Dr. Kevin Brown

In this case study, a new single shade composite system (OMNICHROMA, Tokuyama Dental) was used in a full-mouth restoration of a young man who experienced amelogenesis imperfecta (AI). AI is a hereditary condition that affects the amount and quality of dental enamel and can range from mild to severe. For patients with AI, the chief complaints can range from tooth hypersensitivity and poor occlusion to esthetic concerns. From the perspective of the restorative dentist, AI is frustrating because of the lack of enamel quantity and quality to which restorations can be bonded. Although there are a few ways to treat a patient with AI, this case study will explore the option of an indirect-direct technique using a universal single-shade composite system.

A universal composite formulated to match every shade from A1 to D4.

Its Smart Chromatic Technology utilizes supra-nano spherical fillers to shade match.

Said to exhibit exceptional handling and polishability.

This was a highly unusual case that could have been completed in any number of ways with any number of materials. The primary dentist is a pediatric dentist and has been treating and managing the patient’s dental condition since his youth. The patient’s AI was quite severe and resulted in generalized hypersensitivity to touch, temperature, and air, among other complaints. He had no occlusal function, and chewing normal foods was a challenge. As he grew old enough to start noticing the darker color of his teeth, he became somewhat self-conscious about his smile. His father also has AI and has full coverage porcelain restorations on all his teeth. For this young man, who was still developing, it isn’t the right decision to do full coverage porcelain at this point in his life, primarily due to cost of treatment and he hasn’t finished growing. Both the patient and his father were looking for a more conservative treatment option to get him by until he is older and ready for a more comprehensive and long-term treatment with porcelain.

His pediatric dentist did direct composite veneers on teeth 7 to 10 and 23 to 26 but, because of the AI, the composite frequently flaked or chipped (

). His arch form was very constricted and lingualized (

). So, his dentist tried to do braces to improve his tooth position so restorations could be ideally placed. However, because of the poor bonding surface from the AI, the brackets would frequently pop off, and the treatment was never fully completed.

The pediatric dentist knew of a possible technique that could help this young man and reached out to a colleague to see whether they would be willing to help. The orthodontist sent 3D-printed models of the patient along with a wax bite registration. The models were mounted to an articulator, and a diagnostic wax-up was completed to open up the vertical dimension of the bite and establish a more functional and esthetic position and shape of the teeth. The wax-up then served as the blueprint going forward (

Because this patient had to drive 3 hours to be treated by this dentist, a lot of pretreatment planning was required, and the material selection had to be considered. In addition to this, the patient would require full sedation, limiting the overall treatment time to around 5 hours by the anesthesiologist, and all treatment would need to be completed in 1 visit.

indirect porcelain crowns: not an option due to cost and multiple visits and travel,

indirect composite crowns: not an option due to multiple visits and travel,

direct composite crowns: good option but very challenging to do in the limited time of the single visit with full sedation, and

indirect-direct composite crowns: best option to be done within the time frame and budget.

Just about any composite system could have been used for this application, but the main desired characteristics were strength, ease of use, and esthetics, in that order. These restorations were only expected to last 7 to 10 years until the patient would be ready for porcelain.

OMNICHROMA Technique 

For the indirect-direct technique, a translucent polyvinyl siloxane material and translucent impression tray were used to take an impression of the wax-up. A stone model of the patient’s existing teeth was lightly modified to resolve any undercuts and then coated with petroleum jelly to prevent any composite resin from adhering to the stone (

). The translucent impression of the wax-up was filled with OMNICHROMA and placed over the lubricated stone model, and the composite was light cured through the translucent material (

). This was done for the entire upper and lower arch of teeth to create a shell (

On the day of treatment, the patient was under general anesthesia with nasal intubation, which made it challenging to work with a bite block in 1 side. This is why an indirect-direct technique was necessary. There was some existing composite on teeth 7 to 10 and 23 to 26 and a few other spots in the posterior where the orthodontist made occlusal stops. These composites were removed, and any other undercuts were resolved, and the composite shells were tried to verify the fit (

A maxillary and mandibular full-arch impression was taken and poured up in fast-set stone (Snap-Stone from Whip Mix). The models were then coated with petroleum jelly, and the intaglio of the composite shells were coated with bonding resin (Tokuyama Universal Bond from Tokuyama Dental), filled with a flowable composite (Estelite Universal Flow, Medium Viscosity from Tokuyama Dental), and seated over the stone model with firm pressure (

). The excess flowable resin was removed with a microbrush before light curing 

). Once the prefabricated composite shells were relined and tried back in the mouth for fit verification, each tooth was carefully sectioned, trimmed, and polished to be an individual unit (

The individual crowns were then cemented in the mouth in quadrants using the same flowable composite as cement (

). The teeth were cleaned with a pumice, a prophy cup, and air abrasion (MicroEtcher II, Danville) to ensure the best possible bonding surface for the restorations. It is very difficult to cement a composite crown in the mouth using a resin cement as the resin will bond to the composite and be very difficult to clean, especially interproximally. The composite crowns were polished to a high shine, and the bonding resin for the intaglio of each crown was carefully placed, so no excess resin flowed onto the surface of the crown to minimize unwanted resin cement bonding. Only 3 or 4 restorations were cemented at a time to help control the cleanup of excess flowable composite cement.

