Re-treatment of a Fractured Central Incisor

A 28-year-old female patient presented to the practice with a fractured maxillary right central incisor (ie, tooth No. 8) that was missing the mesial portion of its incisal edge (Figure 1). She explained that she had fractured the tooth when she was younger and that it had been restored by a family dentist using "bonding." The previously placed resin composite restoration had debonded, and the patient indicated that she preferred to have the tooth restored to exhibit a more esthetic, natural look. After clinical and radiographic examination confirmed the healthy status of the tooth, it was determined that a simple composite restoration would be an appropriate treatment to rebuild the incisal edge.

Because tooth No. 8 had a mesial angulation, it was suggested to the patient that by recontouring the damaged mesial portion with the resin composite and then reducing the distal corner, a more favorable alignment could be achieved, creating a straighter appearance. The patient noted that she had always thought that she would someday straighten tooth No. 8 orthodontically but expressed that this procedure would satisfy her desire and agreed to treatment.³

Initially, a small increment of a single-shade composite (Venus^® Diamond ONE, Kulzer) was applied to the facial surface of the tooth without etching or bonding in order to ensure that the material would sufficiently provide optimized esthetics by picking up the shades of the surrounding tooth structures. This test increment was then light polymerized to confirm that the shade would remain acceptable even after polymerization (Figure 2). Upon approval of the shade match by the patient, the test increment was removed.

Using a micro air abrasion unit, the labial, lingual, and incisal surfaces of the tooth were cleaned and abraded in order to remove the aprismatic layer of uncut enamel surrounding the defect and increase the mechanical retention of the universal adhesive (Figure 3).⁴ A clear matrix strip was then placed interproximally to protect the mesial surface of tooth No. 9 and to assist in contouring the composite restorative. A selective etch technique was chosen, and phosphoric acid was applied to the enamel surfaces. After rinsing, drying, and isolation, the matrix strip was replaced, and a layer of universal adhesive (iBOND^® Universal, Kulzer) was applied, air thinned, and light polymerized (Figure 4).

Next, the single-shade composite was placed and sculpted, changing the contour of the mesial-facial line angle of the tooth and creating a straighter alignment in relation to tooth No. 9 (Figure 5). This composite was selected for its firmer consistency when compared with its counterpart (Venus^® Pearl ONE, Kulzer), which possesses a creamier consistency. Once all of the contours were established, the composite was light polymerized on all sides for 20 seconds (Figure 6).

Using multiple 12-bladed finishing burs, the distal incisal corner of tooth No. 8 was reduced to match the length of the distal incisal corner of tooth No. 9. This was followed by adjustments to the incisal, lingual, and labial surfaces of the restorative material. These adjustments created an optical illusion that made tooth No. 8 appear to be in proper alignment in the dental arch.

Finally, a series of rubber points and wheels were used to finish the restoration and accomplish a high final polish using polishing paste (Zircon-Brite, Dental Ventures of America, Inc). The patient expressed her pleasure with the esthetics of the restorative outcome (Figure 7).

In this case, the single-shade composite successfully mirrored the shades of the adjacent tooth structures to produce a final restoration that not only blended seamlessly into the surrounding dentition but also created the illusion of better alignment. The choice of this material eliminated the shade selection process and enabled the patient's goals to be achieved using a more efficient protocol.

Gregg A. Helvey, DDS, CDT
Master
Academy of General Dentistry
Adjunct Associate Professor
Virginia Commonwealth University
School of Dentistry
Richmond, Virginia
Private Practice
Middleburg, Virginia