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Direct Anterior Composites: A Practical Guide

ARTICLE in DENTAL UPDATE MAY 2013

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Louis Mackenzie
University of Birmingham
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Retrieved on: 15 August 2015
RestorativeDentistry

Louis Mackenzie

Dipesh Parmar, Adrian CC Shortall and FJ Trevor Burke

Direct Anterior Composites: A


Practical Guide
Abstract: For more than 40 years dentists worldwide have been using directly placed resin-bonded composite to restore damaged
anterior teeth. While such techniques are invariably more conservative of tooth tissue than indirect procedures, operative techniques using
direct composite can be challenging and are considered technique sensitive. Clinicians require both technical and artistic skill to provide
composite restorations that restore function and aesthetics to blend seamlessly with the residual dentition. This paper provides an update
on the aesthetic considerations involved in the restoration of anterior teeth with directly placed composite and outlines the contemporary
materials, equipment and techniques that are available to optimize every clinical stage.
Clinical Relevance: Successful restoration of anterior teeth with direct composite is an integral component of contemporary clinical practice.
Dent Update 2013; 40: ??????

In 1973, Dental Update published a prize- years and left all other future restorative Therefore, when aesthetic demands are
winning paper detailing a new application options open. high, many practitioners still resort to more
for resin composite in the restoration of Following the work of such destructive indirect procedures, relying on
a fractured central incisor of a ten year- early innovators, the last four decades have their technicians to employ well-established
old patient.1 While the procedure was seen remarkable technological advances in ceramic techniques to mimic the complex
considered a provisional method of long- the fields of aesthetic and, more recently, optical properties of natural teeth.
term stabilization prior to a definitive indirect minimally invasive dentistry. The dental With the objective of reducing
restoration, it was noted that the technique literature now even contains entire textbooks this tendency, this paper aims to provide:
offered a number of benefits:1 devoted to the aesthetic restoration of An overview of aesthetic factors to
The procedure maximized preservation of anterior teeth using direct composite.2,3 consider when to restore anterior teeth with
natural tooth tissue; Operative techniques and direct composite;
Minimal preparation (confined to enamel) materials with enhanced optical properties An update of the latest equipment,
provided a large area for retention via the have been refined to such a highly
acid-etch technique; sophisticated level that they present a
The patients appearance was immediately first line approach,4 delivering predictable
a
improved via a very good and simple means and reliable restorations5 of aesthetic and
of restoring aesthetics; functional excellence, rivalling the best
6

The technique allowed the endodontic ceramics7 (Figure 1). The great popularity of
status to be monitored over a number of composite resin restorations also results from
their acceptable longevity at relatively low
financial cost.8
While anterior composites
Louis Mackenzie, BDS, MSc, BDS, LDS b
restorations are ubiquitous, advanced
RCS, Dipesh Parmar, ???????????????,
multiple-layering techniques using a range
Adrian CC Shortall, BDS, DDS, Reader
of shades, opacities and translucencies
in Restorative Dentistry and FJ Trevor
remain the domain of relatively few
Burke, DDS, MSc, MGDS, FDS RCS
practitioners.2 Dentists commonly
(Edin), FDS RCS, FFGDP (UK), FADM,
report that such techniques are time-
University of Birmingham School
consuming or complicated and do not Figure 1. (a,b) Direct composite restoration of
of Dentistry, St Chads Queensway,
offer predictability in terms of aesthetics.2 two fractured incisors.
Birmingham B4 6NN, UK.
2 DentalUpdate May 2013
RestorativeDentistry

