1. art and entertainment
2. visual art and design
3. restoration

CLINICAL APPLICATION
Composite in Everyday Practice:
How to Choose the Right Material
and Simplify Application Techniques
in the Anterior Teeth
Walter Devoto, DDS
Clinical Lecturer, Department of Restorative Dentistry, University of Siena, Italy
Visiting Professor, University of Marseille, France
Private and referral practice, Sestri Levante, Italy
Monaldo Saracinelli, DDS
Grosseto, Italy
Jordi Manauta, DDS
Barcelona, Spain
Correspondence to: Dr Walter Devoto
Via E. Fico 106/8; 16039 Sestri Levante, Italy
e-mail: [email protected]; www.italianshadeguides.com
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Abstract
In daily practice, composites are the mate-
to make the right color choice. Paradoxical-
rials most commonly used for restorative
ly, they say that the appearance on the
dentistry. They are used for preventive
market of sophisticated materials, de-
seals, microinvasive restorations, build-ups
signed to give ever better results in the
and complex direct and indirect restora-
medium and long term, only makes it more
tions in posterior sections.
difficult to make the correct decision.
Indeed, it is in the anterior sections that
Indeed, many of these colleagues, after
composites have traditionally been used to
the first buzz of enthusiasm, give up on
the greatest effect, enabling clinicians to
the layering technique and opt for mate-
carry out complex restorations using direct
rials which they say are more simple or
techniques with notable esthetic and clini-
“mimetic.”
cal results.
In the present article, the authors will
Recent product developments com-
discuss these topics and make sugges-
bined with clinical research on stratification
tions on how to acheive high quality results
make it now possible to utilize new com-
every day, both from an esthetic and clin-
posites that have excellent opalescence
ical point of view. However, predictability of
and fluorescence characteristics and pro-
the results is more important, as pre-
vide an excellent color range to choose
dictability provides advantages in terms of
1,2
from.
It is however, a common complaint
the quality of work and economy for clinicians and patients.
among clinicians that the layering techniques are rather complex and it is difficult
(Eur J Esthet Dent 2010;5:XXX–XXX)
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CLINICAL APPLICATION
Introduction
Adhesive dentistry has made it possible to
restore teeth to their full functionality by creating a bond with the hard tissues, while
preserving, as much as possible, healthy
tissues of the teeth (Figs 1 to 3).
Prior to the introduction of adhesive systems, clinicians needed to create mechanical retentions for the materials. When that
was not possible, prosthetic solutions
Fig 1
Patient, 16 years old, with incongruous restora-
tion on tooth 11 and evident passive eruption.
rather than conservative procedures were
resorted to.
From a practical point of view, composite resins and adhesive systems have
made it possible to use less invasive procedures to treat clinical cases that at one
time would have required a significant
sacrifice of dental structure. This means
that today, clinicians can propose individually tailored treatment plans characterized
by considerable biological and financial
savings (Figs 4 to 13).
Fig 2
Gingivectomy to redefine the length of the
teeth.
Fig 3
The finished case after composite reconstruc-
tion, which was carried out after gingival healing.
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VOLUME 5 • NUMBER 1 • SPRING 2010
Fig 4
Patient, 33 years old, was not satisfied with her
smile but had limited financial options.
DEVOTO ET AL
Fig 5
Once the old restorations had been removed
Fig 6
After the build up of the cavities, impressions
it was clear that it would not be possible to restore the
are taken to plan the indirect vestibular additive restora-
anterior sector directly in composite within a reason-
tion: diagnostic waxup and silicone stents are funda-
able amount of chair time and to a high standard.
mental to an individual treatment plan.
Fig 7
Fig 8
With the aid of the silicone stent, the planned
The patient can now evaluate the esthetic and
project is transferred to the mouth of the patient using
phonetic impact of the new project and the clinician can
flowable composite.
prepare the required space directly on the mockup.
Fig 9
Fig 10
Impressions are transferred to the laboratory:
The photograph highlights the new dimen-
the veneers are made from the waxup with transparent
sions on the additive composite veneers: the sound tis-
silicone and a flask. This method makes it possible to
sue in the six anterior teeth remains practically un-
realize reconstructions simply and quickly.
touched.
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CLINICAL APPLICATION
Fig 11
The finished case with good esthetic integration achieved at relatively low biological and financial cost.
a
b
Fig 12a and b
The situation before and after the intervention: the additive solution allows for re-intervention
without dental sacrifice should the patient subsequently decide to resort to other restoration solutions, or require
root canal treatment in the future.
