Pedodontics

Ultraconservative
and minimally
invasive aesthetic
restoration of crown
facture

Abstract
|| Brief Background
In aesthetic zone composite bonding procedures are considered
the most conservative and least invasive technique. For composite restorations to mimic tooth structure, the clinician
must have a comprehensive understanding of material science and techniques involved in direct bonding procedures. The article presents techniques to master the anterior
direct composites with the help of two clinical cases.
|| Materials and Methods
In the first case, the most ultraconservative technique is followed by reuniting the fractured tooth fragment to
the tooth in question. All the parameters of etching, bonding
and composites are followed. In the second case, silicon index
(putty index) is fabricated to make lingual enamel as ideal as
possible and then layering concept of composite is followed to
reproduce dentin, enamel.
|| Discussion
Discussion focuses on necessary techniques involving an
understanding of colour, adhesive principles to create polychromatic in effects and perfect finishing and polishing.

Dr. Neeraj Mahajan

Professor and Head

|| Summary and Conclusions

Correspondence Address
Dr. Neeraj Mahajan
Pedodontics and Preventive Dentistry
Guru Nanak Dev Dental College and
Research Institute Sunam Punjab
E-mail: drmahajanneeraj@gmail.com

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The restorations final aspect, smile design and full face

photography was done in both the cases and results were
evaluated and minor corrections were done.
|| Key Words
Composite, tooth fragment, putty index, layering technique.

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|| Introduction
Aesthetic restoration of crown fracture at the central
incisors level may be one of the greatest challenges
a paediatric dentist can face. Generally, this affects
children and teenagers and represents the consequence
of accidental injuries. Much attention has been
given in recent years to the need for clinicians
to embrace minimally invasive and conservative
technique when providing patients with both
necessary and elective dental treatments. We are
fortunate to be practising in an era when sound
science and beautiful aesthetics can be applied
in a less technique sensitive manner in order to
answer todays dental challenges in conservative and
rewarding ways.

fractured 21 composite veneer was planned. The

goal of minimally invasive dentistry is ultimately to
curtail the restoration /re - restoration cycle.
Armamentarium
Lignocaine with 2% Adrenaline local anaesthetic
injection solution.
Vita classical shade guide.
Flame shaped diamond finishing burs.
Composite placement instruments.
35% phosphoric acid etching gel.
Bonding agent 5th generation.
Composite material of different shades.

Mastering anterior direct composite is a necessity

for the contemporary clinician who appreciates
and understands the art and science of cosmetic
dentistry . In the aesthetic zone, composite bonding
procedure is considered the most conservative
and the least invasive technique to return
missing, diseased and unsightly tooth structure
to enhanced colour, form and function. The
attractiveness and popular composites are easy to
explain because these restorations have excellent
aesthetic potential, very good to excellent prognosis
and reasonable fee.

Opaquers

Tints

For composite restorations to mimic tooth structure,

the clinician must have a comprehensive understanding
of material science and techniques involved in
direct bonding procedures. The presentation will
focus on necessary techniques which involved
an understanding of colour, adhesive principles to
create polychromatic in effects and perfect finishing
and polishing.

|| Treatment

Dignosis and Treatment Plan

Here are two patients with crown fractures in central
incisor. In the first case, a female of 14 years reported
with fracture of tooth 11. Adhesive reattachment
of dental fragment (ultraconservative technique)
was carried out. In the second patient, a boy of
13 years reported with fracture of 11 and 21. Crown
morphology was reconstructed with composite resin
using silicon putty matrix technique (minimally
invasive) for 11 and 21 which were fractured 2
years before and were endodontically treated. For

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Light cure unit.

Silicon impression material.
Clear mylar strips, finishing and polishing discs,
inter proximal finishing strips, composite polishing
brushes.
Composite polishing paste.
Digital Camera.

Case I.
In this case, (Fig. I) after proper isolation and
endodontic treatment , the fractured dental fragment
was washed and brushed until anaesthesia took
effect . Once the patient was comfortable ,
the teeth was polished to remove any plaque and
dental fragments fit was checked on tooth.

