composite in everyday practice- how to choose the right material and simplify application techniques...

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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

CLINICAL APPLICATION

THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY

VOLUME 5 • NUMBER 1 • SPRING 2010

102

Composite in Everyday Practice:

How to Choose the Right Material

and Simplify Application Techniques

in the Anterior Teeth

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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to make the right color choice. Paradoxical-

ly, they say that the appearance on the

market of sophisticated materials, de-

signed to give ever better results in the

medium and long term, only makes it more

difficult to make the correct decision.

Indeed, many of these colleagues, after

the first buzz of enthusiasm, give up on

the layering technique and opt for mate-

rials which they say are more simple or

“mimetic.”

In the present article, the authors will

discuss these topics and make sugges-

tions on how to acheive high quality results

every day, both from an esthetic and clin-

ical point of view. However, predictability of

the results is more important, as pre-

dictability provides advantages in terms of

the quality of work and economy for clini-

cians and patients.

(Eur J Esthet Dent 2010;5:102–124)

Abstract

In daily practice, composites are the mate-

rials most commonly used for restorative

dentistry. They are used for preventive

seals, microinvasive restorations, build-ups

and complex direct and indirect restora-

tions in posterior sections.

Indeed, it is in the anterior sections that

composites have traditionally been used to

the greatest effect, enabling clinicians to

carry out complex restorations using direct

techniques with notable esthetic and clini-

cal results.

Recent product developments com-

bined with clinical research on stratification

make it now possible to utilize new com-

posites that have excellent opalescence

and fluorescence characteristics and pro-

vide an excellent color range to choose

from.1,2

It is however, a common complaint

among clinicians that the layering tech-

niques are rather complex and it is difficult

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Introduction

Adhesive dentistry has made it possible to

restore teeth to their full functionality by cre-

ating 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 sys-

tems, clinicians needed to create mechan-

ical retentions for the materials. When that

was not possible, prosthetic solutions

rather than conservative procedures were

resorted to.

From a practical point of view, compos-

ite resins and adhesive systems have

made it possible to use less invasive pro-

cedures to treat clinical cases that at one

time would have required a significant

sacrifice of dental structure. This means

that today, clinicians can propose individ-

ually tailored treatment plans characterized

by considerable biological and financial

savings (Figs 4 to 13).

Fig 1 Patient, 16 years old, with incongruous restora-

tion on tooth 11 and evident passive eruption.

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.

Fig 4 Patient, 33 years old, was not satisfied with her

smile but had limited financial options.

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Fig 6 After the build up of the cavities, impressions

are taken to plan the indirect vestibular additive restora-

tion: diagnostic waxup and silicone stents are funda-

mental to an individual treatment plan.

Fig 5 Once the old restorations had been removed

it was clear that it would not be possible to restore the

anterior sector directly in composite within a reason-

able amount of chair time and to a high standard.

Fig 7 With the aid of the silicone stent, the planned

project is transferred to the mouth of the patient using

flowable composite.

Fig 8 The patient can now evaluate the esthetic and

phonetic impact of the new project and the clinician can

prepare the required space directly on the mockup.

Fig 9 Impressions are transferred to the laboratory:

the veneers are made from the waxup with transparent

silicone and a flask. This method makes it possible to

realize reconstructions simply and quickly.

Fig 10 The photograph highlights the new dimen-

sions on the additive composite veneers: the sound tis-

sue in the six anterior teeth remains practically un-

touched.

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Fig 13 The patient’s smile.




106

In recent years, there has been a break-

through not only in the use of composite

resin, but also in the way it is being manip-

ulated. Initially, the materials were seen as

nothing more than an esthetically agree-

able 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

has led to the development of composites

especially designed for this purpose.9

Fig 11 The finished case with good esthetic integration achieved at relatively low biological and financial cost.

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.

a b

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Colors and form

The choice of color has for decades been

debated by clinicians for whom it repre-

sents a challenging decision.15

Literature

published today provides various sugges-

tions, as does observation of nature and

clinical experience.16

Until a few years ago, it would have been

unthinkable not to refer to virtual color

guides, which gave only an approximate

idea of the color in which to construct a

restoration. Since a universal color con-

cept was introduced, many materials have

been simplified.

Today, it is universally known that the

base color is derived from the dentinal

body and that enamel works as a modifi-

er of the dentin color. It is the thickness of

the enamel which is decisive for the color

of the tooth, and this changes over time

(Fig 14).17

Within the range of resin composites on the

market, there is a continual quest to find

dentin and enamel materials with optical

and mechanical properties similar to natu-

ral tissues.

