July Clinician's Choice Onsert - 5

contacts of teeth #8 and 9. However, until the re-emerging diastema has
stabilized, the width of these teeth would be difficult to be determined. A
lingual matrix was fabricated utilizing the diagnostic wax-up by extruding
Template Ultra Quick Matrix Material (Clinician's Choice) along the
anterior lingual surface of maxillary model, up to and including the
facio-incisal line angle of the anterior teeth. While primarily used for the
fabrication of a provisional matrix, the accuracy of Template is ideal for
capturing the optimal lingual contours and incisal edges of teeth #8 and
9 established in the wax-up. The lingual matrix was replaced intra-orally
in order to check the accuracy of its fit. (FIG. 3) A line corresponding to
the incisal extent of the prepared teeth was scored onto the lingual matrix
using a sharp explorer. The lingual matrix was then set aside.
FIG. 4
FIG. 5
Once the existing midline
restorations were removed, a
starburst bevel was established
on the facial surfaces of teeth #8
and 9 using a F8888 (Brasseler)
fine diamond bur. A short bevel
was placed on the lingual of
these teeth.
A PrepStart air-abrasion system
(Danville) was used on the facial
and incisal to remove unwanted
tooth and composite debris and
aid in increasing the overall quality
of the adhesive bond.
FIG. 3
The lingual matrix is replaced on the prepared teeth
to verify its accuracy of fit. A lingual matrix, using
Template Ultra Quick Matrix Material (Clinician's
Choice), was made from the wax-up. This allowed
for the established, desired lingual contours and
incisal edge locations to be accurately transferred to
the preparations on teeth #8 and 9.
FIG. 6
The patient was anesthetized due to the removal of existing composite
as well as the possibility of wedge placement during the finishing stage.
Shade selection was achieved by placing small round samples of possible
composite shades onto the facial surface of teeth #8 and 9. These were
light-cured and a black and white photo of the selected shade was taken
to confirm the correct value of the shade. Evanesce composite (Clinician's
Choice) was selected for this case because of its handling qualities,
specifically its smoothness in spreading across the tooth surface, its ability
to easily blend into the surrounding tooth structure, its polishability, and
the absence of air bubbles. An Optragate Retractor (Ivoclar) provided a
clear, wide field that allows context for consistency in restoration shape,
inclination and emergence profile with the adjacent teeth. Existing
composite restorations were removed from the mesial surfaces of teeth
#8 and 9 using a F8888 fine diamond bur (Brasseler) at high speed while
establishing a starburst bevel on the facial surfaces. (FIG. 4) A coarse
Contours Finishing and Polishing Disc (Clinician's Choice) was used to
smooth out any sharp edges or points. Finally, a PrepStart (Danville) air
abraded the prepared surface to remove any enamel and composite debris
and enhance overall adhesion. (FIG. 5)
Mylar strips isolated teeth #8 and 9 from the adjacent teeth while the facial
and lingual surfaces were etched with 35% phosphoric acid for 20 seconds
(FIG. 6) then thoroughly rinsed. Adhese Universal (Ivoclar) adhesive
was applied to the etched surfaces (FIG. 7), air- thinned and light-cured.
The intent was to establish the desired length of the restored teeth first
by placing the lingual shelves, then closing the midline diastema before
finishing the incisal aspect of the restorations. A thin layer of Evanesce
Enamel White (Clinician's Choice) was placed into the incisal portion of
the matrix up to the scribed line for both teeth #8 and 9. This lingual
layer of Evanesce Incisal White, at 70% opacity, represents the ideal
translucency, contours, and occlusal contacts of the lingual enamel in this
case and served as a backstop for the subsequent application of the dentin
With a mylar strip providing
isolation from the adjacent teeth,
the facial surface of the tooth
was etched with 35% phosphoric
acid beyond the starburst
bevel, and carried over to the
lingual surface, for a total of 20
FIG. 7
Once the etch was thoroughly
rinsed from the prepared tooth, a
single layer of Adhese Universal
adhesive (Ivoclar) was scrubbed
onto the etched surface for 20
seconds, then air-thinned and
layer. The uncured, uniformly thin, lingual shelves are then attached to
the prepared teeth by replacing the lingual matrix back onto the teeth and
adapting the uncured composite onto the preparation using a #3 composite
brush lightly coated with ResinBlend LV (Clinician's Choice) and an REJ
#4 composite instrument (Clinician's Choice). (FIG. 8) The lingual shelf
was light-cured with the Template matrix in place.
With the incisal length established, restoring the midline diastema could
be completed with a more predictable proximal contour. Using a caliper,
the widths of the individual central incisors and the total distance from
their distal surface to distal surface was measured in order to determine
the ideal width of each individual restoration required to close the midline
diastema. There are several techniques for diastema closure. In my hands,
utilizing the pull-through technique with a mylar strip provides the most
control of proximal contact development and initial emergence profile. It is
essential to use a composite for this technique that has enhanced handling
characteristics in addition to being highly esthetic in order to be easily
manipulated into place and disappear into the surrounding tooth structure.
This technique was used on tooth #9 using a single layer of Evanesce
A1U composite (Clinician's Choice). The Evanesce A1U was extruded
onto the central area of the preparation and spread into place. An REJ #4
composite instrument and the Composite Ninja (Clinician's Choice) easily
sculpted and shaped the composite interproximally, limited by the mylar
strip. (FIG. 9) The pull-through technique was used at this point to create a

July Clinician's Choice Onsert

Table of Contents for the Digital Edition of July Clinician's Choice Onsert

July Clinician's Choice Onsert - Cover1
July Clinician's Choice Onsert - 2
July Clinician's Choice Onsert - Contents
July Clinician's Choice Onsert - 4
July Clinician's Choice Onsert - 5
July Clinician's Choice Onsert - 6
July Clinician's Choice Onsert - 7
July Clinician's Choice Onsert - 8
July Clinician's Choice Onsert - 9
July Clinician's Choice Onsert - 10
July Clinician's Choice Onsert - 11
July Clinician's Choice Onsert - 12
July Clinician's Choice Onsert - 13
July Clinician's Choice Onsert - 14
July Clinician's Choice Onsert - 15
July Clinician's Choice Onsert - 16
July Clinician's Choice Onsert - 17
July Clinician's Choice Onsert - 18
July Clinician's Choice Onsert - 19
July Clinician's Choice Onsert - Cover4