Please activate JavaScript!
Please install Adobe Flash Player, click here for download

Dental Tribune Middle East & Africa Edition No. 3 2015

34 Dental Tribune Middle East & Africa Edition | May-June 2015aesthetics < Page 33 clinically. Necessary digital photographs were taken, along with diagnostic study models for further exploration of exist- ing diseases, force elements and aesthetic defects. The patient had good oral health, normal function and no para-functional or other destructive oral habits. The collected clinical and di- agnostic information, such as extra and intra-oral digital pho- tographs, study models and X- rays, was further analysed to determine her smile aesthetic grading in terms of her health, function and aesthetics, as well as to gain an overview of the clinical problems and the mac- ro-, mini- and micro-smile de- fects. We found a high frenum attachment and the space analy- sis of the study model revealed a MD of 3.5 mm between teeth #12 and 21. The tooth-size ratio of the centrals was nearly 65 % and lacked central dominance. In the design step, a new smile with a closed gap was designed. It is to be noted that the upper central incisors are considered key to a smile10,11 and must be given sufficient prominence.12 The aesthetically acceptable width of the centrals is between 75%and80%oftheirlength.12 In the presented case, it was logical to close the diastema completely by increasing the width of the centrals. The types of treatment involved, complexity, possible risk factors, complications and treatment limitation were eval- uated, and the tentative costs calculated and presented to the patient. The new smile was proposed throughthemodifieddigitalpho- tographs and aesthetic mock-up of the study model. In order to correct her MD, a frenectomy with non-invasive indirect par- tial veneers was proposed as the first option and a direct-bonding restoration without frenectomy as the second option. However, because of financial constraints, the patient preferred the second option. All patient queries related to the proposed new smile and treat- ment modalities were addressed in detail. The informed consent form was signed prior to pro- ceeding to Phase II. Phase II: Achieve In the first step, the patient’s health, function and a healthy lifestyle were established. The patient’s smile was graded as Grade B.8 The established pa- rameters of her oral health and function were within normal limits, the aesthetic parameters were below the accepted level and enhancement treatment was to improve her aesthetic pa- rameters further. Hence, in this case, it was not necessary to un- dergo establishment treatment (like orthodontic, periodontal, occlusal adjustment, etc.) be- fore proceeding to the aesthetic enhancement step. According to MICD TP, the desire of the patient in this case was need- based or naturo-mimetic smile enhancement. Direct-bonding restoration The direct-bonding restora- tion technique represents the preferred therapeutic option in MICD. It preserves maximal tooth structure and helps to re- store function and aesthetics in only a few clinical visits. In addi- tion, the technique is economi- cal and the possible need for so- phisticated indirect restoration can be postponed. Direct-bond- ing restorations demand excel- lent clinical skills. The clinician is required to incorporate vari- ous clinical techniques, tips and tricks. Following, I would like to demonstrate a simple technique that I have applied since 2005 in various clinical scenarios and find helpful for the upgrade of clinicians’ restorative skills. The Flowable Frame Technique The FFT is a simple restorative technique developed to speed up the placement and simplified confinement of material when restoring challenging anterior aesthetic cases such as large Class IV or Class III defects and diastema closure or reduction. As the name suggests, this tech- nique requires flowable com- posite resin as frame material, a plastic strip, composite brush and other usual instruments for direct resin restorations. Clinical steps in the Flowable Frame Technique The following steps are to be taken: Step 1 After the completion of etch- ing, priming and bonding of the tooth surfaces, insert a simple plastic strip to the level of gingi- val sulcus of the tooth to be re- stored (Fig. 2). Step 2 Support the plastic matrix strip lingually with your index finger to create a lingual contour (Fig. 3). Step 3 Inject the flowable composite resin of desired shade (either opacious or translucent) and smooth it to a thin layer with a hand instrument or a composite brush if necessary (Fig. 4). Step 4 Light cure the flowable compos- ite and remove the plastic strip. A flowable frame is now ready (Figs. 5 & 6). The length, shape and thickness of the flowable frame can be adjusted using the sharp edge of the