May 2017 Case Study

PATIENT BEFORE PHOTO Direct Composite Anterior
Restoration: Utilizing Putty Stent

By Ben F. Warner, MS, DDS, MD, FAGD

PATIENT AFTER PHOTO

INTRODUCTION ABSTRACT

Evidence-based dentistry brings together the An elderly patient presents with a fractured
expertise of the dentist, the needs and preferences maxillary lateral incisor. After assessing the patient,
of the patient, and currently available scientific explaining treatment options, and discussing the
evidence1. The MasterTrack® program2 offers a associated risks and benefits, the patient elects and
dentist the opportunity to be exposed to the consents to a direct composite restoration. Dentists
relevant literature, as well as, ask questions during regard the use of direct composite as the most
the lectures given by experts in the field. This newly conservative approach for restoring a damaged
acquired knowledge is then honed through tooth3. Knowledgeable dental assistants can help
directed and monitored hands-on workshops to with diagnostic impressions, quick-set models, and
become part of the dentist’s skillset. When integrat- putty stent procedures to restore the tooth. Good
ed with the patient’s values, the formulating of a clinical questions combined with well-trained
truly customized treatment plan for a patient dental assistants play an important role in the
becomes more than possible - it allows for dentist’s decision to utilize a putty stent in treating
delivering the best in oral health care treatment. this patient.
While guided by the MasterTrack team of directors

CASE REPORT

· Chief Complaint: “I broke my tooth. It’s right up front!” (Figure 1) Figure 1
· Problem Focused Examination:
· VS: BP 117/53, Pulse 78, Resp. 20
· Health History
· Medical
· 81 year old Caucasian male
· History of atrial fibrillation
· Ablation over 4 years ago, asymptomatic
· Hypertension, Quinapril
· No known drug allergies
· Tobacco: Currently no, history of 3 packs/day for 10 years
· Alcohol: 1 ounce daily
· Dental
· Maxillary removable partial denture: “old friend”
· No pain, no sensitivity

· Right Maxillary Lateral: Fractured off incisal of tooth

CASE REPORT (CONTINUED)

· Impression: Tooth #7 is restorable. Figure 2
· Patient is happy with old, worn maxillary RPD and not interested in Figure 3
replacing.
· Additional restorative appears indicated.
· Severe incisal/occlusal wear, deep bite, loss of vertical, multiple
abfractures, bruxism (Figure 2).
· Reduced periodontium, moderate plaque, gingival inflammation,
tissue easily bleeds with probing (Figure 3).
· Discussed need for comprehensive exam including
caries/periodontal charting and oral cancer screening with
fluorescence technology. Patient declines.
· Patient acknowledges importance of comprehensive exam, but is
busy and only interested in fixing #7 at this time.
· Restorative treatment options for #7 discussed:
· Crown: Porcelain fused to metal, lithium disilicate,
monolithic zirconia
· Direct composite restoration
· No treatment
· Risks and benefits of treatment options discussed. Questions
encouraged and answered.

TREATMENT PLANNING

· Plan: Patient elects to restore #7 with direct composite restoration.
· Procedures:
· Diagnostic images and casts to evaluate space/clearance, place composite (can use wax) on cast,
followed by obtaining putty stent then remove stent (Figure 4).
· Applied topical anesthetic Lidocaine/Prilocaine/Tetracaine (10%/10%/4%) gel. No local needed or used.
· Putty stent tried in before prepping tooth (Figure 5).
· Obtain shade of #7 (Figure 6).
· Removed caries and prepped #7.
· Vitrebond Plus Glass lonomer used for pulpal protection.
· Scotchbond Universal etching gel, iBond Total Etch Bonding Agent.
· Flow-It ALC C3 (deeper dentin area), Z250 C3 (dentin area) and C2 (enamel area), Gradio Flow A2 (incisal
enamel area).
· Interproximal contact and occlusion confirmed, polished, #7-MFDLI Resin (Figure #7).
· RX: None.
· Routine post-treatment instructions given.
· Patient tolerated treatment well. Pulse-Ox within normal limits throughout. No complications.
· Patient very pleased with care. Patient now interested in restoring other teeth and will look at
his schedule to call for comprehensive exam appointment.

Figure 4 Figure 5 Figure 6 Figure 7

METHODS AND MATERIALS

Impressions with TriPhasix Alginate, Hydrocal Gypsum Cast, Flow-It on cast, Stent with Capture VPS, VITA
Classical Shade Guide, Lido/Prilo/Tetracaine Gel, Prep #7 with fissurotomy, #4 round, flame shape diamond,
Vitrebond, Scotchbond Etching Gel, iBond Total Etch Bonding, Flow-It Composite C3, Filtek Z250 C3 and C2,
Gradio Flow Composite A2, Kerr Demetron, curing light, Mylar Celluloid Strip at contacts, Piranha fine diamond for
shaping, Diamond football to lingual, Bausch Articulating Paper Blue and Red 40µ, SHOFU Super-Snap
Rainbow Kit to polish #7, Prisma-Gloss Polish Paste for maxillary incisors, POH Floss to check contacts.

DISCUSSION

The training obtained by the dentist in MasterTrack was extremely useful for the smooth execution of the
procedures for this case. Direct composite is a predictable, conveniently available material that is routinely used to
restore damaged teeth to optimal form4. The dentist, by teaching the dental assistants the reversible portions of
this technique, then was able to delegate such tasks under direct supervision. Thus dental assistants perform
permissible services, the dentist provides the treatment more efficiently, and the quality of care remains first-rate.

CONCLUSION

Patient expressed great satisfaction with the treatment received and there was a renewed interest in overall
dental health. Due to remarkable advances in dental materials, esthetic results once possible only when employing
a dental laboratory are now achievable in the dental office. Dental assistants can play an important role when
using a putty stent.

REFERENCES

1. American Dental Association website, ADA Center for Evidence-Based Dentistry.
Available at: http://ebd.ada.org/en/about.

2. Milnar, F., MasterTrack Participation Course, The Art and Science of Shade Selection: A Hands-on Workshop
Seminar, 2014; Sept. 12-14.

3. LeSage, B., Aesthetic Anterior Composite Restorations: A Guide to Direct Placement, Dent Clin North Am, 2007;
51:359-378, viii.

4. Margeas, R., Composite Resin: A Versatile, Multi-Purpose Restorative Material, Compend Conti Edu Dent, 2012;
33(1): 42-45.
About Dr. Ben Warner
Dr. Warner obtained an MS in Neurophysiology from the University of Houston, DDS from The
University of Texas School of Dentistry (UTSD) at Houston, and MD from The University of Texas
McGovern Medical School. He completed residencies and served as Chief Resident in Anatomic
Pathology and Clinical Laboratory Medicine at UT Affiliated Hospital Residencies at Texas Medical
Center which were followed by a fellowship at MD Anderson Cancer Center. He is Clinical Associate
Professor in the Department of General Practice and Dental Public Health at UTSD while maintaining
a full time private practice. He will receive his Mastership in the AGD this July in Las Vegas.

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