Quick, aesthetic restoration
The Scottish Dental Show 2018 keynote speaker Monik Vasant presents a posterior restoration case in a patient found to have caries under an existing amalgam filling
A new patient in her early 30s attended for a check-up. A routine radiograph revealed caries under the amalgam filling on the upper right second premolar (UR5). When advised the tooth needed treatment, the patient revealed she had been unhappy with how it looked. The filling was very visible and shiny when she smiled. The dark appearance of the tooth also made her self-conscious. The patient had thought treatment would be long and expensive, so she hadn’t bothered to ask.
The options were to have another amalgam filling or a composite restoration. The patient was advised that further composite treatment could be needed buccally to mask any remaining grey discolouration, if she was not satisfied with the outcome. As she was concerned about the appearance of the tooth, the patient did not want an amalgam filling and decided to have the composite restoration.
After a local anaesthetic was given, rubber dam was placed, with a clamp on the UR6, exposing the UR 4, 5 and 6. This was secured in place with floss ties. The old amalgam and caries were removed. The final portion of discoloured dentine was left behind as it was very deep, but the pulp was not exposed and it was still firm.
A sectional matrix band was then positioned mesially on the UR5, with a wedge and separation ring (V-ring). Initially, the enamel periphery alone was etched with 37 per cent phosphoric acid for 15 seconds. Etch was applied to the rest of the cavity for a further 15 seconds, before rinsing. A cotton pledget was used to protect the dentine during the drying process, to ensure dry enamel and moist dentine.
A two-bottle adhesive, with separate primer and adhesive, was used to complete the preparation. The dentine was primed and left for 30 seconds. The adhesive was placed on both the enamel and dentine, and allowed to sit for
30 seconds before curing.
In this case, Venus Pearl composite was used. This material exhibits good levels of opacity to block out discolouration and excellent handling for posteriors, making it a very easy-to-use product.
In this restoration, a small amount of Venus Flow base liner was placed and cured. This was to mask the greyness and dark discolouration from the base of the cavity. Next a thin layer of Venus Pearl A2 shade was applied to build up the mesial wall against the matrix. The height was built up to the level of the adjacent marginal ridge. The material was then manipulated with a sharp probe at a 45 degree angle. This ensured the edge of the wall was not straight and the natural curved shape of the marginal ridge was maintained. The dentine mass was built up in increments with Venus Pearl ODC shade.
Enamel A2 shade was placed over the occlusal surfaces cusp by cusp. Complete separation of the masses was achieved by creating fissures down to the dentine layer, using a sharp probe. Secondary anatomy was manipulated into the unset material before light curing.
A mix of Venus Color ‘corn’ and ‘choco’ stains was applied to the fissures using a probe, and pressed in with a long- bristle brush. The excess was wiped away with a conventional micro-brush and the stain was cured. Highlights were placed on the ridges using Venus Color ‘white’ mixed with a little ‘corn’, to give a milky colour. Final adjustments were carried out before rough, dry polishing. The restoration was then sealed with a protective clear coating, covered with glycerine and cured.
In this case, the clinical outcome was good. The tooth is regularly monitored for vitality and the patient has had no problems with it. As the caries was so deep, in the long term the tooth may require root canal treatment, but it is currently sound. The patient was delighted with the result after having endured an unsightly amalgam filling for years.
FIGURE 1: A routine X-ray revealed caries under the amalgam filling in the upper right 5
FIGURE 2: The UR5 filling was very visible when she smiled and the dark appearance made her self-conscious
FIGURE 3: The old amalgam and caries were removed following rubber dam placement
FIGURE 4: Kulzer Venus Pearl A2 shade was applied to build up the mesial wall
FIGURE 5: Separation of the masses was achieved by creating fissures down to the dentine layer and then stain was applied
FIGURE 6: The patient was delighted with the result after having endured an unsightly amalgam filling for years
About the author
Dr Monik Vasant BChD MSc is a highly experienced clinician with a special interest in minimally invasive aesthetic dentistry. He has trained under many of the world’s leading clinicians and has an MSc in aesthetic and restorative dentistry.
He is the director of Freshdental,with sites in Central London and Greater Manchester.
Monik lectures globally on minimally invasive and adhesive dentistry. His highly regarded direct composite course “Totally composite” is held throughout the UK and internationally. He also runs a year long minimally invasive aesthetic dentistry course entitled ‘Totally Aesthetics’.
Monik is a global key opinion leader for several dental companies and has co-authored several books on various aspects of general practice.
Contact firstname.lastname@example.org or for course information and bookings, visit www.monikvasant.co.uk
Follow Monik on Instagram @drmonik
Monik is the keynote speaker at the Scottish Dental Show 2018, to be held at Braehead Arena on 27 and 28 April. He will be presenting two lectures on Friday 27 April, ‘Composite artistry’ and ‘Composites and digital dentistry’.
To find out more and to register for your FREE delegate pass that will get you access to 140 exhibition stands and more than 50 lecture and workshops sessions, with up to NINE hours of vCPD, visit www.sdshow.co.uk
Verifiable CPD Questions
Aims and objectives
To present a case describing cost-effective, minimally invasive treatment for replacing an amalgam filling
- To inform readers of a technique for masking discolouration caused by amalgam fillings
- To inform readers of an incremental composite restoration technique to achieve an aesthetic outcome.
- Readers will gain an understanding of techniques for providing cost-effective, minimally invasive treatment for replacing an amalgam filling.