In the course of its evolution, composite

is no longer considered only an “esthetic”

alternative to materials which are not ac-

ceptable in the anterior, but rather a mate-

rial with its own unique properties that

combines esthetics with function.10

These properties are, in fact, what has

made it possible to apply composite in

both direct and indirect solutions and in the

anterior and posterior sections. Its extreme

versatility allows for a wide variety of appli-

cations.11-14

Not only have composites replaced ma-

terials of the past, but they have also pro-

vided, due to their unique characteristics,

additional value to clinical practice.

Fig 14a The color of the tooth is derived from the

dentin, but the role of the enamel is of fundamental im-

portance as can be seen from these specially con-

structed composite samples. It is the thickness of the

enamel that determines the different dental ages.

Fig 14b By carefully adjusting the thickness of the

enamel on the incisors, it is possible to reproduce the

natural opalescence without the addition of transparent

composite and changing the “age” of the tooth as well.

a b

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Consequently, the choice of dentin is now

focused on a single base hue with different

chromatic shades, and an accompanying

system of enamel to modify the color.

However, many clinicians remain in

some doubt regarding the choice of chro-

matic 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 creat-

ing disks of composite of the same chro-

matic value (A3) but of variable thickness.

This visual analysis demonstrates how a

different thickness corresponds to different

chromatic results (Fig 15).

As a dental restoration is created in var-

ious thicknesses (Fig 16) from the cervical

to the incisor area, clinical experience sug-

gests using a minimum number of dentin

colors and varying the chromatic inci-

dence by adjusting thickness and use of

enamel to modify the base color.

For this type of restoration, it is of the ut-

most importance to correctly manage the

space dedicated for each material. Any

casual application is an irrational choice

(Figs 17 to 19).18

Saving chair time in reconstructive den-

tistry 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 sig-

nificant 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

translucency. The management of the form

Fig 15 Uniform layers of A3 dentin with increasing

thickness: increasing the thickness increases the satu-

ration of the color (chromaticity).

Fig 16 The correct reproduction of the layers of

dentin in a young tooth.

Fig 17 Patient, 8 years old, with traumatic fracture of

teeth 11 and 21.

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of a restoration would therefore appear to be

the fundamental topic in this discussion.19

In order to optimize chair time, as well as

the results, it is necessary to begin to think

about how to apply the reconstruction ma-

terials even before removing the caries or

the old reconstruction, so as to avoid los-

ing all information on the dimensions to re-

produce.

It is crucial to have an efficient and sta-

ble guide for the buildup, and this is pro-

vided by the rigid silicone matrix. This

guide can be obtained from the old

restoration before removing it, from a pre-

restoration, or from a waxup.20

In addition, the authors suggest apply-

ing preformed sectional guides with multi-

ple 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

Utilization of the silicone guide and inter-

proximal matrix allows one to manage the

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 au-

thors' 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 recon-

structing a tooth using composite materi-

als. It is well known that enamel materials

tend to increase the “grayish effect” the

thicker they are, and thus dull the underly-

ing color of the dentin as can be seen in

the samples in Figure 20.

Fig 18a and b For an esthetically pleasing restora-

tion, it is important to obsessively control the layers of

dentin and enamel.

a

b

Fig 19 The case after a 1-year checkup.

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How to resolve this problem

In the most complex cases, authors rec-

ommend preparing an ample silicone

stent, which also reproduces the vestibu-

lar 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

makes it possible to decide how much

space should be left for the chosen enam-

el, after evaluating the opacity of the pa-

tient’s natural enamel as well as the choice

of composite to use (see clinical case).

As a general rule, authors advise leav-

ing space no larger than a half of a natu-

ral enamel thickness.

One of the more interesting innovations

in the world of composites is the recent in-

troduction of high refractive enamel that

has a refractive index very close to that of

natural enamel. As can be seen in the ex-

ample in Figure 21, the use of this kind of

enamel increases the thickness without in-

creasing the graying effect; on the contrary,

the luminosity is increased.

This can be of great help to a clinician

during the difficult management of a cru-

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?

Sometimes, recommendations are giv-

en by a senior practitioner who takes the

role of advisor, or by a trusted speaker at

a conference. The risk in such cases is

Fig 20 In the center, a sample of A3 dentin on which

increased thicknesses of enamel are overlapped. The

thicker the enamel the greater the cover effect on the

color of the dentin with a consequent tendency to re-

sult in a grayish color.

