Esthetic direct restorations in endo- dontically treated anterior ...3 kinds of posts: glass, quartz and zirconia.17 Scientiﬁc literature shows several issues related to zirconia

CLINICAL APPLICATION

44THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY

Esthetic direct restorations in endo-

dontically treated anterior teeth

Gaetano Paolone, DDSPrivate Practice, Rome, Italy

Lecturer, Master of Endodontics and Restorative Dentistry, University of Siena, Italy

Monaldo Saracinelli, DDSPrivate Practice, Grosseto, Italy

Walter Devoto, DDS Private and Referral Practice, Sestri Levante, Italy

Clinical Lecturer, Department of Restorative Dentistry, University of Siena, Italy

Visiting Professor, University of Marseille, France and UIC (Universitat Internacional

de Catalunya), Barcelona, Spain

Angelo Putignano, MD, DDSProfessor Restorative Dentistry

Head of Department of Endodontics and Operative Dentistry, School of Dentistry,

Polytechnic University of Marche, Ancona, Italy

Correspondence to: Gaetano Paolone

Viale dei Quattro Venti, 233, 00152, Rome, Italy; E-mail: [email protected]

PAOLONE ET AL


Abstract

Composite resins are the most common-

ly used materials in restorative dentistry.

When first introduced in dental practice,

they began to change the esthetic ap-

proach to anterior teeth treatments.

At first they simply represented a ‘white’

alternative to unesthetic materials.

Today, the clinician can select different

materials depending on the character-

istics required, such as opalescence,

fluorescence, translucency, transpar-

ency, viscosity, elasticity, and, obviously,

shade. It is no longer a mere matter of

selecting the right single syringe. The

thicknesses of one or several materials

may drastically change the final out-

come. A three-dimensional way of plan-

ning restorations has overcome the old

monochromatic bi-dimensional one.

Sound tooth preservation, affordable

treatments, and reparability are only a

few of the advantages of using compos-

ite resins.

Clinicians generally consider non-vital

anterior teeth a big challenge from an

esthetic point of view and they very of-

ten prefer to treat them with full or partial

indirect ceramic restorations.

In the present article, through the ana-

lysis of several step-by-step clinical

cases, the authors point out that direct

restorations could lead to successful

esthetic outcomes if correct techniques

are applied in order to make up for the

differences between vital and non-vital

teeth.

(Eur J Esthet Dent 2013;8:44–67)




Introduction

Clinical procedures related to restoration

of root canal treated teeth are often con-

fusing for clinicians. This often occurs

either because of obsolete knowledge

or because of the huge diversity in pub-

lished opinions. Adhesive dentistry has

broadened the clinician’s possibilities

and has made more conservative treat-

ments possible.1

Bonding to enamel and dentin has

led to an increased number of direct

and indirect bonded restorations and to

a reduction in porcelain fused to metal

crowns. More conservative treatments

avoid reaching an early end of a “tooth’s

lifecycle”2 and are therefore preferable.

Placing or not placing a post has

become one of the most debated sub-

jects, while it is well known that the most

important element is to have as much

dental structure as possible. In anterior

teeth, as well as in posteriors, it is almost

mandatory to have a “ferrule effect”.3,4,5

A proper ferrule reduces the inci-

dence of fractures in non-vital teeth. The

ferrule reinforces the tooth at its external

surface, dissipating forces that concen-

trate at the narrowest circumference of

the tooth.6

If the clinician has to deal with poor re-

maining dental structures, a periodontal

crown lengthening or orthodontic extru-

sion can be performed in order to have

a ferrule effect. Both solutions have to be

evaluated very carefully in anterior teeth

because of the esthetic consequences

they may produce. Crown lengthen-

ing may lead to missing papillas, while

orthodontic extrusion may produce a

narrower emergence profile due to the

root taper.7-10

Restoring non-vital anterior teeth

means accurately planning and manag-

ing various aspects11,12 such as posts,

color, form, preparation, and surface

geography. Only a strict interconnection

among these elements leads to a suc-

cessful restoration.