materials and techniques that will enable also professionally satisfying, as dentists are their functional survival using conservative
predictable aesthetic restoration of teeth in entirely in control of an aesthetic, biologically renovation techniques such as:
commonly occurring clinical situations respectful technique, without the risk of Re-polishing to regain surface lustre that
(Table 1). communication errors that are common is commonly lost from direct composite over
with indirect procedures.12 In common with time;
the pioneering dentists of 40 years ago, Refurbishing restorations to remove
Advantages of anterior practitioners using these minimally invasive marginal stain (Figure 3);
composites techniques preserve all future treatment
Minimally invasive options.
The main advantage of direct a
adhesive procedures is that they require
minimal (or no) tooth preparation to Disadvantages of anterior
enhance resistance and retention form6 composites
(Figure 2). Multiple studies confirm that these Biological
conservative techniques offer a number of Although direct techniques
benefits compared to indirect restorations, generally maximize tooth tissue
including:9 preservation, it must be stressed that, as with
Significantly fewer endodontic any restorative procedure, an irreversible
complications;10 cycle of restoration replacement and repair
More favourable mode of failure; begins with every operative intervention.
Re-intervention is easier as restorations are The risk/benefit ratio must be considered at
more reversible and amenable to repair; the outset and the patient informed of the
Occlusal scheme can be assessed and potential short- and long-term complications
corrected immediately; that may ensue and his/her ongoing
Reduced risk of wear to opposing teeth. maintenance requirements (Table 2).
b
Aesthetics Longevity
It is a well-established fact Regardless of material, the
that the appearance of a patients teeth average survival statistics for direct
is an important psychological factor restorations are far from encouraging.12,13
influencing his/her attractiveness and self- However, the figures for indirect restorations
confidence.3,11 Techniques that enable the are also poor, averaging approximately
immediate restoration of aesthetics in a ten years before restorations require total
single appointment, requiring no provisional replacement13,14 and, when failure occurs,
restorations and at a lower financial cost, are complications are often catastrophic for the
popular with patients.5,8,12 tooth. With an optimum technique, it should
These versatile procedures are be possible to provide direct composite
restorations that exceed the average lifespan
of indirect restorations and, in addition,
retain the option of being able to increase
Caries management Figure 3. (a, b) Direct composite renovation
Fracture repair using finishing and polishing techniques to
Management of non-carious tooth a remove marginal excess/stain.
tissue loss
Aesthetic improvement by modifying
Post-operative sensitivity
colour/shape/length/alignment, etc
Marginal discoloration
Diastema closure
Restoration fracture
Trial, temporary, long-term
Restoration de-bond
provisional or core restorations b Wear of opposing teeth
Repair of indirect restorations
Iatrogenic damage
Replacement of missing teeth, eg
Pulpal injury
using fibre-reinforced composite resin-
Restoration removal results in an
bonded bridges
increase in cavity size
Table 1. Indications for restoring anterior teeth Figure 2. (a, b) Cosmetic diastema closure using Table 2. Potential complications of aesthetic
using direct composite. direct composite, with no tooth preparation. restorative procedures.

May 2013 DentalUpdate 3


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Re-sealing restorations Ideally, on smiling the entire labial surface central incisors should touch the lower lip at,
Localized repair of the central incisors should be revealed or just behind, the wet/dry border.17,18
and approximately 02 mm of marginal
gingival;17,18 Dental aesthetic factors
Technique sensitivity
Restorations should be designed to allow When providing anterior
The main determinant of success
interdental papillae to fill each interdental restorations, it is useful to refer to widely
in any direct adhesive procedure is based
embrasure3,21 (Figure 4); recognized guidelines describing the key
upon the operators skill in optimizing
The upper central incisor midline should factors that influence the overall dental
assessment, diagnosis, treatment planning/
be vertical and perpendicular to the appearance.17,18,19,24 Tooth shape is generally
sequencing and execution and all operative
interpupillary line; considered to be the most important
stages.15 When providing restorations in the
Ideally, the midline should correspond to determinant of successful aesthetic
aesthetic zone, these demands must extend
the facial midline, but deviation up to 4 mm integration.3,6 Furthermore, a restoration
to detailed anatomical knowledge and
is not usually detectable;3,22 with the correct shape and surface texture is
artistic skill. Therefore it is essential to have
Resting incisal display (often referred likely to integrate with the residual dentition
comprehensive understanding with regard
to as the M position) should average successfully, even when small colour
to:
approximately 12 mm in young males and disparities exist2,3
The optical properties of natural teeth;16
34 mm in young females;23 (Table 3).
Tooth proportions and their relationships
When making an F sound, the tips of the
to each other and to the surrounding soft
tissues; Tooth shape
Selection of appropriate restorative This relates not only to the
materials that match adjacent residual tooth a outline form of individual teeth, but also to
tissue. their relative proportions and relationships
The following summary of the to each other. Useful restoration guidelines
fundamental principles of aesthetics in include17,18,19 (Figure 5):
dentistry aims to provide the basis on which Central incisors should dominate the
to design and carry out aesthetic direct patients smile and be symmetrical to each
restorations involving the maxillary anterior other;
teeth. The ratio of width/length dimensions of a
b