In recent years, there has been a breakthrough not only in the use of composite
resin, but also in the way it is being manipulated. Initially, the materials were seen as
nothing more than an esthetically agreeable way of filling cavities.3 Only later did
clinicians begin to layer predetermined
thicknesses of dentin and enamel to build
up a natural looking restoration.4-8 This
technique, known as stratification, has its
origins in the way ceramicists operate and
Fig 13
The patient’s smile.
has led to the development of composites
especially designed for this purpose.9
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DEVOTO ET AL
b
a
Fig 14a
The color of the tooth is derived from the
Fig 14b
By carefully adjusting the thickness of the
dentin, but the role of the enamel is of fundamental im-
enamel on the incisors, it is possible to reproduce the
portance as can be seen from these specially con-
natural opalescence without the addition of transparent
structed composite samples. It is the thickness of the
composite and changing the “age” of the tooth as well.
enamel that determines the different dental ages.
Within the range of resin composites on the
Colors and form
market, there is a continual quest to find
dentin and enamel materials with optical
The choice of color has for decades been
and mechanical properties similar to natu-
debated by clinicians for whom it repre-
ral tissues.
sents a challenging decision.15 Literature
In the course of its evolution, composite
published today provides various sugges-
is no longer considered only an “esthetic”
tions, as does observation of nature and
alternative to materials which are not ac-
clinical experience.16
ceptable in the anterior, but rather a mate-
Until a few years ago, it would have been
rial with its own unique properties that
unthinkable not to refer to virtual color
combines esthetics with function.10
guides, which gave only an approximate
These properties are, in fact, what has
idea of the color in which to construct a
made it possible to apply composite in
restoration. Since a universal color con-
both direct and indirect solutions and in the
cept was introduced, many materials have
anterior and posterior sections. Its extreme
been simplified.
versatility allows for a wide variety of appli11-14
cations.
Today, it is universally known that the
base color is derived from the dentinal
Not only have composites replaced ma-
body and that enamel works as a modifi-
terials of the past, but they have also pro-
er of the dentin color. It is the thickness of
vided, due to their unique characteristics,
the enamel which is decisive for the color
additional value to clinical practice.
of the tooth, and this changes over time
(Fig 14).17
Consequently, the choice of dentin is
now focused on a single base hue with different chromatic shades, and an accom-
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CLINICAL APPLICATION
panying system of enamel to modify the
color.
However, many clinicians remain in
some doubt regarding the choice of chromatic shade and the number of different
dentin chromas to use when creating a
restoration. In the present study, we have
attempted to simplify the matter by creating disks of composite of the same chromatic value (A3) but of variable thickness.
This visual analysis demonstrates how a
Fig 15
Uniform layers of A3 dentin with increasing
thickness: increasing the thickness increases the saturation of the color (chromaticity).
different thickness corresponds to different
chromatic results (Fig 15).
As a dental restoration is created in various thicknesses (Fig 16) from the cervical
to the incisor area, clinical experience suggests using a minimum number of dentin
colors and varying the chromatic incidence by adjusting thickness and use of
enamel to modify the base color.
For this type of restoration, it is of the utmost importance to correctly manage the
space dedicated for each material. Any
Fig 16
The correct reproduction of the layers of
dentin in a young tooth.
casual application is an irrational choice
(Figs 17 to 19).18
Saving chair time in reconstructive dentistry means the precise management of
the quantities of composite applied. A
small excess or under-application could
determine esthetic failure and the need to
repeat the restoration, in other words, a significant waste of time.
Clinicians should not, therefore seek
esthetic success solely in the brand name
of a particular composite material or in the
use of a large number of syringes on a
single tooth. Rather, they should look for
the methods and the guides which aid the
correct management of space to ensure an
adequate overlay of materials of different
Fig 17
Patient, 8 years old, with traumatic fracture of
teeth 11 and 21.
translucency. The management of the form
of a restoration would therefore appear to be
the fundamental topic in this discussion.19
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In order to optimize chair time, as well as
the results, it is necessary to begin to think
about how to apply the reconstruction materials even before removing the caries or
the old reconstruction, so as to avoid losing all information on the dimensions to reproduce.
