CLINICAL REPORT

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Esthetic anterior composite resin restorations using a singleshade: Step-by-step technique

Mario F. Romero, DDS

ABSTRACTChildren and young adults often present to a dental practice after accidents that affect theiranterior teeth. In many situations, only 1 tooth is affected by the trauma, and choosing the righttreatment option can be complex. Esthetic restoration of the maxillary anterior dentition can beaccomplished by using direct or indirect techniques. Direct resin composite restoration can becharacterized as a life-like definitive restoration and is a predictable, conservative, and reliablechairside procedure. This article describes a straightforward protocol used to restore a patient’sappearance with a single-shade composite resin after a Class IV fracture received during a sportingevent. (J Prosthet Dent 2015;114:9-12)

Esthetic anterior compositeresin restorations are essentialin modern dentistry. Bondingto enamel is reliable if the cor-rect technique is used,1 and theimproved optical properties oftoday’s composite resins allowaccurate replication of toothshade and translucency.2,3

Accidents that cause anterior teeth to fracture arecommon in children and young adults and are mainlyrelated to sports. Even though direct and indirect treat-ment options exist, the common treatment option forthese patients is a direct composite resin restorationbecause it is conservative, predictable, repairable, andinexpensive.4,5 The esthetic demands of the patient orparents should be considered before deciding on thetechnique (layered monochromatic or layered multi-chromatic restoration) to be used, so that the esthetics ofthe smile and face can be restored.6 Strictly mono-chromatic restorations are a common approach but oftencannot reproduce the highly chromatic incisal third ofyoung incisors. However, multichromatic restoration(combining different opacities) can be complex and timeconsuming, and if different opacities are not combinedcorrectly, the results can be compromised. This articledescribes a straightforward technique using a single bodyshade (B) composite resin and color modifiers to suc-cessfully restore a (Class IV) fractured central incisor andthe esthetic appearance of a compromised smile.

CLINICAL REPORT

A caries-free, 23-year-old Hispanic man expresseddissatisfaction with the appearance of his smile. Hisdental history revealed that he had fractured the

fessor, Department of Oral Rehabilitation, Georgia Regents University, Coll

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maxillary right central incisor during a high schoolwrestling match and that it had been restored 11 yearspreviously (Fig. 1). The esthetic evaluation revealedthat the previous composite resin restoration did notmatch the contralateral tooth in color, length, contour, ortexture. The incisal third of this tooth was fairly trans-lucent with a white opaque line at the incisal edge thatcreated a halo appearance. The mesial incisal line anglewas uniform and sharp, whereas the distal angle wasrounded with a pronounced incisal embrasure (Fig. 1).The vitality and periodontal health of the affected toothwere normal.

After reviewing the direct and indirect restorativeoptions with the patient, a decision was made to place adirect composite resin restoration. As has been recom-mended, a diagnostic cast and waxing were developed(Fig. 2),3 and a polyvinyl siloxane (Sil-Tech; IvoclarVivadent) lingual matrix was fabricated.7 After localanesthesia with infiltration of 2% lidocaine with1:100 000 dilution of epinepherine (Xylestesin-A 2%; 3MESPE) was administered, the tooth was isolated withrubber dam, and the previous restoration was removed.A 1.5-mm 75-degree functional esthetic enamel bevel8

was prepared with a diamond rotary instrument (prod-uct no. 8888; Brasseler) on the facial surface (Fig. 3). Thelingual bevel was a 45-degree functional bevel.8 A coarse

ege of Dental Medicine, Augusta, Ga.

9

Figure 1. Preoperative view and esthetic evaluation. Figure 2. Diagnostic waxing.

Figure 3. Functional esthetic bevel. Figure 4. Bevels extended interproximally and apically on facial surface.

Figure 5. Lingual matrix evaluation. Figure 6. Lingual increment.

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disk (Sof-lex; 3M ESPE) was then used to extend thebevels interproximally and extend the facial bevel apicallytoward the middle third of the facial surface (Fig. 4), tocreate what has been called an infinite bevel.3 Poly-tetrafluoroethylene (Teflon) tape was placed on both ofthe maxillary lateral incisors to prevent bonding toadjacent teeth. This was followed by application of 35%

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phosphoric acid (3M ESPE) to the enamel (on the facialsurface it extended to the infinite bevel) and dentin for 15seconds. The acid etchant was then rinsed for 30 seconds,excess water was eliminated, and 2 layers of a dentaladhesive was applied by agitating the adhesive onto thetooth surface for 20 seconds. (Scotchbond Universal; 3MESPE). A gentle stream of air was used to eliminate the

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Figure 7. Second increment placed on portion of lingual bevel notcovered by first Increment.

Figure 8. Anatomic dentin lobes.

Figure 9. Color intensifiers. Figure 10. Final layer.

Figure 11. Immediately after placement. Figure 12. One week postoperative evaluation.

