Flowable Direct Composite Restorations

Using SMILEFY as a 3D Print-Ready Treatment Planning Tool

Case Report by: 

Dr. Diogo Alves, DDS

Dr. Cinthia Amorim, DDS

1. Definition

Recently, in direct composite resin restorations, new techniques have been used in conjunction with digital tools to generate more conservative and faster results according to the patient’s concerns and expectations.

This clinical case shows you how to successfully implement SmileFy into the digital workflow of a no-prep direct injectable composite resin technique to increase teeth volume and close diastemas. The advantage of generating the models from SmileFy is that one of the models has the entire mock-up and the other gives you separate teeth to make it easier for you to isolate and perform the treatment.

2. The Case

A male patient came to the clinic expressing dissatisfaction with the shape and size of his upper anterior teeth, as well as the diastemas between his upper centrals. It was noted that on the right central incisor, an endodontic treatment was performed years ago which darkened the tooth shade. Due to several trials on internal bleachings in the past, the patient was very concerned about preparing any tooth for restorations as well as any periodontal surgery that may come with the proposed treatment. The goal was to initiate a treatment plan that would allow the dentists to perform a non-invasive technique that would improve the overall appearance of the patient’s smile, while respecting the patient’s desires.

After taking clinical and complementary exams, to begin the treatment plan, a frontal facial picture and an upper and lower intraoral scan were taken and uploaded into the digital smile planning program (SmileFy App) to create a digital version of the patient’s face and mouth with a goal of creating Digital Wax-up for the proposed treatment ( non-invasive composite restorations) 

The 3D Smile Design Planning took 2 steps: 

  • Calibration of the patient’s digital files 
  • Selection of 3D teeth & design edits to correct the patients dissatisfaction

2.1. Files Calibration

With the intraoral scan and photo being calibrated, we were able to fully visualize the cervical margins of the teeth’s soft tissues since the lips were partially covering the teeth and gum area in the photo. ( Fig.1, 2)

Fig. 1
Fig. 2

As this was an additive case, to determine the arch form an occlusal curve line was placed on the edge of the buccal cusps of the posterior teeth and incisal edge of the incisors with the goal of expanding the inclination of the buccal segments to give more volume and harmony to the buccal corridor area. ( fig.3)

Fig. 3

A 3D smile frame first outlines the patient’s intraoral scan which will then set the future 3D teeth positions, width, height, and midline. Then the number of teeth for this case were selected and automatically placed onto the STL to begin the design. ( fig. 4A,4B,4C)

Fig. 4A
Fig. 4B
Fig. 4C

2.2. 3D Teeth Selection & Design

Using the facial analysis tool in the application the dentist was able to determine the patient’s facial midline by drawing a line connecting the glabella, nose bridge, philtrum, and chin. This allows the dentist to establish harmony and balance between the facial structures and current dental midline. Additionally, the interpupillary line was determined for parallelism analysis in conjunction with the intercommissural line to guide the practitioner on the current position of the patient’s occlusal plane from a frontal view, helping you align the teeth better according to the facial landmarks. (fig.5)

Fig. 5

To choose the teeth shapes, SmileFy offers an extensive selection of natural teeth formats which allow the dentist to choose the right tooth shape that would best fit the patient’s unique facial features. (fig.6)

Fig. 6

The teeth shapes can be individually viewed from a screen preview that lets the smile designer find details on the tooth such as mamelons and grooves he is projecting for the planning. (fig.7)

Fig. 7

For this particular case both the doctor and patient selected [F08 – Jan Hajto].

To ensure quality of the design, different views of the 3D project are accessible, allowing the smile designer to move the tooth and have a visual reference of its position from various angles and the buccal volume of the anterior teeth. (fig.8)

Fig. 8

Once proper shape, position, and form were selected and adjusted, the design was fine-tuned using the mesh editor tool of SmileFy. The Mesh Editor is a free-hand digital wax-up made to help the designer check on contouring of the teeth design, contact points, thickness of the restoration, and it also allows you to add or remove excess of the design prior to printing, reducing chair-side time when performing the restorations. (fig.9A,9B,9C,9D)

Fig. 9A
Fig. 9B
Fig. 9C
Fig. 9D

The design was completed and saved.