It is crucial to have an efficient and stable guide for the buildup, and this is provided by the rigid silicone matrix. This
guide can be obtained from the old
a
restoration before removing it, from a prerestoration, or from a waxup.20
In addition, the authors suggest applying preformed sectional guides with multiple convexities in the anterior sections to
facilitate a natural emergence profile and
to optimize the position of the interproximal
contact point (see clinical case).
Three-dimensional
thickness
b
Fig 18a and b
For an esthetically pleasing restora-
Utilization of the silicone guide and inter-
tion, it is important to obsessively control the layers of
proximal matrix allows one to manage the
dentin and enamel.
two dimensions of the restoration’s space:
height and width. The greatest difficulty
remains managing the third dimension—
thickness of the tooth—and this, in the authors' experience, is the primary cause of
esthetic failure.
The correct calculation of the thickness
of the alternating opaque and translucent
materials is a crucial step when reconstructing a tooth using composite materials. It is well known that enamel materials
tend to increase the “grayish effect” the
thicker they are, and thus dull the underlying color of the dentin as can be seen in
the samples in Figure 20.
Fig 19
The case after a 1-year checkup.
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CLINICAL APPLICATION
How to resolve this problem
In the most complex cases, authors recommend preparing an ample silicone
stent, which also reproduces the vestibular portion of the teeth. This can then be cut
in different planes, frontally or sagittally.
This application, which has already
been used in prosthetic dentistry, allows
the clinician to adequately control the
thickness of the two materials. It also
In the center, a sample of A3 dentin on which
makes it possible to decide how much
increased thicknesses of enamel are overlapped. The
space should be left for the chosen enam-
Fig 20
thicker the enamel the greater the cover effect on the
color of the dentin with a consequent tendency to result in a grayish color.
el, after evaluating the opacity of the patient’s natural enamel as well as the choice
of composite to use (see clinical case).
As a general rule, authors advise leaving space no larger than a half of a natural enamel thickness.
One of the more interesting innovations
in the world of composites is the recent introduction of high refractive enamel that
has a refractive index very close to that of
natural enamel. As can be seen in the example in Figure 21, the use of this kind of
enamel increases the thickness without increasing the graying effect; on the contrary,
Fig 21
In the center a sample of A3 dentin onto
the luminosity is increased.
which increasing thicknesses of new generation enam-
This can be of great help to a clinician
el (HRI) are overlapped (clockwise). By increasing the
during the difficult management of a cru-
thicknesses, the dentin is covered but the undesirable
gray effect does not result.
cial part of the tooth such as the vestibular
enamel.
The choice of materials
The type of composite material used is an
important choice for a clinician. How can
one identify the best choice?
Fig 22
Teeth reconstructed with nine different com-
posites using A3 dentin with the same thickness and a
medium value enamel of 0.5 modulated thickness. It is
Sometimes, recommendations are given by a senior practitioner who takes the
clear that, on final inspection, the restorations appear
role of advisor, or by a trusted speaker at
completely different from each other.
a conference. The risk in such cases is
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DEVOTO ET AL
that sometimes the abilities of a colleague
Nanofillers deserve a separate discussion.
or famous speaker can affect the intrinsic
Composites made of these materials were
characteristics of the material itself.
created using a complex industrial techno-
On other occasions, the choice can be
logical process and have the advantage of
influenced by the sales team of a compa-
being extremely homogenous and com-
ny who demonstrate the latest materials
posed of particles on a nanometer scale.
on the market, the “wonder product” with
Today, there are very few composites on
miraculous
esthetic
the market made of pure nanofillers. Sev-
properties, new chemical formulas, and
eral companies have adopted the philos-
chameleonic properties.
ophy of combining different percentages
mechanical
and
In yet other cases, clinicians trust the
of nano- and micro-hybrids.
best known brands of composites and,
The disadvantages of these materials
paradoxically, as statistical studies and
regard their manipulation. High viscosity
classifications of the most requested prod-
renders the composite difficult to layer, es-
ucts have demonstrated, some countries
pecially in the anterior region which, as has
still have materials which are notoriously
already been discussed, requires scrupu-
obsolete yet remain in use.
lous control of the layer thickness.
