Aesthetic restorative masterclass: direct vs indirect

The Core > Clinical articles > Aesthetic restorative masterclass: direct vs indirect

Published: 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:

Aesthetic restorative case - pre-op

Aesthetic restorative case - post-bleaching

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

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.

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.

Aesthetic restorative masterclass: direct vs indirect

Indirect restorations

Direct restorations

Summary

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