Key factors influencing the


aesthetic properties of anterior
maxillary teeth 1. Tooth shape;
A complex range of interrelated 2. Surface texture;
factors combine to determine the overall 3. Colour.
aesthetic properties of each individual Table 3. Principal factors affecting dental
patients smile. Principles of smile design are aesthetics, in order of importance.
c
well-documented and the dental literature
contains a number of excellent publications
which provide guidelines for restoring the
aesthetics of anterior teeth.17,18,19 It should
be emphasized that these guidelines are not
designed to form dogmatic rules to which all
restorative procedures must adhere.
d
Extra-oral and soft tissue aesthetic factors
The facial and periodontal tissues
are key ingredients in dental aesthetics.20
Useful guidelines for the relationships
between teeth and these structures are as
follows:17,18,19
The smile line (aka incisal line) is the
imaginary line joining the upper incisal Figure 4. Direct composite restoration of
edges and canine tips and should generally four carious incisors (a, b, c) and at review Figure 5.Study of ideal maxillary anterior teeth:
(d) demonstrating restitution of interdental (a) informs direct composite shaping procedures
follow the curve of the lower lip on
papillae.21 (b, c).
smiling;17,18,19
4 DentalUpdate May 2013
RestorativeDentistry

central incisor should ideally be 7580%;3 outline. The junctions of these zones, colour within the tooth: for example, canine
Incisal edges of central (and lateral incisors) widely referred to as transition lines, are key teeth are usually more chromatic than their
should be generally parallel to the patients features in restorative dentistry.2,3,16 Accurate mesial and distal neighbours as they have
interpupillary line; positioning of transition lines in direct (and a greater thickness of dentine showing
Distal incisal line angles should be more indirect) restorations is critical if restorations through the relatively translucent enamel.3
rounded than their mesial counterparts and are to blend seamlessly with the residual Value: This is considered to be the most
incisal embrasures should increase in depth, dentition.6,16,19 important factor in shade matching2,3
moving distally from the midline; and refers to the brightness of the tooth/
While the majority of lateral incisors are restorative material. High value teeth
Secondary surface texture
asymmetrical, their incisal edges should appear bright as interpreted by the rods in
This is referred to as macrotexture
be approximately 0.51.0 mm shorter than the retina.25 Hue and chroma are detected
and includes:
those of the central incisors (and canines) by cones25and small variations in them will
Developmental lobes (usually three) on the
and their maximum width approximately 2/3 be imperceptible if the tooth/restoration
labial surface;
that of the central incisor; value blends.2,3
Developmental grooves of varying length
The frontal smile should show only the Before selecting materials
dividing the lobes longitudinally;
mesial of canine teeth and the long axis designed to mimic natural teeth it is
A cervical bulge in the gingival third;
of all the anterior teeth should ideally be essential to understand how the optical
Mamelons (often present on the tips of
slightly mesioangular.6 properties of the various tooth layers
unworn incisors in young patients);
influence overall colour.6,12,24
Surface texture Enamel, dentine, pulp and the
Tertiary surface texture amelo-dentinal junction (ADJ) all possess
Following shape, restoration
This is referred to as microtexture different optical properties, which are
surface texture is the next most important
and includes: determined by their composition, structure
factor influencing successful intergration3
Accessory ridges/grooves; and relative thicknesses. These tissues are
and requires a detailed understanding of the
Perikymata - very small surface striations constantly evolving via dynamic interaction
equivalent anatomical features in natural
caused by the formation of enamel prisms with the extrinsic and intrinsic environments
teeth.2,3
(Figure 6); via numerous exchange processes.27
The labial surface texture of
Imbrication lines - subtle, broken, crescent- Numerous natural colour changes occur
young, unworn teeth is highly reflective and
shaped ridges on the cervical bulge, running throughout life.
results in an attractive bright appearance
parallel to the amelo-cemental junction.
(Figure 6).3 Surface texture features may be
divided into three groups. Dentine
Tooth colour In terms of colour, dentine may
Primary surface texture While tooth colour is not be considered the most important layer.28 It
When incident light strikes considered to be the prime factor provides most of the tooths hue which falls
the labial surface of an anterior tooth the determining successful restoration in the yellow/red portion of the spectrum.
majority is reflected back to the observer. integration, it is still a vital component and In natural teeth, light passes through the
This reflective area, which has various is certainly the most complicated parameter. translucent enamel and is reflected from the
names (reflective face/zone; apparent face; The dental literature contains numerous yellowish, relatively opaque dentine, which
silhouette form), is bordered by curved articles devoted entirely to the subject.25 The is approximately 20% less translucent than
surfaces which deflect light giving a darker following outline describes aspects of tooth enamel4 (Figure 7).
colour relevant to direct anterior restorative Dentine colour varies from
techniques. patient to patient and from tooth to tooth
and changes throughout life.27,28 These
variations are influenced by its composition,
Basic tooth colour theory
which is mainly mineral hydroxyapatite
Dentistry is amongst a number
crystals (70%) supplemented by organic
of disciplines that have adopted the famous
material (20%) and water (10%).
Munsell system26 which describes colour in
The organic component is
terms of three basic properties: hue, chroma
partly responsible for making dentine more
and value.
opaque than enamel.28 Opacity is further
Hue: This is the name of the colour
increased by its tubular structure which
and refers to the portion of the spectrum
deflects some of the light rays entering the
(wavelength of light) reflected by teeth
Figure 6. The optical properties of natural teeth tooth.28
back to an observer. Natural tooth colour
and aesthetic restorations are highly influenced The dentine core contour is
has been described as a true colour mosaic
by primary, secondary and tertiary surface as complex as enamel surface texture and
in the yellow/white colour range.27
texture comprises dentine lobes (usually three)
Chroma: This describes the saturation of
May 2013 DentalUpdate 5
RestorativeDentistry

