Log in Register

Login to your account

Username *
Password *
Remember Me

Create an account

Fields marked with an asterisk (*) are required.
Name *
Username *
Password *
Verify password *
Email *
Verify email *
Captcha *

Captcha Image Reload image challenge


Aesthetic Dentistry

Authors : Dr. Neelam Mittal, Dr. Reema Malik.

Abstract

Restoration in the aesthetic zone is a demanding and technique sensitive procedure. Its success depends on operator’s skill, knowledge and also adhering to a systematic treatment approach. It is very important to replicate the tooth anatomy for proper aesthetics and function. The clinical report describes a treatment approach for aesthetically restoring peg shaped laterals using putty matrix technique.

Introduction

Anomalies in the tooth formation process during initiation or proliferation of the tooth bud cause hypodontia1.The congenital absence of 1 or more teeth without systemic disorders is generally considered an inherited dominant condition with varying expression 1. Aberrations in tooth morphology resulting from late disturbances during the differentiation process most commonly result in size variations 1-5.Peg-shaped or mesiodistally deficient maxillary lateral incisors demonstrate variation in the expression of the trait, although the gene(s) causing hypodontia are not known 1-5.

A peg lateral is defined as ‘‘an undersized, tapered, maxillary lateral incisor’’6 that may be associated with other dental anomalies, such as canine transposition and overretained deciduous teeth. Individuals with peg shaped lateral incisors are more prone to midline diastema due to distal drifting of the central incisors 7. Such individuals may exhibit otherwise normal dentitions unless other congenital etiologic factors or habits are present.

The occurrence of hypodontia together with the development of malformations of permanent teeth was found to be 4% 8. Several previous reports have described the association between the presence of peg-shaped maxillary lateral incisors and other developmental anomalies 3,5,9,10with one study(3) showing increased occurrence on the left side of the maxilla. Rate of occurrenceof peg-shaped lateral incisors has been reported to be higher than other developmental malformations of teeth. In a study by Backman and Wahlin11,the incidence of peg-shaped incisors was found to be 0.8% in 739 children. Inanother study, it was found to be 0.4% 12.

Restoration of peg lateral incisors have always been considered a challenge because of patient’s demands and aesthetic expectations13-14.Factors that should be taken into consideration in the type of treatment should be selected based on: functional and aesthetic requirements, need for extractions, the position of the canines, and the potential for coordinating restorative and orthodontic treatment 15.Various treatment options depending upon the clinical situation includes the following: 1 extraction of the peg-shaped tooth and orthodontic movement of the canine into the space of the lateral incisor; the canines can then be recontoured to resemble lateral incisors; 2 extraction followed by implant-supported restoration or a fixed partial denture (FPD); or 3 direct or indirect restoration of the peg lateral incisors to develop normal tooth morphology.

Restorative options include procedures such as porcelain veneers, metal-ceramic restorations, and all-ceramic crowns, as well as minimally invasive procedures such as direct resin composite bonding 13.Porcelain veneers have high abrasion resistance and color stability 16.Also, the properties of porcelain laminate veneer such as color, form, surface, individual characterization through internal and external staining,and the fact that these restorations can be further color corrected during cementation with special cement colors, make them an attractive treatment option 16.However, porcelain laminate veneers are relativelyexpensive16and more prone to fracture.

A conservative veneer technique is the application ofthe resin composite without tooth reduction. Resincomposite veneers can be altered and repolished in-situ, and this feature is very useful when subtle changesto the emergence angles are desirable. Resin composite veneers are more cost effective 16.

This clinical case report describes the systematic use of resin composite via putty matrix technique for restoring the aesthetic appearance ofpeg-shaped lateral incisor.

Report

A healthy 22 year-old female presented with malformed lateral incisors to the department of conservative dentistry and endodontics. Clinical examination revealed the presence of peg shaped lateral, good periodontal health, normal horizontal and vertical overlap and stable inter-cuspal relation (Fig. 1).The peg shaped lateral incisor was planned to restore with resin composite using putty matrix technique.