Fig 21 In the center a sample of A3 dentin onto

which increasing thicknesses of new generation enam-

el (HRI) are overlapped (clockwise). By increasing the

thicknesses, the dentin is covered but the undesirable

gray effect does not result.

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

clear that, on final inspection, the restorations appear

completely different from each other.

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Nanofillers deserve a separate discussion.

Composites made of these materials were

created using a complex industrial techno-

logical process and have the advantage of

being extremely homogenous and com-

posed of particles on a nanometer scale.

Today, there are very few composites on

the market made of pure nanofillers. Sev-

eral companies have adopted the philos-

ophy of combining different percentages

of nano- and micro-hybrids.

The disadvantages of these materials

regard their manipulation. High viscosity

renders the composite difficult to layer, es-

pecially in the anterior region which, as has

already been discussed, requires scrupu-

lous control of the layer thickness.

Another difficulty concerns poor esthet-

ic results. The materials' micromechanical

optimization (surface hardness) was at the

cost of the esthetic results, probably due to

the lack of knowledge concerning the re-

lationship such fine particles have with

light. Mixing nanocomposites with different

percentages of microfiller composites

seems to have optimized the esthetic re-

sult, similar to the quality of the latest gen-

eration of pure hybrids.

How to evaluate composite

materials from an esthetic

point of view

Composite manufacturers usually design

kits made up of a number of syringes that

contain dentin and enamel materials. The

dentin materials are divided into groups of

color (A, B, C, and D) and different chro-

mas according to the color saturation. The

different chromas are then indicated by

numbers, the highest number correspon-

ding to the darkest dentin color.

that sometimes the abilities of a colleague

or famous speaker can affect the intrinsic

characteristics of the material itself.

On other occasions, the choice can be

influenced by the sales team of a compa-

ny who demonstrate the latest materials

on the market, the “wonder product” with

miraculous mechanical and esthetic

properties, new chemical formulas, and

chameleonic properties.

In yet other cases, clinicians trust the

best known brands of composites and,

paradoxically, as statistical studies and

classifications of the most requested prod-

ucts have demonstrated, some countries

still have materials which are notoriously

obsolete yet remain in use.

From a physical and chemical point of

view, materials have undergone many

changes over the course of time as has

been highlighted above. Following the

evolution of industrial systems, companies

have been trying to find a stable material

from both a micro-mechanic and esthetic

point of view. Nowadays, they use a variety

of fillers in different dimensions in order to

optimize the amalgam with a percentage

of resin.

Today, hybrid composites are the most

widely used. This material contains parti-

cles of different dimensions which fit to-

gether like a puzzle, thus reducing the

percentage of resin to a minimum. Al-

though resin is essential for binding the

fillers, it is in fact the weak link in the final

product as it deteriorates in a damp envi-

ronment.

One of the advantages of this family of

hybrid composites is the high level of me-

chanical stability, although it is sometimes

difficult to obtain a highly polished surface

immediately. They also require continual

maintenance to sustain the final result.

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thickness of the residual enamel, which

physiologically loses value or whiteness

over the passage of time, allowing the

base color of the dentin to show through.

In addition, almost all of the manufacturers

offer “special effect” enamels for the repro-

duction of highly translucent layers, such

as the orange or blue opalescence of the

incisal third of the natural tooth.

Certain conclusions may be drawn from

this general analysis:

� manufacturers have a tendency to offer

systems that are, at least theoretically, in-

creasingly simplified to speed up and

optimize the final result

� “globalization” in dentistry leads manu-

facturers to develop products that can

be accepted by different markets with

diverse needs and operational philoso-

phies.

The American market and its demands

can be a principal example of this phe-

nomenon. Composites are widely viewed

as a material for only small to medium

restorations in anterior teeth, while more

complex restorations are preferably re-

solved using ceramic materials. It should

also be noted that American patients favor

uniformity and brilliance, obtained by the

use of shiny white materials. The American

market focuses its attention on chromati-

cally “simple” materials such as low satu-

ration dentins (sometimes less than A1)

and enamels that are suitable for post-

bleaching restorations.

The European market, on the other

hand, tends to be more conservative and

endeavours to integrate a restoration with

the patient’s natural smile. Clinicians work-

ing in Europe are more attentive to detail

and to the nuances of color and effects that

are obtainable with modern composites.23

There are two trends on the market at pres-

ent. Some manufacturers simplify their

systems, as described above, and elimi-

nate all dentin hues except A. In the light

of previous literature21

and the authors'

clinical experience, this would appear to

be a wise decision.