divided by grooves labially and incisally. In largely translucent optical properties.27 The struck by invisible/short wave ultraviolet
unworn teeth, dentine terminates in the overall appearance of enamel depends on a light, reflecting it back as visible, bluish
incisal third, short of the incisal edge. complex interaction of factors2,3,29 (Table 4). longer wavelengths.16 Therefore, for
successful integration, dental materials
should possess fluorescent properties.
Amelo-dentinal junction Translucency
The interface between enamel For successful restoration
and dentine plays an important role in light integration, accurate replication of Characterization
transmission. It has a high mineral content translucency is considered to be almost as Localized mineralization
and may be considered to have properties important as value.29 The translucency of differences, of varying aetiologies, are
similar to a fibre optic cable.28 natural enamel (and restorative material) common in tooth structure and may
is strongly influenced by its thickness27,29 result in unusual colourations. Detailed
(Figure 8). classifications16,30 provide a useful guidance
Enamel
Cervical enamel is thin (average when copying these features in composite
Enamel is 95% mineral (5%
0.20.3 mm in young teeth)27and highly resin (Table 5). Central incisors generally have
water and organic components) resulting in
translucent, allowing the more chromatic more elaborate incisal characterisation than
dentine to show through and creating a lateral incisors.6
considerably more opaque appearance.28
a
Moving incisally enamel thickness increases
Cracks and fissures
and it becomes less translucent. In the
Naturally occurring fissures
incisal third, enamel is thickest (average 1.5
(enamel lamellae) and cracks resulting from
mm)27 and may possess a localized bluish,
opalescent effect27 (Figure 8).

Opalescence
When very fine hydroxyapatite
crystals are illuminated by light in the visible
range of the spectrum, short wavelength
light is scattered.27 Reflected light results
in a blue/grey/violet appearance, often
extending to the proximal surfaces and
transmitted light results in amber/reddish/
orange effects. While these iridescent
phenomena may occur across the entire
labial surface, it is more evident in the incisal
b third, where there is no interference from
dentine.2,28

Fluorescence
Dental hard tissues (particularly
enamel and the ADJ) also fluoresce when

Composition Figure 8. Tooth section demonstrating enamel


Structure thickness in a natural central incisor and incisal
Thickness opalescence.
Transparency
Translucency/opacity Incisal halo effect
Opalescence Intensive white spots, clouds or
Fluorescence bands
Cracks and fissures Chromatic spots or bands, eg amber,
Figure 7. (a, b) To simulate the optical proper- Characterizations brown, white
ties of natural teeth, direct composite restoration Intensive colours Dentine lobes of varying colour
of Class V cavities generally requires only a thin
translucent enamel layer overlying more chro- Table 4. Factors influencing the optical Table 5. Colour characterizations in natural
matic dentine layers. properties of enamel. anterior teeth.