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Exporting the Design to print

SmileFy provides many different export options that go from exporting the digital wax-up as a solid model, provisional shells, single tooth files, and injected mockup technique files (all selected 3D teeth from SmileFy and the patient’s original files are exported into a separate folder). (Fig.10)

Fig. 10

To export the files before sending them to the printer, the injected mockup technique files were selected and two models were 3D printed: one based on a wax-up of every other tooth, and the second model a complete dental wax-up. ( Fig. 11A,11,B)

Fig. 11A
Fig. 11B

Clear PVS impression material was used to create a clear custom index of the printed models and then placed in a 1.5-bar pressure pot to ensure the optimal fit and contours.

The Procedure

A cleaning with pumice and water was performed to clean the dental surface and increase the adhesion to the new resurfaces. Relative isolation was carried out.

Tape for dental isolation (Teflon tape)  was used to protect teeth. Non-isolated teeth were etched with 37.5% phosphoric acid semi gel for 15 seconds, and gently air-dried for 5 seconds. It was then washed, dried, adhered, and light-cured for 3 seconds (Elipar™ DeepCure-S LED Curing Light, 3M).  ( Fig. 12)

Fig. 12

The transparent index was placed in the patient’s mouth and held firmly while the flowable composite resin (Tetric evo-Flow, Ivoclar shade B1) was injected through the access hole of the incisal edge, filling the entire surface. The same step was performed on the other teeth. ( Fig.13A,13B)

Fig. 13A

As the matrix was held, each composite restoration was light-cured through the clear resin matrix for 20 seconds on the facial and 20 seconds on the occlusal/lingual surface.

Fig. 13B

The transparent index was taken out, and the excess flash was removed with a bladed instrument. The teflon tape of the adjacent teeth were removed while a fine metal finishing strip was used to create space in the interproximal areas.  A Cylinder Round End bur was used to inspect not only the emergency profile but the interface for marginal Integrity during gingival retraction in order to give the natural and anatomical facial contour of the buccal surface. 

The same procedure was conducted on the originally isolated teeth.

After fabrication of all the composite restorations, a glycerin-based gel  was applied onto the surface of the restorations to inhibit the layer of oxygen and light cure it for 5 seconds. 

To Inspect the occlusion, the patient was sat in an upright position and in centric occlusion an inspection for any premature contacts in the excursive guidance were evaluated. No adjustments were made to the buccal anatomy.  

Fig. 14A
Fig. 14B
Fig. 14C

The occlusal bite and guidelines were checked to ensure that the final result was functional, harmonic, and aesthetically pleasing.

Fig. 15

3. Discussion

With recent improvements in properties such as shrinkage and microleakage, flowable composite now offers reliability similar to conventional composite.

Due to the excellent handling and sculpting properties, injectable composite restorations have become a popular dental technique providing very predictable outcomes where the flowable composite is applied over the patient’s teeth using a transparent matrix.  

The flowable composite technique can be used for several applications, including repair of fractured teeth, long-term provisional restorations, and even final restorations.

Fig. 16A
Fig. 16B
Fig. 16C

Additionally, since the treatment is planned digitally first, the patient can request modifications on the teeth design before receiving the final restorations. If time permits, and if needed,  a mock-up trial can be performed on the patient to ensure no surprises on the day of the actual procedure using the same 3D fully designed mock-up model.

4.Conclusion

As the need for cosmetic treatments grows, performing minimally invasive flowable composite veneers is an easy and cost-efficient solution that practitioners can offer as a service for those patients that can benefit from such treatment. By implementing digital tools such as SmileFy, it allows dental practitioners to supplement their dental knowledge and know-how to create smiles that give patients confidence in a satisfying end result.

About SmileFy

SmileFy is a Smile Design Plataform that has been presented as a solution to improve diagnostic views and communications, and to deliver dental mockups that are facially guided to achieve natural appearance with the facial aspects and demands of the patient. With simple steps, the Smile Design requires only intraoral scans and facial photograph of the patient that allows the doctor to evaluate and choose different teeth shapes, sizes and customize digital treatment plans that helps on fastening the workflow as it’s done in-office and reduce overall dissatisfaction by the clinician and most important, by the patient.

Authors

Dr. Diogo Alves, DDS

Clinical Content Specialist – SmileFy

Specialization in Surgical Implantology and Prosthesis – UFPR

MBA in Strategic Management – FGV

Partner at ISO Angra Dental Clinic – Brazil

Dr. Cinthia Amorim, DDS

Specialization in Endodontics – UNESA

Specialization in Prosthodontics – UVA 

Owner of Amorim Dental Clinic – Brazil

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