From a physical and chemical point of
Another difficulty concerns poor esthet-
view, materials have undergone many
ic results. The materials' micromechanical
changes over the course of time as has
optimization (surface hardness) was at the
been highlighted above. Following the
cost of the esthetic results, probably due to
evolution of industrial systems, companies
the lack of knowledge concerning the re-
have been trying to find a stable material
lationship such fine particles have with
from both a micro-mechanic and esthetic
light. Mixing nanocomposites with different
point of view. Nowadays, they use a variety
percentages
of fillers in different dimensions in order to
seems to have optimized the esthetic re-
optimize the amalgam with a percentage
sult, similar to the quality of the latest gen-
of resin.
eration of pure hybrids.
of
microfiller
composites
Today, hybrid composites are the most
widely used. This material contains particles of different dimensions which fit together like a puzzle, thus reducing the
percentage of resin to a minimum. Although resin is essential for binding the
How to evaluate composite
materials from an esthetic
point of view
fillers, it is in fact the weak link in the final
Composite manufacturers usually design
product as it deteriorates in a damp envi-
kits made up of a number of syringes that
ronment.
contain dentin and enamel materials. The
One of the advantages of this family of
dentin materials are divided into groups of
hybrid composites is the high level of me-
color (A, B, C, and D) and different chro-
chanical stability, although it is sometimes
mas according to the color saturation. The
difficult to obtain a highly polished surface
different chromas are then indicated by
immediately. They also require continual
numbers, the highest number correspon-
maintenance to sustain the final result.
ding to the darkest dentin color.
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CLINICAL APPLICATION
There are two trends on the market at pres-
thickness of the residual enamel, which
ent. Some manufacturers simplify their
physiologically loses value or whiteness
systems, as described above, and elimi-
over the passage of time, allowing the
nate all dentin hues except A. In the light
base color of the dentin to show through.
of previous literature
21
and the authors'
In addition, almost all of the manufacturers
clinical experience, this would appear to
offer “special effect” enamels for the repro-
be a wise decision.
duction of highly translucent layers, such
Several systems recommend linking
enamel and dentin materials of the same
as the orange or blue opalescence of the
incisal third of the natural tooth.
Certain conclusions may be drawn from
type (eg, dentin A2 with enamel A2, etc.).
This choice seems to based mainly on the
this general analysis:
desire to simplify the manipulation and
■
manufacturers have a tendency to offer
legibility of the system rather than on sci-
systems that are, at least theoretically, in-
entific research. In reality, as has already
creasingly simplified to speed up and
been highlighted, enamel modifies the
base color of dentin and its influence is di-
optimize the final result
■
“globalization” in dentistry leads manu-
rectly linked to the thickness of natural
facturers to develop products that can
enamel—the thicker it is, the whiter and
be accepted by different markets with
22
more opaque is the tooth.
Presumably,
the
above
diverse needs and operational philosomentioned
phies.
products are characterized by a chromatic contrast between dentin and enamel,
The American market and its demands
which have less saturation of color as if
can be a principal example of this phe-
enamel was diluted dentin, in order to ap-
nomenon. Composites are widely viewed
pear more translucent. Some manufactur-
as a material for only small to medium
ers include in their systems a product
restorations in anterior teeth, while more
called “body.” According to the instruc-
complex restorations are preferably re-
tions, a layer of rather opaque missing
solved using ceramic materials. It should
dental tissue should be built up with a cor-
also be noted that American patients favor
responding layer of body material and lat-
uniformity and brilliance, obtained by the
er covered by a layer of enamel. This body
use of shiny white materials. The American
seems to be a material of intermediate
market focuses its attention on chromati-
translucency, sometimes known as “uni-
cally “simple” materials such as low satu-
versal” (a single product used to realize a
ration dentins (sometimes less than A1)
restoration).
and enamels that are suitable for post-
Yet other manufacturers propose sys-
bleaching restorations.
tems which contain only general dentin
The European market, on the other
and enamel materials. Usually, dentin in
hand, tends to be more conservative and
these systems is very intense and the
endeavours to integrate a restoration with
enamel modifies the base color with white
the patient’s natural smile. Clinicians work-
or amber nuances. These manufacturers
ing in Europe are more attentive to detail
suggest identifying the required enamel
and to the nuances of color and effects that
according to the age of the patient and the
are obtainable with modern composites.23
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DEVOTO ET AL
There is, therefore, much opportunity for
confusion. Experience shows that the instructions that come with products are often of little use (Fig 22). What is more, clinicians often fall into the trap of dividing
materials into those considered “simple”
and those designed for the “esthetically
obsessed,” as if there might be patients or
dentists interested in esthetically displeasing restorations. Moreover, clinicians request materials with chameleonic properties, as if a syringe could possibly contain
Fig 23
such a miracle product.
thickness of the material and create individual shade
It is possible to find tools to modulate the
guides.
