilaminar Shade Assessment Technique (BSAT) was employed, which is based on the color combination of dentin and enamel composites. In this technique, the intended enamel shade was stratified over the target dentin chroma to evaluate the resultant shade created by the two composite color layers. The materials were polymerized on the tooth surface without bonding agents; thus, the cumulative color perception resulting from stratification, rather than the individual shades of the materials, was verified for harmony with the natural tooth structure at the onset of treatment. Photos were taken with a camera equipped with a cross-polarized filter (Fig. 5). Subsequently, the fixed retainer was removed, as were the existing composite veneers. To save as much of the underlying healthy tooth structure as possible, the procedure was performed under magnification and blue-light illumination. The selected instruments were red- and yellow-band diamond burs as well as tungsten carbide burs. Figure 6 shows the result of the procedure.

Fig. 5. Shade determination – image taken with the aid of a cross-polarizing filter that eliminates reflections.

Fig. 6. Teeth after the removal of the deficient composite veneers.

The teeth were isolated using rubber dam, which was secured with floss in the cervical area. Then, restoration procedures were initiated on the teeth. After etching of the enamel and application of a self-etching bonding agent (CLEARFIL™ SE Bond 2, Kuraray Noritake Dental Inc.), CLEARFIL MAJESTY™ ES-2 Premium (Kuraray Noritake Dental Inc.) was applied: The dentin core with its pronounced mamelons was modelled using the shade A1D. The incisal edges and mamelons were highlighted with spots of white tint. To create an opalescent effect, a thin layer of the translucent shade Blue was placed on top, while the enamel parts were built up with the enamel shade WE. Since the retainer had been removed, a clear aligner was fabricated and delivered to the patient at the end of the session for use until the subsequent appointment.

Fig. 7. Isolation with rubber dam for restoration of the lateral incisors and canines.

Fig. 8. Vestibular enamel layer applied to the teeth.

Fig. 9. Shape and shade of the restorations created according to the patient’s expectations.

After finishing and polishing with Twist DIA for composite, the patient was sent home and a new appointment was made for re-evaluation and final adjustments.

In the control appointment, the patient asked us to slightly reduce the incisal translucencies and brightness in her maxillary incisors and alter the shape of all restored teeth: She requested longer maxillary central incisors with softer, more rounded line angles and a smoother incisal contour. Rubber dam was placed again. Then, the vestibular surfaces of the composite restorations on the maxillary incisors were reduced slightly using red- and yellow-band diamond burs. To roughen the surface and enhance the topography for optimal micromechanical interlocking, the composite surface was sandblasted with 50-μm aluminium oxide particles. Phosphoric acid etchant, silane and CLEARFIL™ SE Bond 2 were applied sequentially as part of the adhesive protocol. The restorations were then modified by lengthening, shade correction using CLEARFIL MAJESTY™ ES-2 Premium in the shades A1D and A1E and refining of the anatomical contours (Figs. 10 and 11).

Fig. 10. Modification of the central incisor restorations.

Fig. 11. Modified smile with more regular tooth forms and contours as well as a more natural tooth shade.

During this final appointment, the patient expressed that she was very happy with her new smile. The restoration surfaces were re-polished, a new retainer was bonded and final photographs were taken (Figs. 12 to 16).

Fig. 12. Final treatment outcome – frontal view.

Fig. 13. Final treatment outcome – occlusal view.

Fig. 14. Final treatment outcome – lateral view.

Fig. 15. Final treatment outcome – the patient’s smile.

Fig. 16. Detailed view of the inner colour structure – made visible with the aid of a polarized filter.

CONCLUSION

Talking to patients about every detail of the treatment and listening attentively to their ideas, expectations and demands does not always protect us from adjustments – simply because they need to see what they get to be able to judge if they like it. Luckily, selecting appropriate materials and techniques enables dental practitioners to create new smiles that can be modified without harming healthy tooth structure, so that making even the most demanding patients happy is no longer a challenge.

Case by Dr. Onur Alp Yünük 

COMBINING HIGH-PERFORMANCE TOOLS AND MATERIALS FOR A PREDICTABLE OUTCOME

Direct composite restorations are a high-quality treatment option even when large amounts of tooth structure need to be replaced. This is due to recent advancements in resin composite materials and adhesive technology. By selecting appropriate materials and layering techniques combined with modern digital tools for colour difference evaluation, it is possible to predictably produce highly aesthetic outcomes, as demonstrated in the following case example.

The challenge

A young male patient presented to our clinic requesting the replacement of his existing composite restorations on his maxillary incisors (teeth #12 and #11 according to the FDI notation). Clinical examination revealed extensive restoration loss on the lateral incisor. Furthermore, anatomical irregularities, discolouration, and loss of surface gloss were observed on tooth #11. The adjacent central incisor exhibited similar issues regarding colour and surface polish.

In consultation with the patient, it was decided to replace the existing restorations using a modern composite material specifically developed for dual-shade layering – CLEARFIL MAJESTY™ ES-2 Premium (Kuraray Noritake Dental Inc.). For an exact shade analysis, photographs were taken with and without a cross-polarized filter (Figs. 1 to 4).

Fig. 1: Frontal view of the teeth  with extensive restoration loss on the maxillary left lateral incisor.

Fig. 2: Cross-polarized photograph of the teeth allowing for a detailed analysis of the shade irregularities.

Fig. 3: Lateral view of the teeth.

Fig. 4: Lateral view – cross-polarized photograph.

The solution

Following removal of the existing restorations, rubber dam was placed for working field isolation. A self-etching adhesive (CLEARFIL™ SE Bond 2, Kuraray Noritake Dental Inc.) was applied in the selective enamel etching mode before establishing the palatal shell using CLEARFIL MAJESTY™ ES-2 Premium in the shade A1E (Figs. 5 and 6). The mamelon structures were reconstructed with CLEARFIL MAJESTY™ ES-2 Premium in the shade A1D, while the translucent shade Blue was applied  to the opalescent zone. Finally, yellow and white tints were used for characterization. Fig. 7 illustrates the appearance before,  Fig. 8 after finishing and polishing.

Fig. 5: Palatal shell established with the enamel shade A1E of the selected composite.

Fig. 6: Lateral view of the teeth during the restoration procedure.

Fig. 7: Restoration before finishing and polishing.

Fig. 8: Appearance of the restorations after finishing and polishing.

The outcome

To evaluate the final colour integration, another photograph was taken with a cross-polarized filter, holding a grey reference card in place for calibration (Figs. 9 and 10). The lateral view of the restored teeth (Fig. 11) reveals that not only the right colour combination, but also a natural surface texture is required for a highly aesthetic outcome.

Fig. 9: Frontal view of the restored teeth taken with a cross-polarized filter.

Fig. 10: Gray reference card calibration and the resulting L*a*b* coordinates of the restoration.

Fig. 11: Lateral view of the restored teeth stressing the importance of surface texture.

DISCUSSION AND CONCLUSION

Observation, supported by modern tools for photography and image analysis (like polarized filters and L*a*b* coordinates), is  an important skill needed for the lifelike reconstruction of teeth with direct composite materials. By combining this skill with a highperformance composite system that offers fixed shade combinations and innovative light diffusion technology for a nice blend-in  with the surrounding tooth structure, creating beautiful restorations becomes a predictable business.

In the case presented, the patient was very satisfied with the outcome in terms of aesthetics and function. At regular recalls, the quality of the restorations is checked – they still offer a very nice functional and aesthetic integration.