Onur Alp Yünük

Case by Dr. Onur Alp Yünük

A STEP-BY-STEP GUIDE TO POLYCHROMATIC LAYERING

Complicated crown fractures in the anterior region present both functional and aesthetic challenges. They require a restorative approach that closely mimics natural tooth structure. Thanks to modern developments in adhesive dentistry and composite materials, it is possible to achieve highly aesthetic outcomes in a minimally invasive way.

This case report outlines a straightforward, yet highly aesthetic approach to restoring a traumatised lateral incisor using a polychromatic layering technique. By combining precise shade selection, anatomical analysis, and controlled composite layering, it is possible to recreate the optical properties of natural dentition and achieve seamless optical integration.

CASE OVERVIEW

A young female patient visited our clinic with a history of dental trauma, which resulted in a complicated crown fracture of her maxillary left lateral incisor (tooth #22, FDI notation). After completing the necessary endodontic and periodontal treatments for the affected tooth, we placed a temporary composite restoration. This case outlines a straightforward yet highly aesthetic approach to restoring the tooth using a polychromatic layering technique.

Fig. 1. Initial presentation of a complicated crown fracture on tooth #22 following dental trauma.

VISUAL ASSESSMENT AND SHADE MATCHING

Before beginning the definitive restorative phase, we took initial baseline photographs. Using a cross-polarized filter allowed us to evaluate the true internal optical properties of the adjacent dentition without distracting light reflections. Shade matching was performed using a bilaminar colour selection technique in conjunction with the cross-polarized filter to provide for absolute precision.

Fig. 2. Tooth #22 temporarily restored with composite resin after the completion of endodontic and periodontal treatments.

Fig. 3. Pre-operative view and cross-polarized photograph taken before initiating the definitive restorative treatment.

Fig. 4. Shade selection performed using a bilaminar technique combined with an image taken with a cross-polarized filter for accurate colour mapping.

CLINICAL EXECUTION

Following rubber dam isolation, the temporary restoration was carefully removed and the adhesive system (CLEARFIL™ SE BOND 2) was applied. Before layering the composite, we analysed the primary and secondary anatomy of the adjacent teeth from the occlusal plane to guide the build-up.

Fig. 5. Rubber dam isolation and complete removal of the provisional restoration.

Fig. 6. Occlusal view allowing for the evaluation of the primary and secondary anatomy of the adjacent teeth.

THE RESTORATION WAS CARRIED OUT IN SYSTEMATIC LAYERS

• Dentin core: We established the artificial dentin layer using CLEARFIL MAJESTY™ ES-2 in shades A3D and A2D (Kuraray Noritake Dental Inc.).
• Marginal ridges and incisal edge: The mesial and distal marginal ridges were built using CLEARFIL MAJESTY ES-2 A2, while CLEARFIL MAJESTY ES-2 Blue was applied to the incisal region to mimic natural translucency.
• Characterization: To replicate natural internal characteristics, we applied white and yellow tints. A quick control photograph taken at this stage with a cross-polarized filter is useful to verify the internal effects.
• Final enamel layer: The restoration was completed with a final layer of CLEARFIL MAJESTY ES-2 WE. Immediate post-operative photographs were taken right after the procedure.

Fig. 7. Artificial dentin layering utilizing CLEARFIL MAJESTY ES-2 A3D and A2D shades.

Fig. 8. Artificial dentin layering utilizing CLEARFIL MAJESTY ES-2 A3D and A2D shades.

Fig. 9. CLEARFIL MAJESTY ES-2 A2 used for the marginal ridges and CLEARFIL MAJESTY ES-2 Blue for the incisal area. Application of white and yellow tints for internal characterization, verified with a cross-polarized filter.

Fig. 10. Immediate post-operative views after finalizing the restoration with CLEARFIL MAJESTY ES-2 WE composite.

Fig. 11. Immediate post-operative view taken with a cross-polarized filter.

MANAGING COMPLICATIONS

During the course of treatment, the adjacent central incisor (tooth #21) failed to respond to vitality tests. Consequently, endodontic treatment and internal bleaching were successfully performed on tooth #21 in the subsequent sessions.

FINAL OUTCOME

At the final follow-up appointment, comprehensive control photographs were taken. An occlusal view confirmed the successful recreation of both primary and secondary anatomy. Most importantly, evaluating the final result with a cross-polarized filter image demonstrated a seamless colour integration with the surrounding natural teeth.

Fig. 12. Occlusal view confirming the successful recreation of the primary and secondary anatomy.

Fig. 13. Cross-polarized control photograph demonstrating seamless composite shade integration.

