In my early years of practice, I remember when there was a heavy push for resin-based indirect restorations, like ArtGlass, belleGlass and Targus. While there may have been a place for these materials in the early days of metal-free dentistry, they posed challenges because they were composite resin materials.

When patients present with these types of materials that show esthetic degeneration, but no apparent functional or marginal compromise, is it essential to totally replace them with new indirect ceramic or PFM restorations?

Maybe; however, when a patient does not have the financial capability to pursue optimal dentistry, I believe that it is incumbent on the ethical dentist to "think outside of the box" and consider other reasonably appropriate options.

For example, the patient in these photos is well into her sunset years but very active in community activities. She had laboratory indirect resin crowns placed on her maxillary anterior teeth about 15 years ago and she loved the esthetics for several years. However, the veneering layer of resin began to separate from the substructure and staining compromised her smile.

When she presented to me a year or so ago, I discussed an optimal treatment plan to replace her anterior six crowns—an option she had been considering. However, her financial situation stumbled over the past year due to circumstances beyond her control. At a recent recall appointment, she expressed sincere desire to have her crowns replaced, but that would create an undue burden for her at this time, and she was concerned that they would not look the same as the crowns that she originally liked. She asked if there was anything else available to improve her smile.

After a thoughtful discussion, the patient and I decided to repair the crowns. She clearly understood that a repair is unpredictable and that an esthetic outcome that met her expectations would likely not be possible by repairing the old restorations. Our plan was essentially to resurface the facial aspects of the resin crowns on the maxillary anterior six teeth in an attempt to rejuvenate them.

Under rubber dam isolation, the failing veneer layer of resin was removed by air abrasion using aluminum oxide. Secondary anatomy relief was carved into the prepared facial surface with a rotary diamond and then re-abraded. After copious rinsing with water, Ultradent Silane was applied to the facial surfaces and allowed to dry. Scotchbond Universal was used because of its reported ability to bond to anything, including old composite resin. (Although this bonding agent has a silane coupling agent and may have been adequate, an additional layer of silane likely will not affect the bond adversely and may even improve it.)

Blue resin tint was placed on each tooth to create an incisal halo effect, and then Ultradent's enamel shade TransMist composite resin was applied as a facial veneer. After finishing and polishing the restorations and removing the dam, a handheld mirror was used for the reveal.

While much can be said in critique of the final result regarding contour and shading, the patient's goal was to regenerate the esthetics of the crowns she loved. In this particular case, rejuvenation, in my opinion, was the most appropriate treatment. The patient's comment at the reveal sums up how rewarding it is to listen to and understand the desires of our patients: "Oh, my gosh! I can smile again!"

Kevin D. Huff, DDS, MAGD, Spear Visiting Faculty. [ ]



Commenter's Profile Image Jason R. Tubo, DMD
February 7th, 2014
Very nice out-of-the-box thinking, Kevin… I'm hopeful your patient will be pleased with the refreshed surfaces for years to come! I would have followed precisely the same resin-to-resin bonding protocol that you just illustrated… until I went to Gregg Kinzer's Composites Workshop a couple weeks ago. Gregg and Gary DeWood showed that the extra silane step is not necessary - and it appears that it does adversely affect bonding. Obviously, following that protocol can still work - since that's what many of us have been doing for some time. Gary also showed the benefit of H3PO4 etching the abraded composite surface prior to applying the dentin bonding agent. So it looks like we can skip the step of silanating, but should add the step of H3PO4 etching, yielding a better resin-to-resin bond. Again - all of that was news to me as of 2 weeks ago; so I thought I'd spread the word. (Gary, did I get it right?) What you put together here was a great service to your patient. Congrats. Best, Jason
Commenter's Profile Image Kevin Huff
February 7th, 2014
Thanks, Jason. I've heard both approaches, and I would prefer not using the silane. I've heard several materials speakers discuss both, but I've never heard about it reducing the bond.... I trust Gary and Gregg any day, though.
Commenter's Profile Image Gerald Benjamin
February 8th, 2014
Unfortunately, many dentists lack skills with resin to keep the 'renewal' option on the table. Many insurance dependent dentists cannot earn an adequate income doing anything but indirect restorations. Direct resins permit us to place the most tooth conserving restorations which is what ideal dentistry is all about. The only thing that destroys more tooth structure than caries is dentistry