How to overcome these difficulties
To be perfectly clear, the miracle product
does not exist. If used badly, even the most
esthetically favorable material can give
terrible results, just as the worst material in
the right hands can give satisfactory results. Consequently, continual practice
with the material of choice, constructing
Fig 24
Sample of A3 of equal thickness of nine differ-
ent brands compared to one another; note the difference
in color and translucency. Which of these is really A3?
various samples, and applying different
stratification techniques is the path to success.
Another very interesting exercise is to try to
Is it possible to objectively judge
a composite material?
decide whether a tube contains dentin or
enamel without looking at the label. Some
syringes turn out to be of little use, and oth-
The first thing to suggest is to construct a
ers have the possibility of integrating very
personalized color chart. Too often, color
well into different systems. Naturally, this
guides presented by a manufacturer are
experiment does not cover everything, but
unrealistic and often made of a different
it is a good beginning for a critical and an-
material such as plastic or card, or is even
alytical evaluation.
missing completely.
Objectively however, it is clear that when
There are many instruments on the
comparing samples of an even thickness
market that can be used to create disks of
and the same color but of different brands,
the material in various even thicknesses,
the chroma and translucence are com-
and this can give a clear idea to the prac-
pletely different. This accounts for the need
titioner of the properties such as opacity,
to create an individual color scale, espe-
translucency, and pigment saturation in
cially if one uses different composite sys-
the composite (Fig 23).
tems (Fig 24).
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CLINICAL APPLICATION
Table 1
Composite
features
Suggested key parameters for evaluating the ideal choice of material.
Enamel
Dentin
Opalescence
Intensity
Dark
stains
Light
stains
Deep dentin
Mamelon
masses
Fluorescence
2
5
1
4
4
4
5
5
Hybrid
4
5
4
4
4
4
5
5
Opalescence
4
1
5
1
1
1
1
1
Nanofill
3
3
3
1
1
1
0
0
Microfill
1
0
1
1
1
1
0
0
Flowable
1
4
1
1
4
4
3
0
Opacity
3
5
0
4
5
2
5
5
Translucency
4
2
5
3
1
4
1
0
Chroma
1
5
3
0
5
3
5
5
Value
4
2
2
5
0
3
2
4
0: not desirable, 1: not appealing, 2: somewhat appealing, 3: appealing, 4: very appealing, 5: desirable
Next is to focus on the physical characteristics and optical properties of composites
in order to create a scale of general priorities. As shown in Table 1, some mechanical and esthetic properties, in relation to
the necessity of the restoration, are seen to
be absolutely necessary, while others are
appealing or useless, if not damaging.
Based on the recent literature,24 but
above all on clinical experience and passion for the field, authors have attempted
A composite tooth reconstructed in two lay-
to set up a system for evaluating the com-
ers of dentin and a layer of palatine and vestibular
posite materials present on the market.
Fig 25
enamel in different sizes. This is the model chosen to
analyze the materials on the market.
While concentrating on the anatomical
form of the natural teeth, it is possible to
make some suggestions on the thickness
of the layers (Fig 25). It is in fact dentin that
makes up the most important layer from a
volumetric and chromatic point of view,
and represents the crucial layer for the final restoration for integration with the rest
of the teeth.
At this point, it is possible to model the
dentinal body three dimensionally, as has
been shown above, limiting masses of
dentin to two at most and exploiting the
Fig 26
A composite copy of a natural tooth to man-
age the spaces of dentin and enamel.
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thickness variation of the tooth. A rigid silicone impression, taken from an integral
DEVOTO ET AL
natural incisor, allowed the reproduction of
a copy in composite (Fig 26). Using this
copy, the tooth was divided into three layers: dentinal body, dentin (creates internal
anatomy like mamelon and opalescence),
and the vestibular surface enamel (Fig 27).
