THEORETICAL FRAMEWORK

RESTORATIONS OF BROKEN FRONT TEETH OR

OF CLASS IV
Class IV cavity restorations are those in which there is damage.
from the proximal surfaces of the anterior teeth compromising the edge
incisal. This type of restoration can have an infectious or traumatic etiology.

As an infectious etiology, extensive carious lesions that started in

the proximal surfaces that damage the incisal edge, as well as recurrent caries
of Class III cavity restorations in which, upon removing all the tissue
Cariado, the operator removes part of the incisal edge. (MILAGROS, 2009)

Regarding the traumatic etiology of this type of restoration, it is possible to mention

countless causes related to age, sex, socioeconomic factors
and predisposing factors, such as lip coverage and the degree of overjet.

The teeth with the highest incidence of trauma are the upper centrals, since
that are in a more frontal position, in addition to being the first tooth to erupt and,
as a result, they have a longer exposure time in the oral cavity.

The age range in which the most traumas occur is from 9 to 12.
years. The causes of traumatic injuries are very varied, where some are
quite well-known such as, for example, collisions against people or objects,
sports activities, violence, etc.

In cases of fractures in anterior teeth where the fragment is preserved

and intact, appropriately fitting with the remaining teeth, it is chosen to be cemented.

RESTORATIVE TECHNIQUE
The use of a stratified restorative technique, associated with the selection
correct resin allows the operator to obtain a restoration
imperceptible (CRUZ, 2010)

The stages preceding the actual restoration involve,

among other phases, by the preparation of a planning in which the operator goes
use the restorative technique with silicone guide and the freehand technique.
SILICONE MATRIX
If the front tooth is fractured, the professional has two options to
make the palatal guide: one option would be to take an impression with alginate,
empty with plaster and then build the restoration with wax or resin on the model
Of plaster.. The option is to restore the palatine guide of the fractured tooth with resin
directly composed in the mouth without the use of adhesives, then a
silicone printing. In case it is decided to carry out the restoration by hand
free, there is no need for the silicone guide to be made.

STUDY MODEL, DIAGNOSTIC WAXING AND MAKING OF THE

SILICONE MATRIX.

If the operator chooses to make the silicone guide from the diagnostic waxing,
The first step will be the printing for the creation of a model.
of study, in which the waxing will be carried out that will produce the desired shape
of the restoration. (UNAL, n.d.)

The silicone guide can also be made from a restorative trial.

diagnosis, performed directly in the patient's mouth, even if the shape of
If the ancient restoration is satisfactory, the matrix can be made by recording.
only the palatal surfaces of the teeth that are going to be restored and their
adjacent.

DEMARCATION OF OCCLUSAL CONTACTS.

Due to the possible involvement of the palatine surface, the verification and the
Memorization of the occlusal contacts becomes important.

PROPHYLAXIS OF THE AFFECTED TEETH

The prophylaxis of the involved teeth should be performed with pumice stone and water.
or other non-oily material.

COLOR SELECTION

The most common way to select a color using the visual method, what
it is based on the comparison of different nuances within the dental structure
remainder or adjacent and the color guide.

SELECTION OF THE COMPOSITE RESIN

It is important to select resins with good optical and mechanical properties.

that provides, besides resistance, the appropriate brightness and texture.

RESTORATIVE ESSAY AND CHROMATIC MAP

After defining the color, the resins to be used are selected. Being able to
opt for a restorative essay, aimed at evaluating whether the interaction between
the selected resins will provide the expected effects.

The restorative essay of an opportunity to evaluate color and shape. Also

is to serve as a model for the creation of the silicone mold. In this case, it
make the restorative freehand essay and confirm that it turned out well.
ANESTHESIA OF THE AFFECTED REGION

When necessary, we must use the appropriate anesthetic technique for the
involved region.

Isolation of the operative field

Adhesive procedures require a clean and dry field, which is why the
absolute isolation should always be the first choice.

However, in class IV restorations performed in the anterosuperior region and

with the margins separated from the gingival tissue, it is possible to achieve isolation
relative to cotton rolls and the use of retracting thread in the gingival sulcus of
dental element that is going to be restored.

Cavity Preparation and Protection of Adjacent Teeth

In class IV cavities due to fracture, the cavity preparation is minimal.
limiting itself to the removal of the fragile enamel prisms that may be
presents.

For class 4 carious cavities, all the decayed tissue must be removed, just like
that the weakened enamel prisms (remainders) that might have been left
in the cavity.