Several systems recommend linking

enamel and dentin materials of the same

type (eg, dentin A2 with enamel A2, etc.).

This choice seems to based mainly on the

desire to simplify the manipulation and

legibility of the system rather than on sci-

entific research. In reality, as has already

been highlighted, enamel modifies the

base color of dentin and its influence is di-

rectly linked to the thickness of natural

enamel—the thicker it is, the whiter and

more opaque is the tooth.22

Presumably, the above mentioned

products are characterized by a chromat-

ic contrast between dentin and enamel,

which have less saturation of color as if

enamel was diluted dentin, in order to ap-

pear more translucent. Some manufactur-

ers include in their systems a product

called “body.” According to the instruc-

tions, a layer of rather opaque missing

dental tissue should be built up with a cor-

responding layer of body material and lat-

er covered by a layer of enamel. This body

seems to be a material of intermediate

translucency, sometimes known as “uni-

versal” (a single product used to realize a

restoration).

Yet other manufacturers propose sys-

tems which contain only general dentin

and enamel materials. Usually, dentin in

these systems is very intense and the

enamel modifies the base color with white

or amber nuances. These manufacturers

suggest identifying the required enamel

according to the age of the patient and the

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Another very interesting exercise is to try to

decide whether a tube contains dentin or

enamel without looking at the label. Some

syringes turn out to be of little use, and oth-

ers have the possibility of integrating very

well into different systems. Naturally, this

experiment does not cover everything, but

it is a good beginning for a critical and an-

alytical evaluation.

Objectively however, it is clear that when

comparing samples of an even thickness

and the same color but of different brands,

the chroma and translucence are com-

pletely different. This accounts for the need

to create an individual color scale, espe-

cially if one uses different composite sys-

tems (Fig 24).

There is, therefore, much opportunity for

confusion. Experience shows that the in-

structions that come with products are of-

ten of little use (Fig 22). What is more, cli-

nicians 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 displeas-

ing restorations. Moreover, clinicians re-

quest materials with chameleonic proper-

ties, as if a syringe could possibly contain

such a miracle product.

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 re-

sults. Consequently, continual practice

with the material of choice, constructing

various samples, and applying different

stratification techniques is the path to suc-

cess.

Is it possible to objectively judge

a composite material?

The first thing to suggest is to construct a

personalized color chart. Too often, color

guides presented by a manufacturer are

unrealistic and often made of a different

material such as plastic or card, or is even

missing completely.

There are many instruments on the

market that can be used to create disks of

the material in various even thicknesses,

and this can give a clear idea to the prac-

titioner of the properties such as opacity,

translucency, and pigment saturation in

the composite (Fig 23).

Fig 23 It is possible to find tools to modulate the

thickness of the material and create individual shade

guides.

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?

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Next is to focus on the physical character-

istics and optical properties of composites

in order to create a scale of general prior-

ities. As shown in Table 1, some mechani-

cal 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 pas-

sion for the field, authors have attempted

to set up a system for evaluating the com-

posite materials present 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 fi-

nal 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

thickness variation of the tooth. A rigid sili-

cone impression, taken from an integral

Table 1 Suggested key parameters for evaluating the ideal choice of material.

Composite Enamel Dentin Opalescence Intensity Dark Light Deep dentin Mamelonfeatures stains stains 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

Fig 25 A composite tooth reconstructed in two lay-

ers of dentin and a layer of palatine and vestibular

enamel in different sizes. This is the model chosen to

analyze the materials on the market.

Fig 26 A composite copy of a natural tooth to man-

age the spaces of dentin and enamel.

0: not desirable, 1: not appealing, 2: somewhat appealing, 3: appealing, 4: very appealing, 5: desirable

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natural incisor, allowed the reproduction of

a copy in composite (Fig 26). Using this

copy, the tooth was divided into three lay-

ers: 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 me-

chanically prepared:

� type one was made only of dentinal

body

� type two was made of the base dentin

together with dentin that had been

anatomically modeled to reproduce the

incisor opalescence of a young tooth

(three mamelons), adult (horizontal win-

dow), 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 val-

ues (Fig 28).

Serial impressions were taken from these

models that could be inserted in a special-

ly created laboratory flask using a trans-

parent 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 avail-

able 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 deci-

sions on knowledge and clinical experi-

ence, with the aim of selecting three den-

tal ages.

Fig 28 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.