With the aid of calibration and a thickness
gauge, three types of samples were mechanically prepared:
■
■
type one was made only of dentinal
body
Fig 27
type two was made of the base dentin
of dentinal masses and the pre-constructed dentinal
together with dentin that had been
anatomically modeled to reproduce the
The rigid silicone guides for the preparation
masses. From the left: the base dentin followed by the
second dentin to simulate the different anatomies of
opalescence in a young, adult, and old tooth.
incisor opalescence of a young tooth
(three mamelons), adult (horizontal window), and elderly
■
type three was made of a dentinal body,
described above, with three different
free spaces of 0.3, 0.5, and 0.7 mm in
order to be able to uniformly reproduce
the surface enamel of three different values (Fig 28).
Fig 28
Serial impressions were taken from these
Samples for the construction of dentins of dif-
ferent thicknesses (0.3, 0.5, and 0.7 mm) to simulate the
loss of enamel as the tooth gets older.
models that could be inserted in a specially created laboratory flask using a transparent silicone guide (Fig 29).
By analyzing the color samples on the
prefabricated scale, two colors of dentin
and three different types of enamel were
identified for each composite system available on the market. The choice of samples
was based on the analysis of two expert
clinicians, one newly graduated dentist
and a dental technician, who analyzed the
color scales without knowing the product
brand or the masses. The panel was asked
to identify masses and base their decisions on knowledge and clinical experi-
Fig 29
The flask is used to form the enamel, curing
ence, with the aim of selecting three den-
the material through the transparent silicone in order to
tal ages.
obtain a sample with an even thickness.
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Fig 30
The excess composite enamel is now re-
moved mechanically.
Fig 31
The finished and polished samples are ready
to be examined under different light sources for the final evaluation.
Three composite teeth were reproduced
■
Clinicians and specialized dental tech-
with evenly distributed thicknesses of ma-
nicians
terial for each brand of composite and
amount of knowledge and expertise
thus, the final results were easy to compare
concerning the problems linked to re-
(Figs 30 and 31). The data acquired by the
producing the color of natural teeth
authors during this experience was cer-
and the suitable materials.
tainly empirical, but very close to the clini-
■
possess
an
extraordinary
By listening to their suggestions and
cal reality of everyday dentistry. Therefore,
analyzing
it was considered to add value to the as-
measuring instruments that are avail-
sertions above.
able today (spectrophotometer), the
■
using
color-
Every composite system on the market
manufacturers could further simplify
can be reduced to a limited number of
their systems, which would be ex-
syringes that are useful in reconstruct-
tremely advantageous for everyday
ing all natural teeth. Any exceptions can
dentistry practice. Indeed, it was found
be dealt with by using special effect
that the best clinical performance was
masses and super colors, which are
provided by products produced in this
suitable
spirit of collaboration.
for
emphasizing
particular
translucencies and individual features.
■
materials
For the majority of materials analyzed,
the clinician’s choices appeared to be in
disagreement with the manufacturers
suggested use. When it is desirable to
optimize work with the chosen composite, it is imperative to construct a personalized color scale made of samples of
even thickness in order to identify the
correct mass.
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DEVOTO ET AL
Clinical case
The patient was a 32-year-old female with
high esthetic demands who came to the
clinic requiring emergency treatment, having herself glued on a fragment of composite to a pre-existing restoration on tooth
11 using cyanoacrylic glue. She reported
no pain or thermal sensitivity, but complained about a slight sporadic bleeding of
the gums. A clinical examination (Fig 32)
revealed a number of resin restorations on
Fig 32
teeth 11, 21 and 22, which were incon-
tempt to glue on a broken fragment of composite on tooth
gruous for emergence profile, color, and
Pre-surgical image showing the patient’s at-
11. Alterations to the pre-existing restorations and evidence of the degree of contamination by bacterial plaque.
degree of finish, with discolored margins
infiltrated by secondary caries. More importantly however, restorations were esthetically and anatomically inadequate. An
examination of gingival tissues revealed
marginal gingivitis caused by the patient’s
poor hygiene and a large accumulation of
bacterial plaque. However, the periodontal
area appeared to be in good condition.
Radiographic
examination
not
only
confirmed the areas of carious infiltration,
but also revealed an inadequate root canal
treatment on tooth 22, which had been ex-
Fig 33
clusively accessed via the mesial inter-
22 with access through the mesial cavity of the 3rd
proximal 3rd class cavity, with a conse-
class cavity with perio-apical lesions.
quent
periapical
asymptomatic
Radiograph of endodontic treatment of tooth
lesion
(Fig 33).