FINISH OF CAVITY PREPARATION

The finishing preparation should be done with carbide cutters, with cutters
fine-grained diamond-coated, the controversy is the bezel, some authors like Masioli
insist that it should not be done because the adhesive systems and the properties
The optics of the resins have improved.

Restoration proper

In the silicone matrix technique, the first resin increment is placed on

the silicone matrix with the purpose of forming the palatine wall.

It must be a thin layer of a resin with good mechanical resistance and with
optical properties similar to those of enamel. This increase must exceed
slightly the termination line of the preparation. the resin is in contact with
the palatal surface of the dental remnant along the entire margin of the preparation,
so that the increase does not fall once we remove the matrix.

FINISH, OCCLUSAL ADJUSTMENT AND POLISHING.

This stage begins with the removal of proximal excesses using burs.
fine grain, sandpaper strips of decreasing granulation. On the vestibular face of the...
fine and extra fine diamond strawberries, silicone discs of abrasiveness
decreasing.

After the removal of the isolation, we need to check the patient's occlusion.
and compare it with the initial contacts, the adjustment must be made through
wear of the restorative material until there is equilibrium in the contacts.

The final polishing is done after a minimum period of 24 hours. In this

stage, the texture, shine, and polish of the surfaces reign.

RESINFOR
A two-stage sealing technique is usually used. The first term,
a composite core is made and the dentin area is reconstructed without the use of
of the mold; then the preformed angle is filled with the material to prevent the
incorporation of pores and is brought to position in the tooth to allow for the
compositor flows over the bezel.
OPERATIONAL TECHNIQUES

Dental preparation should follow an orderly sequence of steps.

called operational times:

Preliminary maneuvers.
2. Opening and conformation
3. Deficient tissue excision
4. Dentinopulp protection
5. Retention
6. Wall finishing
7. Cleaning

PREVIOUS MANEUVERS

Before the carving of the tooth, various factors must be analyzed that will guide in
the correct treatment of that dental piece. These are the following:

Clinical study of choice as it has already been said, the weakening of the angle
Incisal can be evident or not. Proximal carious lesions usually begin
in the contact relationship zone or in the vicinity of the gum. In pieces
triangular dental contacts, whose contact relationship is more incisal, occurs
a more premature weakening of the angle due to the location of the choice more
close to it. In the opposite case, it happens in the pieces with cavities close to the
where they usually allow restoration without including the relationship of proximal contact.
Square-shaped teeth often show very extensive proximal lesions.
due to the larger surface area of contact. These can even occur without a
cavity by labial or lingual and the extent of the lesion will be visualized after
make the opening.

Transillumination is a very useful tool for observing the extent of cavities,

that will appear as a darker area proximally and it will be possible to determine the

commitment of the incisal angle.

OPENING AND FORMATION

We open it with a round bur, which removes the enamel.

without support and the angle weakened. It can also be performed with a tool.
rotating like a conical frustum at super high speed with cooling
aqueous.

With that, we bevel the piece so that it has good retention.

We can divide this type of preparation into two well-defined areas:

Proximal zone
Incisal angle area

In the area of the incisal angle and according to the dental remnant, the procedure is carried out.

the following way:

Round the weakened angle

Eliminate completely diagonally or eliminate vertically

EXCISION OF DEFICIENT TISSUE

It is performed with hand tools such as spoons or rotary instruments with burs.
smooth round ones, at low speed, of the largest size that fits in the cavity,
one must always remember the shape and size of the camera by consulting
the radiography to observe the proximity of the pulp horns.

Dentinopulpal Protection

The protection of the pulp dentin organ must be done with the cement.
photopolymerizable glass ionomer, which adheres to dental structures and
I tried excellent surface for the adhesion of the restoration.

When it is deep, a cement must first be placed in the deepest area.

of settable calcium hydroxide, acid resistant, that will protect the dentin organ
pulp of the residual acid of the glass ionomer.

RETENTION

There are three mechanisms:

Macro mechanical retention

In large preparations, retention is created in the angles of the proximal box.

trenches in rounded or in the form of a groove that connects them
buccal and lingual triads. They are performed with round burs No. 1/4 or 1/2 or with
hand-held instrument of appropriate size, this type of retention is rarely used
currently.

Additional anchors
If we consider the mechanical retention of the proximal box plus the micro retention
mechanics and adhesion are not enough for the stability of the restoration
(patients with unfavorable occlusion, bruxers, very extensive restorations,
For patients with sclerotic dentin, an additional anchor can be placed.

