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    FERD

    March 2007, Volume , Issue
    Published by AEGIS Communications


    Tips on Shaping & Finishing Composite Restorations

    Larry Holt, DDS and Howard E. Strassler, DMD

    When placing a direct composite resin veneer or restoring traumatically fractured incisal edges with composite resin, all aspects of the technique are important for the esthetics and durability of the restoration. To me, the "crowning touch" for achieving a final esthetic result that the patient can truly appreciate is shaping of the incisal edges.

    For the majority of composite resin placements and finishing of these restorations–especially for the incisors and canines–I seat the patient in a supine position, and I am typically sitting behind the patient.

    During the initial finishing of the veneer or for incisal edge repair, I establish a preliminary incisal length. After completing almost all of the facial and lingual contouring, I sit the patient to an almost upright position (Figure 1). Then I stand in front of the patient, hand the patient a mirror, and then I complete the shaping, establishing the length and embrasures of the incisal edge. I accomplish this task using both coarse and medium grit disksa or diamond disks.b

    By examining the tooth shape from in front of the patient, I am viewing the restoration from the same perspective as the patient, as well as how others view the smile. I can see the interpupillary line, midline, and other soft tissue landmarks in their true visual position. Incisal edges have a chisel-shaped appearance when viewed from a profile view, not a flat, square appearance.

    Therefore, when shaping these aspects of the restoration and tooth, it is important to orient the disks you are using with a lingual tilt (Figure 2). Also, these thin finishing disks can be used to shape the incisal embrasure.

    Larry R. Holt, DDS: The most valuable instrument in my armamentarium for final contouring and finishing is my camera.c Close-up photography, full-face shots, and my dual-monitor computer set-up (Figure 3) are invaluable when evaluating direct composite placement and finishing.

    Direct bonding procedures are typically intense, one-on-one appointments. Direct composite veneers or multiple diastema closures can take two or more hours to complete. By the end of an appointment, everyone in the operatory is tired or downright worn out! Achieving a critical evaluation can be an overly optimistic goal at that immediate moment (Figure 4, Figure 5, Figure 6, Figure 7).

    Therefore, I suggest finishing only as much as possible at that initial appointment. Then, use the camera and take multiple digital photographs from various perspectives (i.e. retracted frontal, retracted left and right lateral, close-up frontal, close-up left and right lateral, full smile frontal, full smile left and right lateral, full smile head shot). Check the quality of the photographic images on your computer.

    Dismiss the patient. Make a follow-up appointment for a week or so later, but don't study the photographs until you are rested and ready to critically evaluate your results.

    Obviously photographic analysis can be performed the day the procedure is completed. However, in my opinion, the follow-up appointment provides you with another opportunity to refine the case with "new vision."

    Viewing images on a 23" monitor is invaluable. Central incisors that are 6" tall reveal every potential flaw in the treatment. Viewing restorative work in this manner provides an opportunity to deliver treatment at an entirely new level. The follow-up images for the case illustrated here (Figure 8 and Figure 9) demonstrate the improvements made possible from critical photographic evaluation.

    a Sof-Lex™, 3M™ ESPE™, St. Paul, MN

    b Gateway diamonds, Brasseler® USA, Savannah, GA

    c Canon EOS 20D, Canon USA, Inc., Lake Success, NY

    About the Authors

    Larry R. Holt, DDS
    Adjunct Faculty, Department of Operative Dentistry
    University of North Carolina School of Dentistry
    Chapel Hill, North Carolina

    Private Practice
    Charlotte, North Carolina

    Howard E. Strassler, DMD
    Director of Operative Dentistry, Department of Endodontics, Prosthodontics, and Operative Dentistry
    University of Maryland Dental School
    Baltimore, Maryland


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    Image Gallery

    Figure 1  Image of the prepared tooth. Significant dentin is exposed. The proposed length flexure and tensile stress risk is at least medium and the restoration thickness would be at least 0.9 mm. This was noted in the chart.

    Figure 1

    Figure 1  After completing almost all of the facial and lingual contouring with the patient in a supine position, elevate them to an almost upright position.

    Figure 1

    Figure 2  Image demonstrating excessive enamel crazing, leakage, and staining. Flexure, tensile, and shear risks would be medium to high. The substrate would depend on preparation.

    Figure 2

    Figure 2  When shaping the incisal edges of teeth and/or composite resin restorations, orient your disks with a lingual tilt.

    Figure 2

    Figure 3  Image demonstrating a deep overbite in which shear and tensile stresses would be at least medium. Bonded porcelain would require maintenance of enamel and an occlusal strategy to reduce leverage on the teeth.

    Figure 3

    Figure 3  View of full-facial shots as seen on a dual-monitor computer set-up.

    Figure 3

    Figure 4  Image of a preparation with a poor substrate and subgingival margins where maintaining the seal would be difficult. High-strength ceramics or metal-ceramics would be indicated.

    Figure 4

    Figure 4  Preoperative view of a patient with noticeable diastema.

    Figure 4

    Figure 5  Image of minimal preparations prior to application of the bonded porcelain.

    Figure 5

    Figure 5  Preoperative full-facial view of the patient.

    Figure 5

    Figure 6  Two-year postoperative image of very conservative Category 1 bonded porcelain restorations.

    Figure 6

    Figure 6  Immediate postoperative right lateral view of the patient after a two-hour bonding appointment.

    Figure 6

    Figure 7  Preoperative photograph of an inlay in tooth No. 18 and an onlay on tooth No. 19.

    Figure 7

    Figure 7  Immediate postoperative left lateral view of the patient after composite bonding.

    Figure 7

    Figure 8  Postoperative photograph showing a non-layer material in use.

    Figure 8

    Figure 8  View of the composite restorations after the second appointment for finishing and refining.

    Figure 8

    Figure 9  Preoperative photograph of a case requiring significant lengthening. There is at least medium risk of flexure and unfavorable stress, and some of the substrate would be dentin. Thus, Category 1 materials were eliminated as a choice.

    Figure 9

    Figure 9  View of the composite restorations after the second appointment for finishing and refining.

    Figure 9

    Figure 10  Postoperative photograph after Category 2 materials were applied, with minimal porcelain layering in the incisal one third.

    Figure 10

    Figure 11  Preoperative photograph of a case in which the patient refused surgery and orthodontics. The treatment goal was to do minimal preparation and use a tough material due to the general medium-to-high risk in every area; obtaining a seal was p

    Figure 11

    Figure 12  Postoperative photograph with bonded full-contour restorations in place on the posterior teeth and incisally layered anterior teeth.

    Figure 12

    Figure 13  Preoperative photograph of an old, unesthetic PFM.

    Figure 13

    Figure 14  Postoperative photograph of a high-alumina crown system.

    Figure 14

    Figure 15  Preoperative photograph of an old PFM. The patient was unhappy with the opacity and metal display at the margin. Category 3 or 4 material is required for this case.

    Figure 15

    Figure 16  Postoperative view.

    Figure 16

    Figure 17  Postoperative photograph of teeth Nos. 18 to 20 in a case with subgingival margins. Photograph courtesy of Yi-Yuan Chang.

    Figure 17