Fig. 14. Final result.

Klīniskais gadījums, autors Dr. Onurs Alps Junuks (Onur Alp Yünük)  

Skaisti zobi, mirdzošs, nevainojams smaids: pacientu estētisko prasību izpilde, īstenojot kompozīta venīru uzklāšanas procedūru, var būt visnotaļ izaicinoša. Lai gan dažiem pacientiem ir konkrētas idejas par to, kā vajadzētu izskatīties viņu jaunajiem zobiem, citiem ir grūtāk izklāstīt savas cerības. Šādos gadījumos ir svarīgi izvēlēties elastīgu ārstēšanas pieeju, kas ļauj veikt korekcijas. Tas var būt pagarināts plānošanas process, kura ietvaros tiek veikta digitāla smaida modelēšana, vai kompozīta restaurāciju izveide, nodrošinot iespēju tās viegli modificēt tieši mutes dobumā.

Otrā no minētajām pieejām tika izvēlēta jaunai pacientei, kura vērsās pēc palīdzības mūsu klīnikā, jo nebija apmierināta ar viņas augšžokļa priekšzobiem uzstādītajiem kompozīta venīriem (1.–4. att.). Veicot mutes dobuma izmeklēšanu, kļuva skaidrs, ka pacientes augšžokļa priekšzobu un ilkņu esošo restaurāciju virsmas ir raupjas un nelīdzenas, to malas ir mainījušas krāsu un ir apdraudēta kompozīta vispārējā strukturālā integritāte. Atbilstoši šiem atklājumiem tika ieplānota esošo augšžokļa priekšzobu restaurāciju noņemšana un optimālas estētiskās un funkcionālās integritātes atjaunošana, izveidojot jaunas tiešās kompozīta restaurācijas (d13-23 virsma saskaņā ar FDI apzīmējumu sistēmu). Paciente norādīja, ka vēlētos, lai mēs viņas zobiem piešķirtu vairāk individualitātes un rakstura, kā arī padarītu smaidu mirdzošāku nekā tas ir ar esošajām restaurācijām.

1. attēls Kompozīta venīri uz augšžokļa priekšzobiem – novērojamas estētiskas un funkcionālas integritātes problēmas.

2. attēls Augšžokļa priekšzobu okluzālais skats ar redzamiem kompozīta venīru defektiem.

3. attēls Labās puses sānskats, kas atklāj virsmas nelīdzenumus.

4. attēls Kreisās puses sānskats –  redzama liela atdalījusies un nodrupusi zona.

KOMPOZĪTA VENĪRU NOMAIŅA

Lai atveidotu pacientes dabīgo zobu caurspīdīguma īpašības un izpildītu viņas estētiskās prasības, tika ieplānota polihromatiskas slāņošanas sistēmas un divslāņu tehnikas izmantošana. Tas ļautu panākt vizuāli patīkamu rezultātu, izmantojot caurspīdīguma īpašības priekšējā zonā.

Toņa izvēles posmā tika izmantota bilaminārā ēnojuma novērtēšanas tehnika (Bilaminar Shade Assessment Technique, BSAT), kuras pamatā ir dentīna un emaljas kompozītu krāsu kombinācija. Izmantojot šo tehniku, paredzētais emaljas tonis tika stratificēts virs mērķa dentīna krāsu gammas, ļaujot novērtēt divu kompozīta krāsu slāņu radīto toni. Materiāli tika polimerizēti uz zoba virsmas bez saistvielām, tādējādi tika pārbaudīta kumulatīvā stratifikācijas rezultātā izveidotās krāsas uztvere nevis atsevišķu materiālu toņi, lai pārliecinātos par tās atbilstību dabīgajai zoba struktūrai jau ārstēšanas sākumā. Fotogrāfijas uzņemtas ar kameru, kas aprīkota ar šķērspolarizācijas filtru (5. att.). Pēc tam tika noņemts esošais fiksators, kā arī esošie kompozīta venīri. Lai maksimāli saglabātu zem venīriem esošo veselo zobu struktūru, šī procedūra tika veikta, izmantojot palielinājumu un zilās gaismas apgaismojumu. Procedūras izpildei tika izvēlēti sarkanā un dzeltenā marķējuma dimanta urbji, kā arī volframa karbīda urbji. 6. attēla redzams šīs procedūras rezultāts.

5. attēls Toņa noteikšana – attēls uzņemts, izmantojot šķērspolarizācijas filtru, kas novērš atstarojumu veidošanos.

6. attēls Zobi pēc bojāto venīru noņemšanas.

