A female patient was very nervous when attending a new patient examination. Her primary complaint was the appearance of her front teeth which made her extremely self conscious of her smile. A fear of dental treatment had prevented her from seeking help sooner, so the decay was quite advanced (fig 1).
Examination revealed carious lesions present on teeth 11, 21 and 22. Periapical radiographs of the anterior teeth were free of any apical pathology and vitality testing with standard ethyl chloride gave a positive response suggesting healthy pulps.
After considering the financial constraints and anxiousness of the patient, a treatment which combined minimal cost, invasiveness and treatment time was proposed. Repairing the cavities with direct composite was presented as the treatment of choice.
The first step undertaken was to create a study cast of the upper arch (fig 2). Once the cast was supplied from the lab, a drop of Adper Scotchbond 1XT total-etch adhesive (3M ESPE) was applied to the cavity surfaces and air dried before light curing. To create a mock up of the final restoration, composite which had passed its use by date was applied to the study cast. A small amount of silicone putty was then pressed over the palatal surfaces of the teeth and allowed to set (figs 3 and 4).
My preferred method of isolation requires the use of a rubber dam. Therefore the silicon putty matrix was trimmed back with a scalpel to expose the palato-cervical surfaces of the upper canine teeth (fig 5). The whole process took less than 15 minutes and was performed during a late cancellation appointment.
During the patient's second appointment the custom matrix was placed in the mouth to assess the accuracy of the fit. Prior to the restorative procedure, a topical local anaesthetic was applied to ease the patient's nerves before a local anaesthetic injection. A rubber dam was then applied using anterior clamps on the canine teeth (fig 6). After caries removal, the labial surfaces of the cavities were bevelled and the custom matrix was then introduced. Due to the elastic tension of the rubber dam pushing against the palatal surface, the matrix was manually held in place whilst the first translucent layer of Filtek Supreme XTE universal restorative (3M ESPE) was applied.
The translucent composite was applied in a very thin layer and formed the outline of the teeth including the incisal edge. A dentine shade layer was then added (fig 7). The matrix was then removed and the rest of the layering technique completed with a translucent shade, an inner dentine shade and an enamel shade to achieve an excellent aesthetic result.
After composite placement, finishing and polishing was initially achieved with fine tapered diamonds, followed by a series of Sof-Lex discs (3M ESPE). After dam removal, the occlusion and protrusive guidance was checked and adjusted accordingly. The patient was delighted with the final result (fig 8).
Whilst use of a custom matrix is not essential, it allows for easy placement of the initial composite layers. In addition, final adjustments to palatal surfaces are minimised and creating the desired morphology is more predictable.
Compared to other composites, the intuitive nature of Filtek Supreme XTE universal restorative makes it very easy to use. The layering process is very straightforward and the enamel shades can be polished to a high shine, or if you desire, a body shade can be used to create a matt finish. In my opinion, the superior optical properties and flexibility of a composite like Filtek Supreme XTE universal restorative enables the dental practitioner to deliver the highest aesthetic result, regardless of technique, which satisfies even the most demanding patient.