CATEGORY 70 AUSTRALASIAN DENTIST Summary Today, the highest aesthetic demands can be satisfied with direct composite restorations. In addition to protecting the hard and soft tissues compared to indirect procedures (veneers, crowns), the restoration can be created in one appointment without an impression or temporary restoration at reduced costs. Keywords composite, direct restorations, anterior teeth, adhesive technique 1. Introduction In dental treatments in the anterior region, the aesthetic result plays a dominant role alongside functional concerns. While both aspects are of great importance to the practitioners, many patients concentrate primarily on the perfect appearance of the restorations. Fortunately, a large number of patients today have developed a strong dental awareness and are therefore prepared to make the necessary financial expenditure for an attractive smile. In recent decades, continuous development in the material science of composites and adhesive systems has resulted in major advances in the material properties and the associated application protocols of adhesive dentistry as well as in treatment safety1-3. At the same time, the range of indications for adhesively bonded composite restorations in the anterior and posterior region has been significantly expanded. Particularly in the last 30 years, the intraoral use of composites to patients in the area of the anterior teeth has been perfected through the introduction and continuous improvement of various layering techniques4-12. Today, direct composite restorations can be used to cover a wide range of indications – from minimally invasive treatments and cavityfree tooth reshaping procedures to extensive anterior tooth reconstructions, which often replace a large part of the crown volume of a tooth13-16. There is now an almost overwhelming CLINICAL variety of composite materials available for direct patient application. These restorative materials can be divided into classic universal composites, traditional flowable composites, bulk-fill composites (with a flowable and sculptable consistency), thermoviscous composites, and even highly aesthetic composites for sophisticated anterior restorations. Of course, almost all composite manufacturers also offer most of these material classes as their own product brands. This often makes it difficult for the practitioner to keep track of which material is best suited for which indication. For some time now, a trend has been emerging towards increasingly favoring composites for universal use. More specifically, these are products with a good chameleon effect, which ultimately allows the entire VITA® spectrum to be covered by using just a few shades. If a dental practice has many demanding patients who also pay the necessary additional costs for aesthetically high-quality anterior tooth restorations, then an aesthetic composite with different levels of translucency/opacity may also be necessary. The highly viscous, sculptable universal composite GrandioSO Unlimited (VOCO, Cuxhaven) is offered in a simplified cluster shade system with only five differently colored composite pastes (A1; A2; A3; A3.5; A4). Due to their pronounced chameleon effect, these composite pastes are able to cover the entire spectrum of the VITA® shade space. The excellent shade adaptation of GrandioSO Unlimited makes it universally applicable in the anterior and posterior dentition. GrandioSO Unlimited can be processed in increments of up to 4 mm thickness, making it one of the most popular bulk-fill composites. It has an inorganic filler content of 91 wt.% and exhibits a polymerization shrinkage of 1.44 vol.% with low shrinkage stress. GrandioSO Unlimited is extremely radiopaque. With a radiopacity of 900% Al, it provides an extraordinary contrast to the tooth structure and other filling materials. 2. Clinical case presentation A 60-year-old female patient came to our dental office with the desire to have the left lateral maxillary incisor, which is clearly positioned palatal in relation to the left central incisor, optically better positioned in the dental arch (Fig. 1 and 2). In addition to the position of the tooth, the patient was particularly bothered by the fact that the tooth appeared significantly darker when smiling compared to the left central incisor and the PFM crown on the left cuspid. The tooth reacted sensitively to the cold test without delay and also showed no abnormalities in the percussion test. After being informed about possible treatment alternatives and their costs, the patient opted for a direct veneer using the universal composite GrandioSO Unlimited (VOCO GmbH, Cuxhaven). Treatment started with thoroughly cleaning the affected tooth of external deposits using a fluoride-free prophylaxis paste and a rubber cup. Subsequently the appropriate composite shade was determined on the still moist tooth (Fig. 3). The selected composite shade was then checked by applying a small button of the composite mass to be used to the tooth that had not been desiccated and had not been pretreated with adhesive17. The composite sample must be light-polymerized for the time specified by the manufacturer in order to obtain a meaningful optical comparison. Only with sufficient light-exposure is the photoinitiator camphorquinone, which is contained in most composites and has an intense yellow color, largely consumed and converted into a colorless reaction product ("photobleach")18-23. After polymerization of the composite sample applied to the tooth surface, its optical properties are compared with the surrounding tooth substance in terms of shade and degree of translucency. At this point, a correction can easily be made by replacing an optically unsuitable sample with a shade-optimized composite material. This individual verification process, which only takes a Direct anterior composite veneer using a universal bulk-fill composite with a simplified shade system – a clinical case report By Prof Dr Juergen Manhart
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