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functional forces fill with air and water, tissue, it should now be possible to select publications detailing the seemingly
effectively dividing the enamel surface into appropriate materials, equipment and limitless capabilities of direct composite
portions with differing optical properties.28 techniques judiciously for the accurate, for the precise restoration of damaged
These features also allow the passage of predictable, aesthetic restoration of anterior teeth, in a comprehensive range of clinical
stains which may extend to the dentine layer teeth using direct composite. situations.24,6,8,12,16,24,29,30,32,3437
and may be simulated using pigmented
composite resins.
Material selection Shade-taking
As with any restorative Analogous to natural tooth
Pulp procedure, a thorough understanding tissue, the appearance of dental restorations
Even the naturally dark red of materials science enables selection of is influenced by shape, surface texture,
colour of pulpal tissue has an influence on composite resins suitable for each clinical translucency/opacity, value, chroma and hue,
tooth colour and can result in a pinkish situation and optimizes the restoration of with each property combining to affect the
appearance, which reduces as pulp volume function and aesthetics. final outcome.
decreases with age.28 A wide range of composites While shape and surface texture
is available for the restoration of anterior are still considered of greatest importance,
teeth, all with subtly different formulations, predictable shade matching is an essential
Effect of age on tooth colour2,27,28 which can be confusing.8 Prior to purchase, requirement for all practitioners and a
Young enamel is thick, with lower practitioners are recommended to study, number of techniques are available to
mineral content, creating high value tooth test and select materials based on their facilitate this process.
colour. With age, mineral content increases fundamental physical properties rather than
and enamel thins due to natural wear. This focusing on their marketing literature. Filler
results in an increase in enamel translucency, Shade guides
content determines a materials mechanical
which may be pronounced or even While shade guides are included
properties and influences volumetric
transparent, allowing the dentine colour to with most composite systems, unfortunately
shrinkage. As with posterior composites,
show through. they are generally considered to be
hybrid materials are commonly used, as their
Young dentine is very opaque. inaccurate and unsuitable for precise colour
combination of large and small filler particles
With age, dentine become less opaque matching for a number of reasons:24,8,12,35,38
provides the strength necessary to withstand
but has more colour saturation as highly The majority of shade guides are not
functional forces.15
mineralized secondary dentine is laid down. fabricated from the restorative material that
Filler particle composition
Tertiary dentine, which has varying structure they represent;
and filler/resin refractive index mismatch
and composition, will also influence tooth Shade guides are generally less translucent
are among the most important variables
chroma. than natural teeth and restorative materials;3
in determining the optical properties of
The ADJ translucency increases Most shade tabs are of standard thickness;
individual materials.32
with age and it can sometimes become Incongruous composite shade
Where high functional forces
completely transparent. classifications are brand (and batch)
are not anticipated, resins containing low
Extrinsic and intrinsic stains can dependent;
average filler particle size (microfills) may
have a potent effect on tooth colour over Composite nomenclature can be
be selected for their superior polishability
time and this may be partially or completely confusing,2 for example, dentine, body and
properties.
reversed by tooth whitening procedures. opaque shades may be synonymous;
All procedures using direct
When restorative procedures There is poor correlation between
resin placement are considered technique
aimed at improving tooth colour are sensitive.15 Therefore, for successful,
planned, it is often recommended to carry predictable restorations, materials must
out whitening procedures first, reducing the be selected that possess the handling
need to mask darker colours with opaque HFO/HRI/Vit~l~Escence (Ultradent)
characteristics favoured by individual
materials. Following tooth whitening, it is Clearfil Majesty ES-2 Classic (Kuraray)
practitioners.12,15
not recommended to carry out adhesive Miris 2 /Synergy D6 (Coltene/Whaledent)
For clinical situations, where
restorative procedures for at least two weeks, Renamel Microfill/Nano (Cosmedent)
aesthetic demands are high, the majority of
to avoid the negative effects of oxygen Venus diamond/ Durafill VS (Heraeus Kulzer)
manufacturers supply materials in multiple
inhibition and to allow colour stabilization.31 Esthet-X HD /Ceram X duo (Dentsply)
shades. These are designed to be placed
Filtek Supreme Ultra (3M ESPE)
using stratification techniques similar to
IPS Empress Direct/ Tetric Evoceram (Ivoclar)
those used by dental ceramists6 (Table 6).
Clinical stages for restoring While the perfect composite
Gradia (GC)
anterior teeth using direct with optical properties identical to those
GrandiSO/ Amaris (Voco)
composite of enamel and dentine does not exist,2,33
Herculite Ultra/ XRV (Kerr)
Having studied the anatomical the dental literature now contains a Table 6. Examples of polychromatic composite
and optical properties of natural tooth growing number of ground-breaking resin materials designed to be applied in layers