Posts

Generally, when we have a sufficient

tooth structure no post is required

(Fig 1).13 Sometimes we have the oppo-

site situation, where the tooth structure

is very poor and more than one post is

placed in order to support build-up ma-

terial (Fig 2).

For many years, the cast gold post and

core solution has been considered the

“gold standard” in post-and-core restora-

tions.14,15 Today we can count on alterna-

tives to cast posts and cores. The use of

prefabricated posts and custom-made

build-ups with composite resin gives

clinicians several advantages. It is time

and cost saving, it simplifies the restora-

tive procedure because all steps can be

completed chairside, and a fair clinical

success can be expected.16 Generally,

a post is recommended in order to sup-

port build-up material, not to strengthen

the tooth structure or to increase pull-out

strength. In fact, it has been evaluated

that the post length or design are of sec-

ondary importance for fracture resistance

if a sufficient ferrule can be provided.6

Sometimes posts are placed if the

clinician thinks that direct restorations

are to be considered as a long-term pro-

visional solution. In this way, we can have

teeth ready to be prepared for prosthetic

purposes whenever needed.

PAOLONE ET AL


When a post is required, the clinician

has to choose between the type of ma-

terial and its shape:

�� The material. While it is mandatory to

use an esthetic post in the anterior

teeth, especially when using direct

restorations, which do not have a

complete masquerading capacity,

the clinician can choose between

3 kinds of posts: glass, quartz and

zirconia.17 Scientific literature shows

several issues related to zirconia

posts, such as debonding, root frac-

ture, etc.18,19

�� The authors of this article suggest

the use of glass/quartz fibre posts,

while the literature shows better

results for their mechanical prop-

erties.20 Research is continuously

evolving in its aim to develop new

posts with different flexural proper-

ties.21

�� Post Shape. Companies provide us

with posts with different tapers and

with drills to create post space. Post

space should be obtained by remov-

ing as little sound tooth as possible.

Drills should only be used to remove

endodontic filling. The post should

be adapted to the canal shape; we

should not modify the canal shape to

make it “post compliant”. Therefore,

it is better to have different shapes in

order to select the most appropriate

one and have uniform cement thick-

ness.22,23

Fiber posts are generally cut to size with

a diamond disc after having delimited

the length with a felt-tip pen. (Fig 3)

If the post needs to be placed in a

region such as the palatal concavity,

specific shape modification may be

Fig 1 When there is sufficient tooth structure, gen-erally no post is required.

Fig 3 Posts are cut to size.

Fig 2 Sometimes more than one post is placed.



a b

Fig 4 Posts can be shaped for anatomic purposes.

Fig 5 (a and b) When no post is required, the endodontic filling is removed at least 2 mm below bone level. (c) A flowable composite resin is placed right above the endodontic filling. A high opacity, high value and fluorescent flowable composite resin is preferred, as it may balance dentin fluorescence loss and can

be easily detected in case new treatments or future post placements are needed. (d and e) Layering of dentin and enamel.

Fig 6 (a and b) A post space is created, removing as little sound tissue as possible. Drills are only used for removing endodontic filling. (c) Post is shortened so that it may fit (though passively) in the best way in the canal and it is also shaped so that it may be covered with a uniform restorative material layer. (d) Post is cemented with auto or dual composite cement. (e) In order to avoid bubbles and to fill undercuts, a small amount of flowable composite resin (violet in the diagram) is placed around post and post cement.

Layering is then completed with dentin and enamel composite.

2 mm

a cb d e

a cb d e

PAOLONE ET AL


performed through the use of abrasive

discs (Figs 4a and 4b).

Color and form

The color of a tooth is determined by the

dentinal body. Enamel works as a modi-

fier of the dentin color, and its thickness

(changing over time) is decisive for the

final color of the tooth (Fig 7).24

When we choose a color for our res-

toration, we choose a single base hue

dentin with different chromatic shades,

and an enamel able to modify the color.25

While various thicknesses from the cer-

vical to the incisor area are to be creat-

ed, clinical experience suggests using a

minimum number of dentin colors vary-

ing enamel thickness to modify the base

color.26

Fig 7 Enamel thickness is very important for the esthetic outcome of a restoration.

