Direct Composite Resin Vs Porcelain to Restore Severely Fractured Anterior Teeth
A clinical post-accident case report
Abdi Sameni, DDS, FACD | Alireza Moshaverinia, DDS, MS, PhD, FACP
In modern dentistry, there is an increasing demand for esthetic materials with the capacity to preserve the natural tooth structure. Direct resin composites in the esthetic zone have become a viable alternative restorative material for patients who require anterior restorative procedures.1-5
Recently developed resin composites exhibit superior mechanical and optical properties. They have improved handling properties and are easier to contour during direct procedures.3-7 In the authors' experience, when direct restorative composite resins are an option, they offer the following advantages in comparison to indirect porcelain restorations:
1. More biologically conservative to the teeth being restored
2. Less abrasive to the opposing dentition
3. Fewer appointments
4. Less expensive
5. Minimal or no laboratory assistance/ No provisional restorations
6. Easily repaired
7. More pleasant patient experience
8. More enjoyable to perform
9. Great practice builders7-9
Still, practitioners are often hesitant to consider directly applied composite resin in situations where a large part of the damaged teeth needs to be reconstructed and restored.
In this article, the authors report the step-by-step technical approach utilizing a highly esthetic and newly developed resin composite as a direct restorative material in the esthetic zone to solve a clinically challenging case.
A 32-year-old male patient was referred to the office by his endodontist after a severe bicycle accident (Figure 1). The stated chief complaint was, "I want to restore my teeth like they were before my accident" (Figure 2). Upon examination, the patient was found to have fractured his central incisors and left lateral incisor (Figure 3). Intraoral and radiographic examination by the referring endodontist revealed pulpal involvement for the left central incisor, which required root canal therapy and internal bleaching; both were performed prior to the authors meeting the patient. Following primary stabilization of the damaged teeth, the patient was given the option of restoring his smile with either direct composite resin or indirect bonded porcelain restorations. After a thorough cost/benefit analysis and risk assessment, the patient decided to begin the process using direct composite restorations.
Upon patient approval, a PVS impression was made and a diagnostic waxup was completed (Figure 4), followed by fabrication of a silicone putty matrix. Subsequently, the matrix was filled with bis-acrylic provisional material and adapted to the maxillary anterior teeth until the material was fully polymerized. The incisal-edge position and midline were checked and approved by the patient (Figure 5).
At the following appointment, the teeth were abraded with particle abrasion, and all sharp edges were rounded using a fine diamond bur and soflex discs.
A shade mock-up was performed to preselect the appropriate shades and correct opacities prior to the teeth dehydrating (Figure 6).
The teeth to be restored were isolated using a rubber dam, the enamel was generously etched, and universal bonding agent (G-Premio Bond, GC America Inc., gcamerica.com) was applied. Subsequently, the putty with a palatal silicone index was used as a matrix during the direct buildup, and the resin composite material (G-ænial™ Sculpt, GC America Inc.) was utilized in an incremental fashion to restore teeth Nos. 7 through 9 (Figure 7).
G-ænial™ Sculpt (GC America, http://www.gcamerica.com/products/operatory/G-aenialSculpt/) is a light-cured, universal nano hybrid composite resin material.
This material is compactable and radiopaque, and it comes in 17 shades with opaque and translucent options. Due to the novel uniform nano-filler dispersion technology, this resin composite material possesses high wear-resistance and long-term gloss retention. Additionally, this material exhibits excellent "chameleon" color match to enamel with a self-shining effect, making it a promising material for direct restorations in the esthetic zone.
First, higher-opacity dentin body resin composite material (AO2) was used to recreate the missing dentin. A more translucent composite resin was utilized to recreate the missing incisal enamel and its optical properties. The direct composite restorations were contoured and polished and the patient was satisfied with the esthetic outcome. A 5-month follow-up appointment showed that the direct composite resin had been in service for 3 months with no postoperative clinical complications (Figure 8 and Figure 9).
A knowledge of material selection and the required skillset to master direct restorations in the esthetic zone is of the utmost importance for clinicians. The integration of esthetic consideration into the proposed treatment plan is a crucial factor to achieve desirable outcomes. Esthetic direct resin composite restoration is a practical treatment modality that offers durable and esthetically pleasing outcomes. The advantages of direct composite restorations include time savings, cost savings, and conservation of tooth structure. The authors acknowledge that composite resins are more likely than porcelains to chip and discolor over time, but these are minor problems with conservative and inexpensive solutions. In the authors' opinion, it is ultimately the "informed" patient's responsibility to make the decision of sacrificing more tooth structure to "potentially" reduce further maintenance.
1. Dietschi D. Free-hand composite resin restorations: a key to anterior aesthetics. Pract Periodontics Aesthet Dent. 1995;(7)7:15-25.
2. Dietschi D. Optimising aesthetics and facilitating clinical application of free-hand bonding using the "natural layering concept." Br Dent J. 2008;204 (4):181-185.
3. Dietschi D, Ardu S, Krejci I. A new shading concept based on natural tooth color applied to direct composite restorations. Quintessence Int. 2006;37(2):91-102.
4. Araujo EM, Jr, Baratieri LN, Monteiro S, Jr, Vieira LC, Andrada MA. Direct adhesive restoration of anterior teeth: part 2. Clinical protocol. Pract Proced Aesthet Dent. 2003;15(5):351-357.
5. LeSage BP. Aesthetic anterior composite restorations: a guide to direct placement. Dent Clin North Am. 2007;51(2):359-378.
6. Mackenzie L, Parmar D, Shortall AC, Burke FJ. Direct Anterior Composites: A Practical Guide. Dental Update. 2013;40(4):297-299, 301-302, 305-308.
7. Brodbelt RH, O'Brien WJ, Fan PL. Translucency of dental porcelains. J Dent Res. 1980;59(1):70-75.
8. Baratieri LN, Araujo E, Monteiro S Jr. Color in natural teeth and direct resin composite restorations: essential aspects. Eur J Esthet Dent. 2007;2(2):172-186.
9. Blank JT. Creating translucent edge effects and maverick internal tints using microhybrid resin. Pract Proced Aesthet Dent. 2006;18(2):131-136.
For more information, contact:
Abdi Sameni, DDS, FACD
Associate Professor of Clinical Dentistry, Clinical Director of Advanced Periodontology
Herman Ostrow School of Dentistry
University of Southern California
Los Angeles, CA
Alireza MOSHAVERINIA, DDS, MS, PhD, FACP
Assistant Professor, Division of Advanced Prosthodontics
UCLA School of Dentistry
University of California, Los Angeles
Los Angeles, CA