Fig 1 : Pre-operative view


Putty matrix technique: A diagnostic impression was made with alginate (Zelgan) and a study model was fabricated with dental stone (Fig 2). Mock waxup was performed with tooth colored carving wax (Fig 3). A high-viscosity putty index(D G honigum) was made from mock wax-up to aid in contouring the morphology of lateral incisor for better aesthetic results. Using #15 blade putty index was splittedmesio-distally. All the soft tissue imprints were removed to minimise the interferences while seating in the mouth. A1 shade was selected using vita shade guide. Rubber dam (GDC dental dam) was placed for proper isolation (Fig 4). Putty matrix was checked for fit and necessary adjustments were made (Fig 5). Mylar strips were used to isolate the adjacent teeth. All of the facial and lingual surface was etched using 37% phosphoric acid gel for 20 seconds. The gel was then rinsed off with water and lightly blown dried with air. Dentine bonding agent (Ivoclar-vivadent) was applied following manufacturer instructions prior to being light cured for 20 seconds.

 

 

Fig 2 : Pre-operative cast Fig 3 : Mock wax up
Fig 4 : Rubber dam isolation Fig 5 : Putty index try-in


Using the putty index thin layer of lingual composite was placed and light polymerised for 20 seconds. This led to creation of lingual wall which acted as a 3 dimensional framework to support the additional layers of composite. Composite restorative material was added layer by layer to sculpture the entire restoration using putty index intermittently. After the establishment of primary anatomy, occlusion was evaluated to rule out any premature contacts. Finishing was done using medium grit diamond bur followed by medium grit polishing discs (Shofu). Proximal line angles and contacts were contoured using finishing strips. The entire tooth was then polished with fine pumice on a rubber cup using firm pressure to aid the removal of any irregularities 17 (Fig 6).

 

 

Fig 6 : Post operative view


Discussion

Composite restorations offer a cost effective treatment alternative where esthetics is a major concern. The survival rates of these anterior composites were reported to be extremely satisfactory even in patients with worn dentition 18. With improvements in the bonding chemistry and introduction of nano-composites, it is speculated that the success rate of composites will improve even further. Wallset al 14 used resin composite laminate veneers for masking discoloration or hypoplasia of the anterior teeth of 68 patients. The treatment plan for the patients described consisted of retaining the peg-shaped right maxillary lateral incisor and restoring the natural tooth form with bonded composite. This conservative option was chosen because it preserved tooth structure. Resin composite restorations exhibit excellent physical properties, marginal integrity, and esthetics 19,20.Moreover, in comparisonto all-ceramic restorations, resin composite doesnot have the potential for catastrophic brittle fracture,nor does it cause abrasive wear of the opposing dentition 19-21. Other advantages of this type of treatmentare the lower cost compared to an indirect technique, and the reversible nature of this procedure, which allowsfor other treatment approaches in the future. A significantadvantage of resin composite restorations overother restorative materials is that repair may be possible intraorally without the risk of modifying aesthetics or mechanical performance.

Putty matrix technique allows for a Mock-up to be fabricated with great ease and short clinical time. A mock-up review of anticipated final restoration is an important tool of communication between the doctor and the patient. This technique has several advantages:

 

 

  1. Does not require sophisticated software or digital imaging.
  2. Requires minimum chair time for setting of material and trimming
  3. Patient can anticipate the results before hand.


The chair-side benefits of this matrix are acreation of precise contact and contour which minimizes later adjustments for occlusion, incisal edge and thickness determination. Also, Facial and lingual anatomy can very well be replicated using putty matrix as a guide. Lastly, the composite finishing and polishing protocol enabled a highly polished surface and resulted in a satisfied patient.

Conclusion

Restoration of any malformed teeth to be aesthetically acceptable,depends on adherence to a systematic approach outlined in the clinical technique. Putty matrix technique is not only simple and cost effective but also provides a method to communicate anticipated result to patients with ease.

References

  1. Arte S, Nieminen P, Pirinen S, Thesleff I, Peltonen L. Gene defect in hypodontia:exclusion of EGF, EGFR, and FGF-3 as candidate genes. J Dent Res1996;75:1346-52.
  2. Schmitz JH, Coffano R, Bruschi A. Restorative and orthodontic treatmentof maxillary peg incisors: a clinical report. J Prosthet Dent 2001;85:330-4.
  3. Peck L, Peck S, Attia Y. Maxillary canine-first premolar transposition,associated dental anomalies and genetic basis. Angle Orthod 1993;63:99-109.
  4. Kook YA, Park S, Sameshima GT. Peg-shaped and small lateral incisors notat higher risk for root resorption. Am J OrthodDentofacialOrthop 2003;123:253-8.
  5. Peck S, Peck L, Kataja M. Prevalence of tooth agenesis and peg-shapedmaxillary lateral incisor associated with palatally displaced canine(PDC) anomaly. Am J OrthodDentofacialOrthop 1996;110:441-3.

More References are available on request.