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cosmetic dentistry_ beauty & science

24 I I case report _ direct restorative procedures Subsequently, we created a palatal silicone key ontooth#11withtheappropriateshapeandocclu- sion. Once in place intra-orally, this key helped to createthepalatalwalloftherestorationinonestep. Thekeyincludedtheteethadjacenttothetooththat needed to be restored and covered the incisal area. _Preparation and application of the adhesive The existing restoration was removed with the help of both rotary and ultrasonic instruments and with care to prevent any damage to the adjacent teeth. During the preparation of the tooth, the mechanical properties of the material used and the aesthetic integration needed to be taken into ac- count. In the case of IPS Empress Direct, the ideal preparation design involved a vestibular chamfer and a straight, right-angle proximal and palatal margin (Fig. 4). Before proceeding with the adhesive cementa- tion, it was necessary to protect the operatory field from saliva or blood in the oral cavity. Therefore, we isolated the anterior teeth, including the canines, with a rubber dam. The expanded treatment area allowed us to assess the incisal line, and the size and shape of the adjacent teeth. We checked whether the silicone key could be positioned exactly. (If required, interfering areas can be adjusted using a scalpel until a precise fit is achieved.)Theenamelareaswereetchedfor30sec- ondsandthedentinefor15seconds.Bothwerethen thoroughly rinsed and dried. Subsequently, the adhesive was applied, while the adjacent teeth were protected with a metal matrix. We used the ExciTE F total-etch adhesive (Ivoclar Vivadent) for this step. Owing to the non- retentive preparation design and the fact that most of the restoration would be created on enamel, this type of adhesive proved superior to self-etching products. In order to facilitate penetration into the dentine tubules, the adhesive was gently massaged into the cavity walls. (After the adhesive has dried, thecavitymustexhibitaglossyappearance.Ifthisis not the case, the procedure needs to be repeated.) Theadhesivewasthenlight-curedfor10seconds with a bluephase curing light (Ivoclar Vivadent). _Building up the palatal and proximal walls As a first step, the palatal enamel was built up. A thin layer of enamel material (shade A2) of less than 0.5 mm was applied to the palatal key and smoothed out with a brush. Then the key loaded with composite material was placed in the mouth and the fit was checked again. If necessary, the material may be modified before it is polymerised for 10 seconds. The palatal wall created in the process showed the exact desired shade and did not touch the ad- jacent teeth (Fig. 5). Applying a thin layer of enamel material (A2) to the proximal walls changed the complex cavity into a simple one. In order to create the thin layer, we fixed a transparent matrix in place with a wooden wedge, which allowed us to create the transition lines (the convex area that separates the proximal from the vestibular area)—the restorative outcome is influenced by the successful design of these transitionalareasbecauseitisnotpossibletodesign them with rotary instruments. We then applied compositematerialfromthedistalsideoftooth#11, while tightening the matrix from the opposite side and polymerising the material in this position (Fig. 6). Thus, sufficient composite material could be added until the desired transition area was achieved. The mesial side was built up in the same manner (Fig. 7). _Building up the dentine core Using dentine materials, a restoration is created that shows decreasing saturation from the cervical Fig. 9_Application of dentine material in shade A2. The previous layer was entirely covered with this material. Fig. 10_Application of a covering layer of enamel material in shade A2. cosmeticdentistry 2_2013 Fig. 9 Fig. 10