Clinical articles

Aesthetic restorative masterclass: direct vs indirect

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Published on 31/10/2022

By Liv Schorah

Indirect restorations

85% of UK adults have restored teeth. 37% have crowned teeth, with an average of three per person in this group. It is estimated that there are 47.6 million crowned teeth in the UK, but unfortunately surveys report that over one quarter of these exhibit signs of failure, with secondary caries being the most common diagnosis.


Indirect restorations are associated with a range of widely documented disadvantages including poor longevity. The average indirect restoration lasts just ten years before replacement or extraction of the supporting tooth. Crown and bridgework is also responsible for the greatest proportion of negligence claims against dentists, accounting for the largest element of all damages and legal costs1:

Complications of indirect restorations

  • Poor longevity < 10 years

  • Prone to secondary caries (33% of failures)

  • High risk of iatrogenic damage to adjacent teeth (73%)

  • Increased risk of pulp death (~20%)

  • Increased risk of periodontitis, biological width violation and tooth loss

  • Routinely associated with gingival recession (1.2mm average at 2 months post-op)

  • Tooth wear of opposing teeth by ceramic restorations

  • Radiopacity frustrates radiographic monitoring

  • Poor aesthetic integration

  • Increased dento-legal risk

Direct restorations

Fortunately, younger patient cohorts have fewer crowns compared to older groups. The poor prognostic factors listed in the table above, coupled with the advantages of direct restorative techniques, mean that composite resin is the contemporary material of choice for the vast majority of anterior and posterior restorations:

Advantages of direct composite

  • Minimally invasive, adhesive procedure preserves maximum amount of tooth tissue

  • Equal or superior longevity to indirect restorations

  • Excellent aesthetic capability

  • Versatile (irrefutable evidence base for most procedures)

  • Cheaper to patient / single appointment

  • Increased patient satisfaction and operator control

  • No laboratory fee (↑profit margin)

  • Reduced microleakage

  • Similar physical properties to conventional porcelain (and amalgam)

  • Low thermal conductivity

  • Command set

  • May resist crack propagation / tooth fracture

  • Easier to reverse/renovate/repair

  • Accessibility for pulp-testing

  • Metal-free

  • Fewer endodontic complications

  • Reduced risk of catastrophic failure e.g. tooth fracture/loss

  • Reduced dento-legal risk

This clinical case demonstrates the materials, equipment and clinical techniques used to optimise the minimally invasive aesthetic direct restoration of anterior teeth:

Restorative dental teeth

Aesthetic restorative case - pre-op

Restorative dental teeth

Aesthetic restorative case - post-bleaching

Restorative dental teeth

Aesthetic restorative case - post-op

Direct composite veneers clinical stages

CLINICAL STAGE

DETAILS

EQUIPMENT/ MATERIALS/ CLINICAL TIPS

DIAGNOSIS

  • Erosive tooth wear

  • Dark, endodontically treated UR1

  • Enamel hypoplasia

  • Worn composite UL1

Preoperative clinical photographs enhance aesthetic diagnosis, assist patient communication, and form an important dento-legal record

SHADE SELECTION

  • Shade taken immediately to prevent dehydration

  • Vita™ Classical shade guide rearranged into value order to assist shade change monitoring

  • Pre- and post-op clinical images assist patient communication

TOOTH WHITENING

  • Inside/outside bleaching UR1

  • Home bleaching

Inside/outside bleaching

  • GP sealed with RMGI (Fuji II LC)

  • 6% Hydrogen peroxide / sectional bleaching tray (Every 1-2hrs for 7 days)

  • Tepe brush and hand mirror to aid gel application

Home bleaching

  • 16% Carbamide peroxide (2 weeks)

  • 10-day interval after review (before bonding)

REVIEW

  • Aesthetic co-diagnosis

  • Treatment plan

  • Consent

Clinical photographs demonstrate aesthetic improvement, assist discussion of treatment options and support documentation of valid consent

TOOTH PREPARATION

  • Conservative preparation limited to removal of existing restorative material UL1

  • Composite finishing burs (50µm- red band)

  • Copious water spray

  • Intermittent diagnostic etching, washing and drying and use of a blue light to detect restoration/tooth interface

ISOLATION & ADHESION

  • Soft tissue retraction

  • Universal adhesive application following manufacturer’s instructions

  • Isolated with Optragate™ (Ivoclar)

  • 37% phosphoric acid etch (SDI Super etch)

  • 30 seconds -unprepared enamel

  • 15 seconds -prepared enamel

  • iBond Universal™ (Kulzer)

DIRECT COMPOSITE VENEERS

  • Highly aesthetic nano-hybrid composite chosen for superior handling properties and polishability

  • Placement of each shade in singular increments

  • Restorations accurately shaped (slight over-build) to minimise excess/finishing time

  • IPS Empress Direct™ (Ivoclar) Shade BL-L (dentine & enamel)

  • Application with Optrasculpt™ instrument (Ivoclar)

  • Line angles defined with IPCL instrument (Cosmedent) and #3 Cosmedent brush with the aid of Composite Wetting Resin (Optident)

  • Single increment reduces risk of layers/voids and cavity c-factor minimises polymerisation shrinkage stress

LIGHT CURING

  • 60 second light cure

  • Full power/all angles

  • Light guide close and perpendicular to restoration surface

  • Valo™ (Optident)

  • LED output >1000 mW/cm²

  • Uniform beam profile

SHAPING/FINISHING

  • Minimal finishing of veneers completed using discs (gentle/intermittent)

  • Sof-Lex™ discs (3M ESPE)

  • Reusable metal interproximal finishing strips (Komet-yellow)

POLISHING

  • To high surface lustre

  • ASAP Pre-Polisher (purple)

  • ASAP Final High Shine Polisher (peach) (Optident)

REVIEW

  • Restoration assessment

    Patient feedback

    Refinements if necessary

    Long-term monitoring

  • Reinforce oral hygiene/maintenance instructions

  • Post-operative clinical photographs

  • Written consent for image publication/social media

Summary

Minimally invasive direct techniques have transformed restorative dentistry. They focus on biologically respectful interventions that are designed to address aetiological factors and maximise preservation of natural tooth tissue. They promote smaller restorations of increased longevity, that are easier to maintain and renovate and leave future restorative options open as required.


With an insurmountable evidence base, they demonstrate excellent biological, functional and aesthetic success and are a proven, cost-effective, replacement to traditional restorative techniques, which in many cases should now be considered as historical.

References

  1. Maglad AS, Wassell RW, Barclay SC, Walls AWG. Risk management in clinical practice. Part 3. Crowns and bridges: BDJ; Vol 209, No.3. Aug 2010.

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Liv Schorah

A Yorkshire-based GDP with an interest in aesthetic restorative and cosmetic dentistry, compares indirect and direct restorative techniques and provides a step-by-step guide for optimising minimally invasive direct composite veneers.

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