Fig 8 Wax-up and silicone matrix.

Therefore, it is mandatory to plan the

space dedicated to each material. Small

excesses or under-applications could

determine esthetic failure and the need

to repeat the restoration.27-31

a b



So, while the thickness of every mass is

pre-determined, the shape and the form

of the surface reconstruction has to be

considered. In order to do this, we need

an efficient and stable guide for layering

our masses, and the rigid silicone matrix

provides this. This useful device can be

obtained in three different ways:

�� From the old restoration before re-

moving it.

�� From a pre-restoration (it is simply

a matter of applying, modeling and

polymerizing composite resin direct-

ly on the tooth without the use of the

adhesive system).

�� From a wax-up (Figs 8a and 8b).

When we need to restore the inter-

proximal surfaces, preformed sectional

guides with multiple convexities are of-

ten very useful. They easily provide a

natural emergence profile and optimize

the position of the interproximal contact

point.

With the silicone matrix we have de-

fined the palatal surface; with the pre-

formed sectional guides we have de-

fined the interproximal ones. Now we

need something to help us restore the

thickness.

What is the thickness of the dentin lay-

er? And, much more importantly, what is

the thickness of the enamel? With nearly

all enamel materials, the thicker they are

the more they tend to increase the “grey-

ish effect,” hence dulling the underly-

ing color of the dentin. What we need

is more silicone indexes cut along the

sagittal plane (Fig 9). In this way (as we

do in prosthetic dentistry), the clinician

can control the thickness of the two ma-

terials.We can also count on new instru-

ments designed by the “Style Italiano”

study club, that help measure the thick-

ness of the enamel layer. (Fig 10).

Because of its different refractive

index, we should leave space for com-

posite enamel no larger than a half of

a natural enamel thickness. Today we

also have highly refractive composite

enamels that have a refractive index

very close to that of natural enamel.32-37

Tooth preparation

The preparation of the tooth begins by

removing old restorations and caries.

After that, unsupported enamel is re-

moved and a margin is defined. This is

characterized by a small chamfer in the

vestibular portion (to make the transition

from composite to natural enamel invis-

ible) and in flat margins (90 degrees) in

the interproximal and in the palatal por-

tion.

Great care has to be taken in finishing

the preparation margins, using silicone

points mounted on a blue ring counter-

angled hand piece, at a low speed, to

carefully smoothen the preparation and

remove unsupported enamel prisms,

which would break off during light cur-

ing contraction, leading to discoloring

and infiltration of the restoration. This

operation has to be carried out under a

constant cooling spray.25

The surface

Every single step in direct restorations

is important. Often clinicians devote too

little time to taking care of the restoration

surface. This happens because often

the clinician only regards the “color

matching” issue. This is a common er-

PAOLONE ET AL


ror, while surface management is in fact

just as important as the form, being a

part of it. Technicians spend a long time

polishing indirect ceramic restorations

before sending them to dental offices.

In direct restorations we have to do this

ourselves. Macro and micro-geography

have to be reproduced carefully. Young

teeth have a very well pronounced macro

and micro-geography, while aged teeth

have smoother surfaces. Sometimes we

can play with the micro-geography in

order to obtain more light-reflecting ar-

eas. This can give the illusion of a tooth

with a higher value. While non-vital teeth

have generally a lower value, this can

be a technique used to solve the prob-

lem.

Clinical cases

In the following clinical cases, “step-

by-step” procedures related to various

aspects of direct restoration of non-vital

teeth will be described.

Case 1

Initial photos (Figs 11a and 11b) show

inappropriate composite restorations for

teeth 12, 11, 21, and 22. Tooth 21 was

also discromic.

The radiograph (Fig 12) shows radio-

paque material in the periapical region

of tooth 21 with no root treatment. Areas

of demineralization can be seen around

nearly all the restorations

Tooth 21 has been root treated and a

new apicoectomy was performed.