May 2013 DentalUpdate 7


RestorativeDentistry

composite shades and those used for dental selecting shades for direct (and indirect) communication.16 Digital images may be
ceramics; restorations, including: underexposed or manipulated with software
Composite resins frequently undergo Shade should be taken immediately at to reveal characteristic internal features,
a significant shade change during the start of restorative procedures before particularly occurring in the incisal third16
polymerization;39 dehydration has occurred (see below); (Figure 10).
Set composite resin material absorbs Study cavity configuration and anticipate
water post-operatively and this may result in optical requirements of the final restoration, Occlusal record
unpredictable colour changes;40 eg cavities extending from labial to palatal As with all restorative procedures,
Various techniques have surfaces must transmit light in the same way functional integration is as important as that
been described that aim to overcome the as the adjacent tooth tissue; required for aesthetic blending. Restoration
limitations of commercially available shade Assess (or measure) the cavity with regard of guiding palatal surfaces using direct
guides and include: to the relative quantities of missing enamel techniques presents challenges, but can be
Placing a sample of the material(s) on the and dentine;3 simplified by using a template constructed
tooth surface (or a suitable adjacent tooth).7 Note any discolorations that will require from a prototype restoration or a pre-
Ideally, use the same quantity required for masking with opaque material;4,12 operative wax-up3,6,7,34 (Figure 11).
the restoration and the test sample should Where both enamel and dentine are The initial palatal composite
be light-cured to account for polymerization exposed, take the shade of both (Figure 9); increment may be applied to a template
shade shift;2,3,15 When assessing control teeth, use the made of conventional silicone putty or
Chairside construction of customized middle third to record the basic shade;3 specialized transparent material before
shade guides made from genuine Take shade quickly. (After five seconds or after insertion into the mouth. Once
materials, which may be layered in various staring at a tooth or shade guide subtle light-cured, the palatal shell immediately
thicknesses;2,3,4,12 colours blend);28 establishes the three dimensional form of the
Practise prototypes copying anticipated Look away at a complementary (opposite) whole restoration.12
proportions of definitive restorations;3,6 colour, eg blue to re-sensitize the eyes to the
Purchase of materials with innovative yellow/orange/red spectrum;2,3,16,28
two component shade guides, eg Miris 2 Use different lighting sources to avoid
(Coltene-Whaledent); metamerism, where coloured objects appear
Purchase of systems containing shade the same under one light source and different
guides fabricated from composite, eg under another;27
CeramX duo (Dentsply) (Figure 9). Use a colour-corrected light source
(International daylight standard 5,500K) to
Shade-taking technique select hue and chroma;2,27
Various technique tips have Use less bright light to select value (5,500K
been identified to improve precision when is considered too bright for this).27

Colour mapping
As enamel loses water rapidly,
shade selection should be carried out as early
as possible and before isolation.3 Dehydration
blocks the passage of visible light and this
decrease in refractive index causes enamel
(and dentine) to become lighter and more
opaque, in less than three minutes.2
Maximum dehydration is reported
to occur 3045 minutes after isolation2 and
complete rehydration may not occur for
2448 hours.2 Dehydration also masks the
internal colour characteristics.3
For these reasons, experienced
practitioners refer to a pre-operative
photograph or diagram of well-hydrated teeth
to guide their placement sequences. This is
commonly referred to as a colour map.6,12,16,30 Figure 10. Pre-operative digital photographs
A good photograph used with enable colour mapping. (a) and may be
Figure 9. Enamel and dentine shade tabs an appropriate shade guide is reported manipulated with suitable software to accentuate
fabricated from composite. to be the most precise method of colour incisal characterizations (b).

8 DentalUpdate May 2013


RestorativeDentistry

moisture control for adhesive restorative guide restoration shape.


Cavity preparation procedures2,15 (Figure 13). Another useful isolation
In certain clinical situations, tooth Following isolation with a rubber technique for Class III, IV and V restorations
preparation may be avoided completely, eg dam, stabilizing cord, wedges or floss involves the use of gingival retraction cord,
fracture repair (Figure 12) or diastema closure ligatures may be used to optimize the seal which may be soaked in an astringent
(Figure 2). and prevent the dam partially obscuring product.34
Where preparation is necessary, adjacent teeth which are being used to
it should be minimized and confined to the
Matrix technique
enamel to optimize adhesion and reduce the
There is a variety of matrices
risk of marginal staining.
designed for anterior composites
Natural cavity undercuts or pulp a
restorations involving proximal surfaces.
chambers/root canals of endodontically
They are made from a number of translucent
treated teeth may also be used to enhance
polyester materials, commonly referred to by
retention.34 Particle air abrasion may be
the brand name Mylar. They are available in
employed to clean cavities and increase the
a number of shapes including: full contour
surface area available for micro-mechanical
crown forms, strips and specially designed
and chemical retention.4 In certain clinical
sectional matrices designed to facilitate
situations, it may be necessary to bevel
restoration of the complex curvature of
enamel margins to assist retention and
anterior teeth.3 Matrices should be secured
to mask the transition between the tooth
with suitable wedges to minimize cervical
structure and the restorative material.
excess, provide tooth separation and soft
Opinion varies on the size and
tissue control and stabilize the rubber
form (eg scalloping7) of enamel bevels or
dam.3,15 Thin metal sectional matrices
whether discs, ultrasonic tips or rubber points
designed for posterior composites may also
should also be used to remove fragile enamel
b be used or dead soft foil wrapped around
from preparation margins.3
adjacent teeth.
A popular technique employs
Isolation plumbers tape (Polytetrafluoroethylene
While use of a rubber dam is (PTFE) tape). This inexpensive, inert, non-
far from commonplace,41 it is generally sticky material is usually wrapped around
considered to be the optimum method of adjacent teeth to protect them from etch,
adhesive, and excess composite. PTFE tape
is of negligible thickness promoting tight