Micro-mechanical retention enamel dentin

Retentions are made using the technique of acid etching of the enamel and of the
dentin. To increase the surface of the enamel by etching, as well as to
improve the conditions of the enamel, a beveling of the cavity edge is performed with a
fine to medium speed tapered end mill. The bevel will have a minimum extension.
from 1 to 2 mm, depending on the amount of remaining tissues.

In many cases, this form of retention is the only one carried out in the
preparation and the sixth operative time is performed.

Wall finishing

in the finishing of walls of a class IV restoration used steps:

Bezel
Smoothing

The bezel serves the following purposes:

Increase the surface area of enamel by etching. This contributes to the micro
retention.
Improve the marginal sealing of the restoration.
Improve the aesthetic properties

The outer walls of the preparation will be smoothed with hand tools or
rotary at medium or low speed, braking the milling cutter at the cavity edge to
eliminate loose prisms.

CLEANING

It is continuously carried out in all operational times, with jets of water to

water and air spray to remove the dentin tissues that are being cut and the
dental mud. Surfactants, detergents, and antibacterial substances are used.
in hydroalcoholic solutions of the type of mouthwashes that contain
chlorhexidine or commercially prepared products specifically for this purpose. It should be

be cautious not to use with fluoride, as it can alter the action

of the etching acid on the surface of the enamel.

FREEHAND TECHNIQUE
The so-called freehand technique consists of working with few elements.
that help to shape the restoration; this technique is performed by
incremental technique or in a load according to the size of the lesion, it is created the

dental anatomy and returns the lost optical harmony. This procedure is
more suitable for small restorations. (PONCE, 2011)

The dental tissue is conditioned with the chosen adhesive system, protecting the
neighboring piece with a piece of matrix to prevent action on unwanted tissues.

The insertion of the composite applying the first layer to generate the palatal surface
with translucent material that emits glaze and is photoactivated, then a
second added to form the proximal face and then a layer is placed
dentin color to form the body, to finish the last color addition
nail polish.

In order to achieve the desired anatomical shape, it is worn down with stones.
fine-grain diamonds and/or flexible discs adjusting the convexities and the length
until achieving the final restoration. Then finishing maneuvers are carried out.
and polished.

ADHESIVE TECHNIQUE

Before applying the phosphoric acid, a Teflon band is placed over the tooth.
neighbor to prevent accidental recording. Phosphoric acid is placed in
enamel for 10 to 15 seconds, in dentin for 5 to 10 seconds, rinse
abundantly for a similar time, it dries without drying out the dentin and the
two-step or one-step adhesive system depending on the type used such as
indicate the manufacturer, polymerize.
At this moment, the enamel and dentin have been hybridized, and the process continues with the

material insertion.

MATRIX SYSTEM PLACEMENT

A matrix of acetate or polyester must be placed next to the tooth that is going to be
restore, held with a wooden wedge to serve as support for the resin
by palatine and by proximal.

INSERTION AND ADAPTATION OF COMPOSITE RESIN

The composite resin is carried to the preparation with appropriate spatulas and is adjusted.
with the incremental technique, layer or layer with a thickness of less than 2 mm.

The first increase is made on the axial wall that is in contact with the
pulp, using resin with characteristics of opaque dentin. (VILLAO, 2016)

The second increase is made in the palatine and subsequently in the vestibular.
take into account the same considerations as the previous technique described in the
reproduction of morphological details How are the developmental lobes or
dental molds and the types of resins indicated according to the tissue being used
replacing.

TERMINATION OF THE RESTORATION

It should be given vertical texture, marking the lobes and development grooves, and,
horizontal texture, simulating periquematies, with diamond grain tips
fine or multi-blade files with 12 leaves.
By giving texture to the restoration, the light is ensured, provoking an appearance
of a lighter tooth compatible with a young tooth.

In the reconstructed proximal wall, abrasive paper strips can be applied.

fine grain for finishing and extra fine for polishing.

To achieve shine, multiple carbide tips with 30 or 40 blades are used.

shape of a flame, lanceolate or truncated conical, silicone rubber tips, discs of
polished as it is made of felt, brushes, brushes and abrasive pastes.

POST OPERATIVE CONTROL,

After finishing the restoration, the absolute insulation is removed and is

control the occlusion just as it was done at the beginning as a preliminary maneuver. It is used the

film of articulation, achieving centric contact and laterality with the antagonists.
Abnormal contact points are removed with a multi-blade burr.

The proximal control is done with dental floss to check that there are no excesses.
of material and that the gingival finish is appropriate