After all the crowns were cemented, a mosquito tip diamond bur was used to smooth all facial and lingual margins. Then, composite polishing cups, disks, and points were used to polish the restorations sufficiently to be comfortable. Because time was running out and the anesthesiologist didn’t want the patient under for too long, final texturizing and polishing would wait for a follow-up visit when the patient wouldn’t have to be sedated. Occlusion was impossible to evaluate while the patient was sedated, and even when he awoke, he was too groggy to occlude reliably. He had never had a normal bite in his life, so he had no reference for what normal felt like. So, the patient was dismissed, and he and his family decided to stay the night at a hotel and leave the next morning. This way, he was able to have the dentist check the bite later that night when he was awake and had half of a day to test things out. Only minor adjustments were needed. The pediatric dentist would also be able to make any other minor adjustments as needed.

shows immediate results post cementation, and 

 illustrates the patient’s 1-month post-operative full smile.

Articles

OMNICHROMA from Tokuyama Dental was used on a young patient with a rare hereditary condition.

How to Use a Single-Shade Composite System in an Indirect Application

	Direct composite restorations are the most common procedure for the majority of general dental practices. Conventional dental composites achieve their color-matching capability by adding dyes or pigments to the mixture to provide a color range within the 16 shades of the VITA shade guide. Even within these 16 shades there are variations of opacity and translucency. When the correct shades are selected, the results can be excellent. However, the shade selection and application of the shades can vary from one dentist to the next. Additionally, the cost of keeping a current inventory for the variety of shades can become expensive and frustrating.

	To overcome this issue, Tokuyama Dental America has developed a single shade composite that utilizes “smart chromatic technology” that can match a wide range of natural teeth colors. Whereas traditional composites achieve their color chemically by adding colors into the mixture, OMNICHROMA achieves its color by using structural color. Structural color is expressed only by the physical properties of light (diffraction, refraction, interference, scattering, etc.) and not by pigments or dyes. This is done by controlling the size and shape of the filler particles so that they reflect color in the red-yellow spectrum. Once it’s cured onto a natural tooth, it will combine with the reflected light of the surrounding tooth structure in an additive color mixing process to achieve perfect color matching.

Related reading: The evolution of dental materials

	In the cases of typical small to even large composite restorations on posterior teeth that a general dental practice performs routinely, it would be easy to consider the use of a single-shade composite like OMNICHROMA in such applications because they generally aren’t visible in the smile zone. Using a single-shade composite on an anterior tooth where the patient and his or her family/friends can scrutinize it is much more demanding. Composite restoration in comthe anterior segment is an art unto itself. There are many hands-on courses dedicated to teaching the art of polychromatic layering of different shades and opacities to perfectly match a fractured front tooth, close diastemas, or to sculpt full composite veneers. Color selection and managing the thickness of these different layers is difficult and can lead to frustrating results if not done properly. On the other hand, if one is doing these types of anterior restorations using a single shade of a traditional composite, the results are most often less than stunning.

	So, how does OMNICHROMA compare to traditional composite in the anterior segment? Here are a few examples to illustrate.

	The first example shows the replacement of old Class III composites on teeth #6-11 that had discolored over the years while also improving tooth shape on tooth #10 (Figs. 1-3).â¯There was no decay, so it was decided to simply remove the visible portion of the old restorations and then add the new composite over the top of the old composite in an effort to minimize any pulpal trauma from drilling (Fig. 4).

	No anesthetic was needed for this procedure, which the patient appreciated. After the teeth were prepared, a light air abrasion (Danville) was used prior to the total etch and bond protocol (Figs. 5-6).

	This patient had some mild white decalcification spots, enough so that it made sense to recreate these within the composite for perfect blending. Beginning with teeth #7-8, an initial layer of OMNICHROMA was placed and cured but not to full contour (Fig. 7). A sable brush was then used to apply a white resin stain (Estelite Color, Tokuyama Dental America) to replicate the mild white effects, and a final thin layer of OMNICHROMA was then sculpted into place and light cured (Figs. 8-9).

	Teeth #6, 10 and 11 were layered in the same fashion. Finishing and polishing resulted in a seamless transition between enamel and restoration (Figs. 10-12.) This is a great case to show OMNICHROMA’s versatility as this patient had darker canines (A3.5) and lighter incisors (A2) and it was able to blend perfectly with the different shades.

Trending article: How to perform a void-free restoration

	In this next example, the patient had lots of wear from years of parafunctional habits and abrasion from opposing PFM crowns (Fig. 13). His treatment plan included restoration of full upper arch with indirect restorations to increase the vertical dimension and direct composite veneers on the lower anteriors to cover the exposed dentin and restore form and function. Eventually he’ll do indirect porcelain restorations on the lower anteriors, but to control cost and stage his treatment, direct composite was chosen, which can serve for many years in this case. Teeth #22-27 were prepared using a pumice slurry and prophy cup and light air abrasion (Danville). Tooth shade was determined to be between A3.5/A4. 

	A silicone putty index was fabricated from a diagnostic wax-up and used to create the lingual shelf of teeth #22-27 using the OMNICHROMA BLOCKER (Fig. 14). The purpose of OMNICHROMA BLOCKER is to prevent shade-matching interference caused by other parts of the mouth and to mask slight staining. Before completing the facial contour, a thin diamond IPR disc (Axis Dental) was used to separate and maintain incisal embrasures and interproximal contact (Fig. 15). A clear Mylar strip was then placed for separation as needed to complete the facial layers using OMNICHROMA one tooth at a time (Fig. 16). Finishing and polishing was completed with a variety of discs (3M ESPE), diamond and carbide burs (Axis) and composite polishers (Kerr) (Fig. 17).

	In today’s dental economy, it’s more important than ever to try and control overhead costs wherever you can. Keeping a full and current stock of traditional composites in a variety of shades can be costly and difficult to manage and maintain. As a single-shade universal composite, OMNICHROMA allows the dentist to forego the time and stress of shade selection and simplifies life for the assistant with composite ordering and maintenance. All of this also results in time and cost savings.

Tokuyama’s OMNICHROMA uses smart chromatic technology to match a wider range of natural teeth colors.  