A cervical seal with a light colored

flowable resin (in order to be easily found

when the post space has to be created)

was made in order to bleach the tooth

(Figs 13a and 13b). The coronal height

of the seal should protect the dentinal

tubules and conform to the external epi-

thelial attachment.38 Bleaching was then

performed internally and externally.

An impression was made in order to

make a wax-up.

Silicone indexes were made on the

wax-up (Fig 14) and a personalized color

Fig 9 Sagittal silicone matrixes. Fig 10 Space to be left for enamel is checked with “Misura” instrument.



chart was also compiled, subsequent to

careful analysis of the teeth under a light

source of 5500 K.

After at least 21 days after bleaching,

adhesive and restorative procedures

can be performed.39 After carefully iso-

lating the operative field with the rubber

dam, and checking the rigid silicone

matrix guide to fit perfectly by trimming

it with number 15 scalpel blade where

necessary, the old and provisional fill-

ings were removed using a medium

a b

Fig 11 Initial situation.

Fig 12 Initial radio-graph.

a b

Fig 13 (a) External bleaching (b) At the end of bleaching procedures.

PAOLONE ET AL


Fig 14 Wax-up.

a b

Fig 15 (a) Teeth preparation and silicon matrix in situ. (b) Teeth preparation palatal view.

grain cylindrical diamond bur. Prep-

aration was performed with the above

mentioned criteria defining a chamfer

on the vestibular finishing line. (Figs 15a

and 15b).

A post has been placed in order to

sustain restorative material and because

it may turn out to be useful for a future

crown coverage of the tooth. The post

was cut to size and shaped in order to

reflect palatal concavity and to be cov-

ered completely by the composite resin.

The palatal wall of the tooth was restored

by placing composite resin directly on

the silicone guide after having defined

on it the palatal region with an explorer

(Figs 16a–16c).

A sectional matrix with multiple convexi-

ties was used for restoring the interprox-

imal anatomy (Fig 17). Furthermore, it

was also used to avoid accidental con-

tamination of adjacent teeth during ad-

hesive procedures. Once the cavity’s

solid was limited by interproximal well-

defined margins and incisal angles, it

was possible to focus on building up the

dentinal body (Fig 18).

The dentinal body was built leaving

enough space to add the specific opal-

escence taken from the color scheme

compiled in the preliminary investiga-

tive phase. Management of the inter-

nal composite thickness was controlled

using another laboratory-produced rigid

silicone matrix sectioned in the sagittal

plane, as seen previously (Fig 9). This

made it possible to control the quantity



a

c

b

Fig 16 (a) Post selection. (b) Post is shaped in accordance to palatal wall. (c) Palatal wall is lay-ered.

Fig 18 Dentin is layered on 2.1

Fig 17 Mescal and incisal portions are restored.

Fig 19 1.1 and 2.1 before polishing.

PAOLONE ET AL


and distribution of the composite dentin

in section, in order to leave just the right

space for the enamel and not to lower

the value of the restorations. Layering

finished with a very thin layer of compos-

ite enamel no thicker than 0.3 to 0.4 mm

(Fig 19).

The same procedure was followed to

layer composite resin on tooth 11. A final

60-second curing was performed under

glycerine, which eliminates oxygen ac-

cess to the surface. This procedure will

provide the composite resin’s complete

polymerization, improving surface re-

sistance and giving better polishing per-

formances.

Case 2

The patient (Fig 22) complained of dis-

coloration around fillings and restoration

translucency. Because the color of the

two central incisors did not differ much

from the contiguous teeth and to avoid

the risk of a bleaching color relapse, it

was decided not to perform bleaching.

Root treatments for teeth 11 and 21 were

unsatisfactory (Fig 23) and had to be re-

peated.

Removing old restorations was done

carefully, because every single portion

of sound tooth was crucial for the pro-

spective restoration. Often we have big

Fig 20 Final result. Fig 21 Final radiograph.



bevels and fortunately restorative ma-

terial is sometimes thicker and overlaps

sound enamel. Unfortunately this was

not the case here (Fig 24).