Fig. (1) (case 1): pre operative

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After proper isolation the tooth in question was

prepared for acid etching, washing, drying and
adhesive application on both the remaining crown
abutment and retrieved dental fragment (Fig.
II) . During this time, the adjacent teeth were
protected with celluloid strips. Bonding was done
with adhesive resin cement and proper shade
material, the excess material being removed before
the onset of polymerization.

Case II:
After proper isolation, a long circumferential
concave bevel preparation was carried out with
irregular outline on the fractured tooth. The facial
bevel was carried 2-3mm beyond the fractured
area , with an up and down motion, so that the
finishing line would not go against straight across
and would seem disappear in the middle one third
effectively.
A silicon putty matrix was placed over the mock up
(which was repositioned at the arch level) to serve
as a confirmer to restore the crown morphology .
Before the silicon putty matrix was repositioned, the
prepared tooth surface was etched, washed and
dried; then bonding agent was applied. (Fig. I).

Fig. (2) (case 1): Fragment of fractured tooth

A thin layer was applied on both involved

adhesive surface maintaining the fragments
closely related in their position during photo
polymerization . A groove was carried across the
fracture line into enamel thickness by means of a
flame shaped diamond finishing bur in order to
strengthen the bonding, the groove was filled by
composite of matching shade. The treatment was
then completed with standardized finishing and
polishing procedures, abrasive discs and strips with
decreasing granulation; abrasive composite polishing
brushes with polishing paste to refine the outline
from , develop texture and anatomy and smooth
margins of restoration (Figure III ).

Fig. (3) (case 1): Fragment in place after finishing

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Fig. (1) (case 2): Pre operative

The proper restoration was achieved by composite

layering technique on the silicon putty matrix
surface so that optical effects simulate to the
adjacent tooth could be achieved (Fig. II). This is also
known as multiple layering technique. But to do so
one has to understand the basic nature of composites,
colour, optical effect, translucency, opalescence etc.
(Figure III).

Fig. (2) (case 2): Lingual putty index being fabricated in lab

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The restorations final aspect , smile design and full

face photography was done in both the cases and
results were evaluated and minor corrections were
done.
When faced with class IV fracture of central incisors,
the minimalist approach to treating such cases
dictates that the operative decision be based on
what would extend the life time of the remaining
tooth structure with as little future intervention
as possible . To this end, it is now possible to
conservatively place direct composite restorations
in the anterior region- for such indication of class
Iv fractures that replicate the form , function and
aesthetics of natural teeth.

Fig. (3) (case 2): Finished composite build in tooth 1

The first layer of composite is given corresponding

to the palatal enamel , then selected shade of
greater opacity for dentinal reproduction , then
again a new composite layer to represent enamel
and finally a thin layer of shade translucent . ( incisal
edge reproduction). (Fig. IV).

|| Conclusion

|| Discussion

By achieving adhesive reattachment in the first case

and reconstruction with silicon putty matrix technique
in the second , the rationale behind a minimalist
approach is ultimately to curtail the restoration cycle,
to benefit the patient over his or her lifetime. The goal
is to conserve as much healthy tooth structure
as possible through these clinical procedures. Visible
damage to the maxillary central incisors of an
adolescent or young adult patient is a common clinical
presentation and we are often challenged to restore
chipped and fractured dentition in this patient group.
To answer the professions demands, manufactures
have recently introduced direct composite material
that demonstrates improved physical properties
, durability and strength for long term function
and polychromatic qualities for the placement of
restorations that essentially reproduce natural
tooth structure.

The general aesthetic outcome was evaluated by

the patient and her mother in the first case and the
patient and his father in the second case and
by the dentist . Everyone as satisfied especially the
patient and parents who were really thankful to the
dentist as this can be easily judged in their eyes.

What determines the restoration technique selected

is the patients age: the younger the age, the more
the conservative treatment should be . And from
this viewpoint reattachment involved in the fracture
and crown morphology restoration by means of
composite materials represent the best options.

In this case , the treatment was completed with

standardized finishing and polishing procedures,
abrasive
discs
and
strips
with decreasing
granulation ; abrasive composite polishing brushes
with polishing paste to refine the outline form ,
develop texture an anatomy and smooth margins
of restoration. The use of silicon putty matrix during
composite layering process facilitated the finishing
and polishing procedures. This tool minimized the
amount of lingual finishing required and developed a
relatively accurate in edge contour.

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