Preperation Day

Kuraray Majesty ES-2 Premium shade guides were used to ascertain the enamel, dentin and effect shades prior to tooth dehydration. A1 Enamel, A1 Dentin, Trans Clear and Trans Amber were selected. It was noted that a value enhancer (i.e. Majesty Esthetic HO) may need to be used to enhance the value of the bleached teeth.

The patient was anaesthetised and the old Class IV restoration removed (Figure 3). The teeth were isolated using a curved serrated metal strip (Komet) to protect the adjacent dentition. Following micro air abrasion using 27 micron aluminium oxide, the enamel was selectively etched and a self- etching bond (Clearfil Universal Bond) applied.

As there was no opportunity to complete a diagnostic wax-up, the lingual shelf was completed freehand, with the help of a Mylar strip. As the Digital Smile Design specified a 0.9mm extension of tooth 11M into the diastema, this dictated the dimension of our lingual shelf. As this area only features enamel, A1 Enamel (A1E) was placed to full contour in this area (Figure 4). The midline was refined and shaped using Sof-Lex discs (3M ESPE) and the final dimension of 11 measured with calipers to ensure perfect mesiodistal symmetry with 21 (Figure 5)

The Mylar strip was placed on the lingual axial aspect of 21 and the lingual shelf built to a thickness of 0.3mm, extending facially to the mesiofacial line angle (Figure 6). 

The join line was addressed next. Two layers of A1 Dentin (A1D) were placed with the second layer extending incisally and featuring dentin lobule irregularity and small connections to the incisal edge (Figures 7-8)

Following placement of a thin layer of Translucent Clear within these dentin ngerlings incisally, a thicker worm of Translucent Amber was placed at the incisal edge and brushed into place (Figures 9-10). At this stage, the join line was invisible but we still had space for additional dentin volume, needed to brighten the value of the restoration (Figure 11).

The value was toned up using a thin layer of Majesty Esthetic HO (Hollywood Opaque) before the enamel volume was replaced using A1 Enamel. Primary, secondary and tertiary anatomy were established using a combination of Sof-Lex discs (3M), red-stripe needle-point diamond burs (Mani), Astropol polishers (Ivoclar Vivadent), 45 micron diamond grit and 5 micron diamond grit progressive rubber polishers (Clinician’s Choice) (Figure 12). Finishing and polishing was completed using an Astrobrush (Ivoclar Vivadent) and 1 micron aluminium oxide paste (Enamelize, Cosmedent) in conjunction with Flexibuff discs (Cosmedent) (Figure 13).

The final result demonstrates successful placement of a seamless Class IV restoration to a dimension symmetrical to that of the contralateral tooth whilst simultaneously respecting the need to close the diastema; all guided by Digital Smile Design and facial landmarks. Clearfil Universal Bond features a time-tested, 10-MDP monomer with multi-modal functionality for a predictable bond to hydroxyapatite.

The selective etch technique was used as Erhardt et al demonstrated a detrimental effect on shear bond strength of a total etch technique using a self-etching bonding system on a dentin substrate.2 The composite system used (Majesty ES-2) displayed remarkably smooth handling and esthetic properties that were perfectly predictable featuring ultimate esthetics (Figure 14).

Sources:1. Leonard, R.H. Jr., Bentley, C, Eagle, J.C., Garland, G.E., Knight, M.C. et Philips, C. Nightguard Vital Bleaching: a long-term on efficacy, shade retention, side effects, and patient perceptions. J Esthet Restor Dent. (2001). 13(6): 357-369. 2. Erhardt, M.C., Cavalcante, L.M et Pimenta, L.A. Influence of phosphoric acid pre-treatment on self-etching bond strengths. J Esthet Restor Dent. (2004) 16:(1): 33-40; discussion 41.