First of all a high-contrast fluorescent

white flowable composite resin was used

as a cervical seal so it could be easily

found in case of new treatment or post

insertion needs (Fig 25). An opaque,

high value, fluorescent composite was

used to build the dentin body, starting

from the cervical seal.

Both of the interproximal walls were

raised in one single step, using sec-

tional transparent matrices with multiple

convexities (KerrHawe) in order to keep

proportions between the two central in-

cisors and to control the mid-line. It is al-

so a time-saving procedure and can be

quickly removed and made once again

if we notice differences when compar-

ing dental and facial mid-lines (Fig 26).

Due to the poor thickness of interproxi-

mal walls, putting a little amount of flow-

able composite resin at the base of the

walls would help their consistency.

The palatal wall and the incisal portion

were built as a second step, stratifying

composite resin on the silicone index.

Then the two “frames” were filled with

dentin and then with a thin enamel layer

(Fig 27).

While dehydration occurs using the

dental dam, it is very important to have a

color chart compiled on hydrated teeth.

A tip for managing low teeth value is a

marked micro-geography which raises

the number of reflecting areas, giving

the illusion of a higher value. Finally, a

shiny smooth surface will give the res-

toration a more natural aspect and it will

blend more effectively25 (Fig 29).

Fig 22 Initial situation. Fig 23 Initial radiograph.

PAOLONE ET AL


Fig 24 Teeth preparation.

Fig 26 Interproximal walls.

Fig 28 Restorations before polishing.

Fig 25 Cervical seal is performed with white flow-able composite resin.

Fig 27 Incisal and palatal walls.



Case 3

Teeth 13, 12 and 11 had old restorations

that needed to be substituted because

of secondary caries and discoloration.

Tooth 12 also underwent a root canal

treatment (Fig 31).

All old restorations, secondary caries

and temporary fillings were removed.

Particular attention was given to saving

as much sound enamel possible. In this

particular case, tooth 12 had a precious

buccal enamel wall, which was crucial to

a predictable esthetic outcome (Fig 32).

The post space was then created, re-

moving root canal filling and shaping it.

Largo burs and postspecific burs were

used for this purpose. To obtain a good

post space debridement, sandblasting

with aluminium oxide or air polishing with

glycine-based powder was performed.

After having selected the correct post,

the length can be adjusted, cutting the

excess. The post should be completely

covered by the restorative material, so

this has to be kept in mind when adjust-

ing post length and shape.

A 3-step etch and rinse was then

used to perform the adhesive proced-

ure. A self-cure activator may be added

to the adhesive when used in the root

canal. This is done because light can-

not reach the deepest portion of the

root canal. The post was placed using

a small quantity of post cement only for

the canal portion. After curing it, the res-

toration was performed using composite

resin. A flowable composite resin is use-

Fig 29 Final result. Fig 30 Final radiograph.

PAOLONE ET AL


Fig 31 Initial situation. Fig 32 Tooth preparation.

a

Fig 33 Step-by-step post placement procedures.

b



ful to fill in hard-to-reach portions, espe-

cially around the deepest portion of the

post. In this way, it is possible to avoid

bubbles in the restoration (Figs 33a and

33b).

Case 4

This patient complained about the color

of her teeth (Fig 35), in particular, tooth

22. The radiograph showed the need for

a b

Fig 34 (a and b) The clinical view of the final result.

Fig 35 Initial situation. Fig 36 Initial radiograph.

PAOLONE ET AL


endodontic and conservative treatments

and retreatments (Fig 36). After having

endodontically treated teeth 12 and 22

and after having set a reliable cervical

seal, an external and internal bleaching

was performed on those teeth (Fig 37).

In this case, a bleaching agent (White-

ness HP Maxx, FGM) was used, which

changes color to green when its efficacy

is over (Fig 38). This could be useful to

optimize chair time for more than one

application. Vital teeth were treated with

the same bleaching agent. A liquid dam

was used to protect soft tissues (Fig 39).

A personalized colour chart was pre-

pared after the bleaching treatment and

before applying the rubber dam. (Fig 42)

Three weeks after the end of bleach-

ing, the rubber dam was applied and

teeth were restored in a single chair ap-

pointment (Figs 43–50).