After careful cleaning and a motivating
oral hygiene session (Fig 34), the treatment plan proceeded with an accurate
cleaning of the cavity to eliminate the carious infiltrations. The margins were polished to eliminate areas which could retain
bacterial plaque and the root canals were
then correctly re-treated.
Fig 34
View of incisor group after oral hygiene, mo-
tivational talk to patient, and cleaning of provisional
restorations.
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CLINICAL APPLICATION
Only at this point did research begin on the
form of the teeth, and the first step was to
ask the patient to provide photographs taken before the restoration work was carried
out. A diagnostic waxup was made on extra hard plaster casts (Fig 35). These plaster models were used to create a series of
Fig 35
Laboratory-created silicone stent based on
the waxup.
laboratory-made rigid silicone guides for
palatal support, and sectioned in a saggital plane in a vestibular-palatal direction as
well. These guides are indispensable in determining palatal walls and controlling the
thickness of the composite during the stratification technique, as well as acting as a
matrix for the final form of the restorations.
In addition, a personalized color chart
was
compiled,
subsequent
to
careful
analysis of the teeth under a light source of
5500 K (Trueshade Lamp, Optident, Ilkley,
UK). After carefully isolating the operative
field from tooth 14 to 24 with a medium
weight rubber dam (Nic Tone, Cooley &
Cooley, Houston, TX, USA) and W2 clamps
(Hu-Friedy, Rotterdam, The Netherlands)
and checking the rigid silicone matrix guide
to fit perfectly by trimming it with number 15
Fig 36
Isolation of the field with rubber dam and
cavity preparations (palatal view)
scalpel blade where necessary, the provisional composite fillings were removed using a medium grain cylindrical diamond
bur (Fig 36).
The preparation of the enamel was limited to clean, well-finished margins and a
chamfer on the vestibular finishing line to
render the transition from composite to
natural enamel invisible. Great care was
taken to finish the preparation margins using silicone points mounted on a blue ring
counter-angled hand piece, at a low
speed, to carefully smooth the preparation
and eliminate the prisms of unsupported
Fig 37
Finishing cavity margins step.
enamel which would break off during polymerization contraction and lead to discoloring and infiltration of the restoration. This
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VOLUME 5 • NUMBER 1 • SPRING 2010
DEVOTO ET AL
operation was carried out under a constant
cooling spray (Fig 37).
Once the cavity preparation was finished, a silicone stent made it possible to
visualize form, thickness, future dimensions, and correct interproximal relationships. This is of significant help as it renders the work predictable, allowing for
time management and limiting chair time.
Also, sectional transparent matrixes with
multiple convexities (KerrHawe, Bioggio,
Switzerland) are a useful aid for time man-
Fig 38
agement as they allow the clinician to re-
the correct emergence profiles and contact points.
Use of a sectional transparent matrix to restore
alize and simply and intuitively correct
emergence profiles. These are the tools to
correctly manage the build up of restorations, eliminating any excess of material
which otherwise would demand laborious
and difficult remodelling interventions that
risk damage to the adjacent teeth and losing contact points. A sectional matrix is a
useful means for restoring interproximal
anatomy due to its intrinsic elasticity,
which makes it highly adaptable to a large
number of dental morphologies (Figs 38
and 39). Furthermore, it also helps to
avoid accidental contamination of adja-
Fig 39
Layering step, 3rd class cavity on tooth 22.
Fig 40
Use of the sectional matrix during the cavity
cent teeth during the phases of etching
and adhesion (Fig 40). The combined application of a stable stent and sectional
matrices allows the clinician to simply and
intuitively manage even the most complex dental forms in a single step, thus optimizing both operative time and the final
result (Figs 41 to 44).
Once the cavity’s solid geometry has
been limited by interproximal well-defined
margins and incisal angles, it is possible to
focus on building up the dentinal body
(Enamel plus HFO, Micerium, Avegno,
Italy). This involves desaturating the color
in a cervical-incisal direction with two different layers of dentin and gradually covering
etching phase to avoid contaminating the contiguous
elements.
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CLINICAL APPLICATION
Fig 41
Combined use of the silicone stent and sec-
tional matrix to contemporarily “box up” palatally and
Fig 42
Silicone stent in the vestibular/palatal section
on a waxup.
interproximally.
Fig 43
Layering phase. Distribution and thickness of
Fig 44
Combined use of silicone stent and the sec-
the different masses are controlled in the vestibular/
tional matrix for the control and stratification of the
palatal section through the use of the sectional silicone
emergence profile and mesial contact point.
stent.