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solvent, and the adhesive was light polymerized for 20seconds. The lingual matrix was first seated to ensureproper fit (Fig. 5), followed by the application of a thinlayer of A3 body shade nanofilled composite resin (FiltekSupreme Ultra; 3M ESPE) onto the matrix, which wasthen seated (Fig. 6). A second increment of the samecomposite resin was then placed on the portion of the

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lingual bevel not covered by the first increment and onthe incisal aspect of the fracture with sufficient opacity tohide the fracture line (Fig. 7). A3 body shade compositeresin was shaped into 3 lobes to mimic the naturalanatomy and left approximately 1 mm short of the incisaledge. This increment was also extended over the beveledfacial surface (Fig. 8). The space between each lobe and

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the spaces between the lobes and incisal edge were usedto add iridescent blue and opaque white color modifiers(Vit-l-esence; Ultradent Products Inc) to recreate the haloeffect and decalcification spots (Fig. 9). A final incrementof the same shade was placed on the facial surfaceextending from the beveled area toward the incisal edge,with the composite resin placement instrument lubri-cated with wetting resin (Ultradent Products Inc) tofacilitate handling of the composite resin (Fig. 10). Thefinishing process was initiated with coarse and mediumcoarse disks (Sof-lex; 3M ESPE), following the contoursof the contralateral tooth, followed by the fine (8888;Brassler USA) and extrafine diamond rotary instruments(ET6; Brasseler USA) for texture and microanatomy.Finishing strips (Sof-lex; 3M ESPE) were used inter-proximally to eliminate flash, and coarse, medium, andfine rubber polishing points were used on the lingualsurface (Jiffy Polishers; Ultradent Products Inc) afterocclusal adjustment (Fig. 11). Definitive esthetic qualityof the shade and texture of the restoration was evaluated7 days postoperatively (Fig. 12).

DISCUSSION

Preoperative esthetic analysis, including the use of pho-tographs, is a key factor in selecting the restorative tech-nique to be used. The decision to use a single shade (andopacity) or a combination of shades (2 or more opacities)depends on the individual characteristics of the incisalthird. Some patients will present with little to no intrinsiceffects at this level, and a monochromatic restoration willserve them well. However, other patients will have acombination of translucency, white spots, and a halo ef-fect that will require special attention to detail by theclinician.

With the improved optical properties of today’scomposite resins, a monochromatic restoration enhancedby the use of resin color modifiers can deliver excellentresults and eliminate the possibility of either an opaqueor translucent restoration when an inadequate combi-nation of shades is used. By incorporating the lingualmatrix technique, the clinician has a guide with which todevelop the correct lingual proportion and shape createdin the diagnostic waxing that helps save chair time. Theintermediate composite resin layer was placed in a waythat recreated the dentin mamelons. If a monochromaticrestoration were chosen for treatment, a uniform dentinlayer would achieve a good result. Between the mame-lons, a thin layer of the chosen color intensifiers wasplaced. Opaque white, translucent gray, ochre, and

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iridescent blue are used the most, and choosing theappropriate one depends on each individual patient.

The facial aspect of the restoration should be devel-oped in 3 separate increments. The first and secondlayers should recreate the mesial and distal line angles. Inthe clinical treatment presented, this was created bymeans of the Mylar pull technique, in which the strip isdisplaced to the lingual side prior to light polymeriza-tion.9 The third layer should be a flat layer of compositeresin filling the area between the line angles. Specialattention should be given, while restoring this area andduring the finishing process, because many young pa-tients will require creation of developmental grooves andsecondary anatomy in the incisal third. The finishingprocess should be minimal and oriented toward dupli-cating gingival and incisal embrasures as well as creatinga polished surface that resembles the texture present inthe neighboring teeth.

SUMMARY

The high predictability and simplicity of the technique andthe improved optical, physical, and handling properties ofthe materials presented in this article allow them to beused by any experienced clinician to achieve a naturaldefinitive appearance that can meet or many times exceedboth the patient’s and the clinician’s expectations.

REFERENCES

1. Simon JF. Principles of adhesion and bonding. Consideration for making thebest clinical choices. Inside Dentistry 2014;10:88-93.

2. Denehy G. The importance of direct resins in dental practice. Pract Peri-odontics Aesthet Dent 1999;11:579-82.

3. Fahl N Jr. Predictable aesthetic reconstruction of fractured anterior teeth withcomposite resins: A case report. Pract Periodontics Aesthet Dent 1996;8:17-31.

4. Bello A, Jarvis RH. A review of esthetic alternatives for the restoration ofanterior teeth. J Prosthet Dent 1997;78:437-40.

5. Roeters JJ. Extended indications for directly bonded composite restorations:A clinician’s view. J Adhes Dent 2001;3:81-7.

6. Mondelli RFL, Oltramari PVP, Taveira LAA, Lopes LG, Mondelli J. Multi-disciplinary approach to the establishment and maintenance of an estheticsmile. Quintessence International 2012;43:853-8.

7. Denehy GE. Simplifying the class IV lingual matrix. J Esthet Restor Dent2005;17:312-9.

8. Vargas M. Conservative aesthetic enhancement of the anterior dentition using apredictable direct resin protocol. Pract Periodontics Aesthet Dent 2006;18:501-7.

9. Willhite C. Diastema closure with freehand composite: Controlling emergencecontour. Quintessence Int 2005;36:138-40.

Corresponding author:Dr Mario F. RomeroCollege of Dental MedicineGeorgia Regents University1120 15th St, GC-4328Augusta, GA 30912Email: Maromero@gru.edu

Copyright © 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.

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