Fig 37 Isolation used to perform bleaching.

Fig 40 Clinical situation after bleaching.Fig 39 External bleaching for vital teeth.

Fig 38 Internal and external bleaching for 1.2 and 2.1.



Fig 41 Wax-up and silicon matrix.

Fig 43 Teeth preparation.

Fig 45 Interproximal walls are built-up with the help of sectional matrixes.

Fig 42 A personalized color chart was prepared after the bleaching treatment and before applying

the rubber dam.

Fig 44 Frontal view of teeth preparation.

PAOLONE ET AL


Fig 46 Composite layering steps on tooth 21.

a b

Fig 47 (a and b) Sectional matrixes make our treatment quicker and predictable.

Fig 48 Restorations finished and polished.



Fig 49 A close-up of the final result.

Fig 50 Final radiograph.

Tips and tricks to manage color in non-vital teeth

As we have seen, a non-vital tooth has little cor-

onal dentin. This causes the tooth to have less

fluorescence and to appear dull.40

For this reason we have to minimize this incon-

venient by applying one or more of the following

procedures:

Using (when the use of a post is chosen) posts

with high levels of fluorescence to make up for

the lack of dentin. These posts integrate with

the material in the reconstruction, illuminating

the tooth from within, making it appear less

dull.

Using fluorescent and opaque dentin. Com-

posite dentin has to cover either the black-

ness of the oral cavity or the tooth substrate,

in order to raise the tooth value and avoid the

“grey” aspect of a restoration.

Emphasize micro and macro-geography in

order to raise the tooth’s value “perception”.

PAOLONE ET AL


65

Conclusions

The procedures exposed in this article

can be the key to the long-term suc-

cess of a restoration from both a clinical

and esthetic point of view.

The combined application of silicone

indexes and sectional matrices allows

the clinician to manage directly, in a

single step, complex direct restoration

cases, thus optimizing both operative

time and the final result.

It is crucial to understand that a suc-

cessful restoration begins with a cor-

rect initial treatment plan, which is often

based on impressions and wax-up. Af-

ter this, the knowledge of material com-

position, optical properties and overall

characteristics is mandatory in order to

give a natural aspect and a predictable

performance to our restorations. Clini-

cians often look for a miracle mater-

ial, but the final result is fundamentally

linked to the clinician’s manual skills

and knowledge and, what is more, skills

in choosing the correct techniques that

simplify everyday work.

All steps in direct restorations are

mandatory. The procedures, and espe-

cially the time to finish and polish di-

rect restorations, are to be respected.

Too often, composite resins are consid-

ered unreliable for esthetic purposes,

but rarely are they managed as they

should. Recent indirect solutions are in

fact based on a41,42,43 composite pre-

fabricated veneer system. This points

out that this material can be rightfully

used for esthetic purposes and gives

the clinician the possibility to manage

every step of restoration.

With composite resin materials we

can carry out esthetic restorations that

are minimally invasive, affordable for

patients, and long-lasting.

Repairing fractures or defects in the

material is relatively easy and cheap,

and it is not necessary to carry out the

whole restoration again.

The clinician has to deal with the loss

of natural fluorescence of non-vital teeth

because a great amount of coronal

dentin, which is the most responsible

for fluorescence, has been removed

to perform the endodontic treatment.

Generally, a post is only recommended

only when a big portion of the tooth is

missing to sustain the material and in

consideration of any future treatment.

Direct restorations should be consid-

ered as an effective choice when re-

storing root-treated teeth, while indirect

solutions like veneers or crowns inevit-

ably lead to further tooth structure loss.

Acknowledgements

The endodontic treatments shown in the radio-

graphs of this paper were performed by Dr Federico

Menghetti and Dr Roberto Kaitsas. The clinical pro-

cedures detailed in this paper were performed by

Style Italiano club members (www.styleitaliano.org).



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Documents

Esthetic direct restorations in endo- dontically treated anterior ...3 kinds of posts: glass, quartz and zirconia.17 Scientiﬁc literature shows several issues related to zirconia