b
d

Figure 12. (ad) Fractured tooth fragments


Figure 11. (a, b) A silicone template made from may be adhesively reattached to deliver
a prototype restoration (or wax-up) simplifies unsurpassable aesthetic results, at negligible Figure 13. Rubber dam optimizes moisture
placement of the palatal composite increment. biological cost. control and may be stabilized with floss ligatures.

May 2013 DentalUpdate 9


RestorativeDentistry

contact formation34 and it does not interfere All composites shrink during techniques.2,29 The overall outcome is
with adaptation of silicone templates. polymerization and create stresses, with determined by the propagation of light as
the potential to cause a range of well- it passes through these layers to create an
documented complications.15 illusion of depth, equivalent to that seen in
Etching
Fortunately, the wide, open natural teeth 6,32,36 (Figure 14 ).
Before etching, cavities must be
configuration of many anterior cavities Unfortunately, a utopian
thoroughly washed, dried and inspected for
allows restorative material particles to material, engineered to replace enamel and
any debris. Starting with enamel, etchant is
flow during their polymerization reaction. dentine in their exact dimensions, does
applied to the entire cavity and just beyond
This relaxes stresses and often permits not exist.2 To avoid restorations having
the margins. Excessive etchant should not
placement of larger increments than those an excessively translucent, grey-looking
extend beyond this area, to prevent excess
recommended for cavities with a less appearance, it is widely recommended to
composite adhering and being difficult
favourable configuration factor. apply enamel composite layers in thicknesses
to remove without iatrogenic damage to
Composite increments may be no greater than half that of the total enamel
underlying enamel. When application to the
injected from compules or applied using thickness.2
dentine is complete, it is left for 15 seconds
a variety of instruments. Practitioners A wide range of composite
and then rinsed off thoroughly.
are recommended to master placement stratification techniques, of varying
With total etch systems, enamel
techniques with a select range of complexity, have been described.2 To
can be dried to a frosty appearance but
instruments designed for the purpose.2,15 ensure predictable, aesthetically pleasing
dentine desiccation should be avoided.
Composite may be warmed using specialized results, layering concepts should be simple,
This also promotes adhesion to dentine
(or improvised) heaters to enhance standardized and reproducible.3
and reduces the risk of post-operative
adaptation to the cavity and between The following basic dual-shade
sensitivity.12,15 Unprepared enamel should
increments.16 The common practice of and more complicated multi-layered
be etched for longer (3060 seconds)42 to
lubricating instruments with adhesive agents (polychromatic) placement sequences
optimize adhesion to the acid-resistant
should be avoided as they contain solvents
aprismatic surface layer of enamel.
that may dilute composite resin materials
and have negative effects on their physical,
Bonding optical and surface staining properties.44 a
As successful adhesion is a Solvent-free modelling liquids, eg
fundamental requirement for long-lasting Biscover (Ultradent), Enaseal (Micerium), are
restorations. Fastidious attention must be also available, but their use is not universally
given to manufacturers protocols.15 recommended,2,3 other than to recover the
Self-etching adhesives are not oxygen inhibited layer following corrections
recommended when restoring cavities that to subsurface increments using rotary
lack sufficient resistance and retention form instruments.2
(eg Class IV), as they contain weaker acids b
that will not sufficiently penetrate enamel to
a depth that maximizes resin-tag formation.43 Layering techniques
Before light-curing, all cavity Despite technological advances
surfaces should appear glossy/shiny.15 in contemporary composite systems, the
majority of practitioners use monochromatic
materials for anterior composites.2 Such
Placement techniques techniques are ideally suited for small c
A wide range of placement cavities but they may deliver sub-optimal
protocols have been proposed for anterior aesthetic outcomes in more aesthetically
resin composites. With multiple cavities important areas.
the general recommendation is to restore Although placement of
the central incisors first, one at a time, successive increments helps to minimize the
following the aesthetic principles previously effects of polymerization shrinkage stress,
described.34 Once complete, restoration of aesthetic layering techniques are considered
lateral incisors and then canines is carried problematic3 and less predictable than those
out.6 which use a single material.
Proficient operators tend Errors in layering techniques
to slightly overbuild restorations before result in restorations which appear too
reducing them to correct contour. This avoids translucent or opaque.
the need for time-consuming additions, The thickness relationship of Figure 14. (ac) The relative thicknesses of
enamel and dentine composite layers is critical to
which may also lead to visible layers/voids opaque dentine composites and translucent
success with stratification techniques.
between increments.3 enamels is the key to successful layering
10 DentalUpdate May 2013
RestorativeDentistry