Zobi tika izolēti, izmantojot gumijas koferdamu, kas nostiprināts zobu kakliņu zonā. Pēc tam tika uzsākta zobu atjaunošanas procedūra. Pēc emaljas kodināšanas un paškodināšanas saites (CLEARFIL™ SE Bond 2, Kuraray Noritake Dental Inc.) uzklāšanas zobu virsmai tika uzklāts CLEARFIL MAJESTY™ ES-2 Premium (Kuraray Noritake Dental Inc.): dentīna kodols ar izteiktajiem izciļņiem tika modelēts, izmantojot toni A1D. Incizālās virsmas un izciļņi tika izcelti, uzklājot baltas nokrāsas materiālu. Lai radītu opalescentu efektu, virspusē tika uzklāts plāns caurspīdīgā toņa Blue slānis, bet emaljas daļas tika slāņotas, izmantojot emaljas toni WE. Tā kā procesa ietvaros bija noņemts fiksators, sesijas beigās tika izgatavots caurspīdīgs reteineris, kas tika izsniegts pacientei lietošanai līdz nākamajam apmeklējumam.

7. attēls Izolācija ar gumijas koferdamu sānu priekšzobu un ilkņu atjaunošanai.

8. attēls Uz zobiem uzklāts vestibulārās emaljas slānis.

9. attēls Atbilstoši pacientes vēlmēm izvēlēts restaurācijas tonis un izveidota forma.

Pēc kompozīta gala apstrādes un pulēšanas ar Twist DIA kompozītam paciente tika nosūtīta mājās, vienojoties par nākamo apmeklējumu atkārtotai novērtēšanai un galīgo korekciju veikšanai.

Kontroles apmeklējuma laikā paciente lūdza nedaudz samazināt augšžokļa priekšzobu incizālo zonu caurspīdīgumu un spilgtumu, kā arī pielāgot visu restaurēto zobu formu: viņa vēlējās pagarināt augšžokļa centrālos priekšzobus, piešķirot tiem maigākas līnijas un noapaļotākus leņķus, kā arī gludāku incizālo kontūru. Atkal tika uzstādīts gumijas koferdams. Pēc tam, izmantojot sarkanā un dzeltenā marķējuma dimanta urbjus, viegli tika reducētas augšžokļa priekšzobu kompozīta restaurāciju vestibulārās virsmas. Lai padarītu virsmu raupjāku un uzlabotu topogrāfiju optimāla mikromehāniska savienojuma izveidošanai, kompozīta virsma tika apstrādāta ar smilšu strūklu, izmantojot 50 μm alumīnija oksīda daļiņas. Kā daļa no adhēzijas protokola secīgi tika uzklāts fosforskābes kodinātājs, silāns un CLEARFIL™ SE Bond 2. Pēc tam restaurācijas tika modificētas, veicot pagarināšanu, toņa korekciju, izmantojot CLEARFIL MAJESTY™ ES-2 Premium (toņi A1D un A1E), kā arī pilnveidojot restaurāciju anatomiskās kontūras (10. un 11. attēls).

10. attēls Centrālo priekšzobu restaurācijas pārveidošana.

11. attēls Modificēts smaids ar regulārākām zobu formām un kontūrām, kā arī dabiskāku zobu toni.

Pēdējā apmeklējuma laikā paciente atzina, ka ir ļoti apmierināta ar savu jauno smaidu. Tika atkārtoti nopulētas restaurētās virsmas, nostiprināts jauns fiksators un uzņemtas galarezultāta fotogrāfijas (12.–16. attēls).

12. attēls Ārstēšanas galarezultāts –  skats no priekšpuses.

13. attēls Ārstēšanas galarezultāts – okluzālais skats.

14. attēls Ārstēšanas galarezultāts – sānskats.

15. attēls Ārstēšanas galarezultāts – pacientes smaids.

16. attēls Detalizēts iekšējās krāsas struktūras skats – uzņemts, izmantojot polarizācijas filtru.

NOSLĒGUMA SECINĀJUMI

Runāšana ar pacientiem par katru ārstēšanas procesa aspektu un rūpīga ieklausīšanās viņu idejās, cerībās un vēlmēs ne vienmēr pasargā mūs no korekcijām – vienkārši tādēļ, ka viņiem ir jāredz galarezultāts, lai varētu spriest, vai viņiem tas patīk. Par laimi, atbilstošu materiālu un metožu izvēle ļauj zobārstiem radīt jaunus smaidus, kurus var modificēt, nekaitējot veselajai zobu struktūrai, tādēļ pat visprasīgāko pacientu iepriecināšana ar viņiem vēlamo galarezultātu vairs nav tik liels izaicinājums.

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.