Fig 27 The rigid silicone guides for the preparation

of dentinal masses and the pre-constructed dentinal

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.

Fig 29 The flask is used to form the enamel, curing

the material through the transparent silicone in order to

obtain a sample with an even thickness.

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� Clinicians and specialized dental tech-

nicians possess an extraordinary

amount of knowledge and expertise

concerning the problems linked to re-

producing the color of natural teeth

and the suitable materials.

� By listening to their suggestions and

analyzing materials using color-

measuring instruments that are avail-

able today (spectrophotometer), the

manufacturers could further simplify

their systems, which would be ex-

tremely advantageous for everyday

dentistry practice. Indeed, it was found

that the best clinical performance was

provided by products produced in this

spirit of collaboration.

Three composite teeth were reproduced

with evenly distributed thicknesses of ma-

terial for each brand of composite and

thus, the final results were easy to compare

(Figs 30 and 31). The data acquired by the

authors during this experience was cer-

tainly empirical, but very close to the clini-

cal reality of everyday dentistry. Therefore,

it was considered to add value to the as-

sertions above.

� Every composite system on the market

can be reduced to a limited number of

syringes that are useful in reconstruct-

ing all natural teeth. Any exceptions can

be dealt with by using special effect

masses and super colors, which are

suitable for emphasizing particular

translucencies and individual features.

� 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 compos-

ite, it is imperative to construct a person-

alized color scale made of samples of

even thickness in order to identify the

correct mass.

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 fi-

nal evaluation.

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Clinical case

The patient was a 32-year-old female with

high esthetic demands who came to the

clinic requiring emergency treatment, hav-

ing herself glued on a fragment of com-

posite to a pre-existing restoration on tooth

11 using cyanoacrylic glue. She reported

no pain or thermal sensitivity, but com-

plained about a slight sporadic bleeding of

the gums. A clinical examination (Fig 32)

revealed a number of resin restorations on

teeth 11, 21 and 22, which were incon-

gruous for emergence profile, color, and

degree of finish, with discolored margins

infiltrated by secondary caries. More im-

portantly however, restorations were es-

thetically 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-

clusively accessed via the mesial inter-

proximal 3rd class cavity, with a conse-

quent periapical asymptomatic lesion

(Fig 33).

After careful cleaning and a motivating

oral hygiene session (Fig 34), the treat-

ment plan proceeded with an accurate

cleaning of the cavity to eliminate the car-

ious infiltrations. The margins were pol-

ished to eliminate areas which could retain

bacterial plaque and the root canals were

then correctly re-treated.

Fig 32 Pre-surgical image showing the patient’s at-

tempt to glue on a broken fragment of composite on tooth

11. Alterations to the pre-existing restorations and evi-

dence of the degree of contamination by bacterial plaque.

Fig 33 Radiograph of endodontic treatment of tooth

22 with access through the mesial cavity of the 3rd

class cavity with perio-apical lesions.

Fig 34 View of incisor group after oral hygiene, mo-

tivational talk to patient, and cleaning of provisional

restorations.

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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 tak-

en before the restoration work was carried

out. A diagnostic waxup was made on ex-

tra hard plaster casts (Fig 35). These plas-

ter models were used to create a series of

laboratory-made rigid silicone guides for

palatal support, and sectioned in a saggi-

tal plane in a vestibular-palatal direction as

well. These guides are indispensable in de-

termining palatal walls and controlling the

thickness of the composite during the strat-

ification 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

scalpel blade where necessary, the provi-

sional composite fillings were removed us-

ing a medium grain cylindrical diamond

bur (Fig 36).

The preparation of the enamel was lim-

ited 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 us-

ing 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

enamel which would break off during poly-

merization contraction and lead to discol-

oring and infiltration of the restoration. This

Fig 35 Laboratory-created silicone stent based on

the waxup.

Fig 36 Isolation of the field with rubber dam and

cavity preparations (palatal view)

Fig 37 Finishing cavity margins step.

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operation was carried out under a constant

cooling spray (Fig 37).

Once the cavity preparation was fin-

ished, a silicone stent made it possible to

visualize form, thickness, future dimen-

sions, and correct interproximal relation-

ships. This is of significant help as it ren-

ders 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-

agement as they allow the clinician to re-

alize and simply and intuitively correct

emergence profiles. These are the tools to

correctly manage the build up of restora-

tions, eliminating any excess of material

which otherwise would demand laborious

and difficult remodelling interventions that

risk damage to the adjacent teeth and los-

ing 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-

cent teeth during the phases of etching

and adhesion (Fig 40). The combined ap-

plication of a stable stent and sectional

matrices allows the clinician to simply and

intuitively manage even the most com-

plex dental forms in a single step, thus op-

timizing 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 differ-

ent layers of dentin and gradually covering

Fig 38 Use of a sectional transparent matrix to restore

the correct emergence profiles and contact points.