hand instru- ment or a diamond point if re- quired. The advantages of the FFT are: - time and cost saving (no direct or indirect mockup required); - thickness of the layer of restor- ing materials (dentine, enamel and opacious group) can be pre- dicted; - as with the silicone template method, an opaque halo, ma- melons, and translucent areas in the proximal and incisal areas can be created; - smooth palatal surface is achieved with minimal finish- ing; - smooth adaptation of the resto- rations can be achieved even in the gingival sulcus; - it is the most suitable lingual frame creation technique for di- astema reduction or closure. Material selection and clinical steps for diastema closure Material selection for diastema closure should be guided by op- tical properties (light transmis- sion and diffusion characteris- tics) and tissue responses of the materials (restoration in dias- tema closure normally touches the gingival tissue and sulcus). Amongst the various materials available, giomers are amongst the latest category of micro-hy- brid lightcured restorative mate- rials and are touted as the true hybridisation of glass ionomers and composite resins. They have the fluoride release and recharge of glass ionomers and the aesthetics (shade, polish and optical properties), handling and physical properties of composite resins. Giomer restorative and adhesive systems have good bio- compatibility13 and have been reported not to result in long- term post operative sensitivity.14 They have also been found to possess anti-plaque formation properties.15 Hence, giomer direct-restorative materials and adhesive systems were selected to close the MD in this case. Beautifil Flow Shade #A3T with giomer adhesive system FL-Bond II (SHOFU Inc.) were used in FFT to create the lingual frame. Beautifil II (SHOFU Inc.) dentine shade A1 and enamel shade Inc. were used to restore the defects using the bi-layered shading technique to achieve the desired aesthetics with an invisible restoration. The Direct Cosmetic Restoration Kit and the Super-Snap Rainbow Technique Kit (both SHOFU Inc.) were used to prepare the teeth and to finish and polish the final restorations (Figs. 7–22). Phase III: Keep in touch After completion of the treat- ment, the importance and role of the keep-in-touch concept to the long-term success of aesthetic enhancement rocedures were briefly explained to the patient. She was advised to continue her normal oral hygiene procedures and shown how to keep the in- terdental space of the closed diastema clean. In the final step of MICD TP, the patient was re- quested to fill out the MICD clin- ical evaluation form. The patient evaluated her new smile as ex- cellent and mentioned that she was fully satisfied with the over- all clinical services at our centre. The MICD summary ten (Table 1 ) helps to evaluate the overall success of the case. Conclusion Diastema closure or reduction in clinical practice requires de- tailed case analysis. The suc- cessful treatment of diastemata depends on etiological factors, size and extent of the diastema, and the patient’s affordability in terms of treatment time and costs involved. The MICD TP guides the clinician and the pa- tient and helps both to under- stand, plan and complete the clinical case using diagnosis and treatment modalities that are the least inva sive in order to preserve sound tooth structure and achieve natural aesthetics, considering the patient’s best interests. Editorial note: A complete list of references and the MICD forms are available from the publisher. Fig. 12. FL Bond II and not FL Bond. Fig. 14. Injection of flowable resin (Beautifil Flow shade A3T). Fig. 13. Placement of plastic strip for FFT. Table 1 Fig. 15. Adjustment of lingual frame with sharp hand instrument. Fig. 16. Application of Beautifil II entine shade A1. Fig. 18. Application of enamel layer in Beautifil II shade Inc. Fig. 20. Lingual frame created on tooth #21. Fig. 22. Final smile. Fig. 17. Dentine layer is smoothed with a brush and light cured. Fig. 19. Tooth #12 after final restora- tion. Fig. 21. Teeth #12 and 21 after finish- ing and polishing. MICD summary ten 1. SMILE SELF-EVALUATION: BELOW SATISFACTORY 2. SMILE GRADE: B 3. TREATMENT CATEGORY: TYPE I 4. TREATMENT COMPLEXITY: GRADE I 5. PROPOSED TREATMENT: ACCEPTED 6. ESTABLISHMENT OUTCOME: NOT APPLICABLE (N/A) 7. SMILE RE-EVALUATION: N/A 8. ENHANCEMENT CATEGORY: NATURO-MIMETIC (NEED-BASED) 9. EXIT REMARKS: EXCELLENT 10. CLINICAL SUCCESS: SATISFACTORY Visiting Professor , Faculty of Dentistry Thammasasrt University, Thailand. President: Vedic Institute of Smile Aesthetics ( VISA) President: Asian Academy of Aesthetic Dentistry ( AAAD) Chairman: National Dental Hos- pital , Kathmandu , Nepal Global Coordinator: MiCD Global Academy E: drsushilkoirala@gmail.com Contact Information

Pages Overview