Fig 45
Reconstruction step of the dentinal body us-
ing the color desaturation technique working in a
palatal-to-vestibular direction.
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VOLUME 5 • NUMBER 1 • SPRING 2010
Fig 46
Realization of the incisal opalescence and in-
ternal features.
DEVOTO ET AL
the preparation almost completely from
the vestibular margin in order to render the
meeting point between the enamel and
composite almost invisible. The dental
body on the incisor was modeled leaving
enough space to add the specific features
and opalescence taken from the color
scheme compiled in the preliminary investigative phase.
Management of the internal composite thickness is controlled using another
laboratory-produced rigid silicone matrix
Fig 47
sectioned in the sagittal plane (Fig 42).
curing using glycerine gel.
Vestibular composite enamel and final step of
This makes it possible to control the
quantity and distribution of the composite
dentin in section, in order to leave just the
right space for the enamel and not to lower the value of the restoration (Fig 43).
Layering finishes with a very thin layer of
composite enamel (Enamel plus HFO),
no thicker than 0.3 to 0.4 mm. A final 60
second curing is performed under glycerine, which eliminates oxygen access to
the surface. This prevents the composite’s
complete polymerization and reduces the
surface resistance of the material (Figs 45
Fig 48
to 48).
Fig 49
Search for macro- and micro-surface texture
before final polishing.
View of reconstructions and rehydrated ele-
ments after 72 hours.
Fig 50
Good esthetic integration of restorations and
health of the periodontal tissues 30 days after treatment.
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CLINICAL APPLICATION
b
a
Fig 51
Radiographic check of restorations and root
Fig 52
Two-year follow-up.
canal treatment (a) and radiographic check of restorations 2 years after treatment (b) with resolution of apical radiolucency.
Final polishing is fundamental to the es-
servative and financial advantages for pa-
thetic success of the restorations, as a
tients.
shiny smooth surface reduces plaque ac-
Doubts that clinicians may have are
cumulation and prevents the teeth from
usually associated with the amount of chair
discoloring (Shiny System, Micerium). In
time required as well as the difficulty in
the end, the polished restoration had a
achieving good esthetic results every day.
surface very similar to that of a natural
As a consequence, more invasive tech-
tooth (Figs 49 and 50). However, this lev-
niques such as ceramic restorations are
el of clinical result obtained with a direct
favored.
technique is possible only with correct
The authors believe that operation
and accurate management of form and
times are inevitably linked to certain oblig-
buildup. These parameters must be deter-
atory steps (preparation, adhesion phase,
mined before clinical procedures are car-
buildup with limited quantities of compos-
ried out (Figs 51 and 52).
ite in order to reduce contraction, correct
curing times for each layer of material).
Nevertheless, with the instruments and
Conclusions
guides that have been analyzed in the
present article, the stratification technique
Today, composite materials allow clini-
can be key to the long-term success of the
cians to realize restorations on a high es-
restoration from both a clinical and esthet-
thetic level while being minimally invasive,
ic point of view. This enables the clinician
26
affordable to patients, and long lasting.
In
addition, the associated risk level over time
to avoid short-term disappointments that
require re-facing and a waste of time.
is low and manageable. Re-intervention is
It is crucial to understand that a suc-
relatively easy and cheap, and fractures or
cessful restoration begins with the correct
defects that may appear in time are re-
choice of a base material. However, there
pairable without the necessity to remake
is no miracle material on the market and
the whole restoration, which provides con-
the final result is fundamentally linked to the
22
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 5 • NUMBER 1 • SPRING 2010
DEVOTO ET AL
Fig 53
Constant practice and a good knowledge of the materials allow clinicians to reproduce every detail,
even serious esthetic defects such as a tooth which has been discolored by antibiotics
clinician's manual skills and, what is more,
to skills in choosing the correct techniques
that simplify everyday work (Fig 53).
Acknowledgements
The authors wish to express their heartfelt gratitude to
the following people: Dr G Paolone (Rome) for his help
In this profession, success should not
in compiling the bibliography, Dr F Menghetti (Grosset-
be measured solely by exceptional results,
to) for the root canal and surgical treatment of the clin-
but rather by a good everyday standard
ical case, and Mr D Rondoni (Savona) for his precious
collaboration in analyzing the composite.
with regard to time management and limiting long-term risk.
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