Fig 39 Layering step, 3rd class cavity on tooth 22.

Fig 40 Use of the sectional matrix during the cavity

etching phase to avoid contaminating the contiguous

elements.

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Fig 41 Combined use of the silicone stent and sec-

tional matrix to contemporarily “box up” palatally and

interproximally.

Fig 42 Silicone stent in the vestibular/palatal section

on a waxup.

Fig 43 Layering phase. Distribution and thickness of

the different masses are controlled in the vestibular/

palatal section through the use of the sectional silicone

stent.

Fig 44 Combined use of silicone stent and the sec-

tional matrix for the control and stratification of the

emergence profile and mesial contact point.

Fig 45 Reconstruction step of the dentinal body us-

ing the color desaturation technique working in a

palatal-to-vestibular direction.

Fig 46 Realization of the incisal opalescence and in-

ternal features.

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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 inves-

tigative phase.

Management of the internal compos-

ite thickness is controlled using another

laboratory-produced rigid silicone matrix

sectioned in the sagittal plane (Fig 42).

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 low-

er 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 glyc-

erine, which eliminates oxygen access to

the surface. This prevents the composite’s

complete polymerization and reduces the

surface resistance of the material (Figs 45

to 48).

Fig 47 Vestibular composite enamel and final step of

curing using glycerine gel.

Fig 48 Search for macro- and micro-surface texture

before final polishing.

Fig 50 Good esthetic integration of restorations and

health of the periodontal tissues 30 days after treatment.

Fig 49 View of reconstructions and rehydrated ele-

ments after 72 hours.

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servative and financial advantages for pa-

tients.

Doubts that clinicians may have are

usually associated with the amount of chair

time required as well as the difficulty in

achieving good esthetic results every day.

As a consequence, more invasive tech-

niques such as ceramic restorations are

favored.

The authors believe that operation

times are inevitably linked to certain oblig-

atory steps (preparation, adhesion phase,

buildup with limited quantities of compos-

ite in order to reduce contraction, correct

curing times for each layer of material).

Nevertheless, with the instruments and

guides that have been analyzed in the

present article, the stratification technique

can be key to the long-term success of the

restoration from both a clinical and esthet-

ic point of view. This enables the clinician

to avoid short-term disappointments that

require re-facing and a waste of time.

It is crucial to understand that a suc-

cessful restoration begins with the correct

choice of a base material. However, there

is no miracle material on the market and

the final result is fundamentally linked to the

Final polishing is fundamental to the es-

thetic success of the restorations, as a

shiny smooth surface reduces plaque ac-

cumulation and prevents the teeth from

discoloring (Shiny System, Micerium). In

the end, the polished restoration had a

surface very similar to that of a natural

tooth (Figs 49 and 50). However, this lev-

el of clinical result obtained with a direct

technique is possible only with correct

and accurate management of form and

buildup. These parameters must be deter-

mined before clinical procedures are car-

ried out (Figs 51 and 52).

Conclusions

Today, composite materials allow clini-

cians to realize restorations on a high es-

thetic level while being minimally invasive,

affordable to patients, and long lasting.26

In

addition, the associated risk level over time

is low and manageable. Re-intervention is

relatively easy and cheap, and fractures or

defects that may appear in time are re-

pairable without the necessity to remake

the whole restoration, which provides con-

Fig 52 Two-year follow-up.Fig 51 Radiographic check of restorations and root

canal treatment (a) and radiographic check of restora-

tions 2 years after treatment (b) with resolution of api-

cal radiolucency.

a b

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clinician's manual skills and, what is more,

to skills in choosing the correct techniques

that simplify everyday work (Fig 53).

In this profession, success should not

be measured solely by exceptional results,

but rather by a good everyday standard

with regard to time management and lim-

iting long-term risk.

Acknowledgements

The authors wish to express their heartfelt gratitude to

the following people: Dr G Paolone (Rome) for his help

in compiling the bibliography, Dr F Menghetti (Grosset-

to) for the root canal and surgical treatment of the clin-

ical case, and Mr D Rondoni (Savona) for his precious

collaboration in analyzing the composite.

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

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