enamel composite is light-cured in place.


In this example, using a silicone template
made from a pre-operative wax up (Figure
16a, b, c).

Dentine layer
To avoid a monochromatic
appearance, dentine lobes are restored
using progressively chromatic
increments2,3,16 (three in this example)
(Figure 16d, e, f). The dentine build-up
should stop short of the incisal edge and
should be shaped into lobes, leaving room
for the incorporation of materials designed
to replicate the appropriate optical
properties of the incisal third.2,3,16

Special features
These are very case specific.
In natural teeth, they are generally optical
properties of enamel, but materials aiming
to mimic these features are ideally placed
before the final enamel layer2 (Figure 16g).
Painting these features on
the surface layer often appears artificial,
because it lacks the quality of depth and
may wear off. When the translucent enamel
material is subsequently applied and
Figure 15. Dual-shade layering technique: (a) cavity preparation; (b) dentine layer; (c). enamel layer; (d) polished these features show through,
completed restoration. producing very natural appearances, such
as the incisal halo effect.6,16
Materials designed to
replicate special features may be divided
are presented as methodical guidelines then layered, freehand over the opacious into opalescents, characterizations and
for all clinicians wishing to create more central core at approximately half the intensives16,30 and are usually applied in
natural looking direct anterior composite thickness of residual enamel (Figure 15c, d). that order.
restorations.

Polychromatic layering Opalescents


Dual-shade layering technique Opalescent materials are
technique When aesthetic demands are
placed in spaces left between the dentine
lobes and, if required, extended into mesial
Inexperienced practitioners high, the widely accepted stratification
and distal proximal spaces.2,3,6,16
are recommended to develop confidence technique proposed by Lorenzo Vanini is
Opalescent composite
in layering techniques by beginning with recommended.16 As each clinical situation
transmits light more efficiently and is
two material shades, as this simplified presents different aesthetic challenges,
designed to reproduce the iridescent
technique is reported to deliver an study of detailed atlases2,3 describing the
optical properties commonly seen in the
acceptable colour match in a large number comprehensive range of layering options
incisal third.2 The degree of opalescence
of clinical situations.2 is highly recommended. The fundamental
is judged by the amount of blue that the
Following etching and principle of polychromatic layering
material shows under direct light and
adhesive application, an opaque dentine technique is to use different composite
amber features seen under transmitted
material is applied, shaped and light-cured shades to replicate the layers seen in natural
light. Composites specifically designed to
(Figure 15a, b). Most dentine restorative teeth,32,37 as demonstrated in Figure 16,
recreate opalescent effects include Trans
materials (and 80% of natural dentine) are which is now described in stages.
Opal (Empress Direct; Ivoclar), OBN (Enamel
in the shade group A and selection of the Palatal enamel layer Plus HFO, Micerium) and Effect Blue (Miris
correct chroma is a key to success.2 Palatal, A palatal shell of translucent 2, Coltene/Whaledent).
proximal and labial enamel increments are
May 2013 DentalUpdate 11
RestorativeDentistry

Figure 16. Use of different composite shades to replicate the layers seen in natural teeth.

Two generalized groups of Labial enamel layer seconds) from all angles; keeping the light
material may be used to create opalescent The final layer generally tip as close to the material as possible and
effects: tinted flowable materials or comprises an enamel or incisal material avoidance of premature polymerization
artificially achromatic enamel (AAE) with smaller average filler particle size by ambient light.16 A layer of translucent
composite,12 which is inherently pigmented with translucent (and often opalescent) material, such as glycerine, may be placed
and not keyed to the vita shade system.6 optical properties that modify those of the over final increment.34 This minimizes
Either material may be used to impart underlying layers (Figure 15g). contact with oxygen which inhibits surface
various degrees of translucency and subtle It is advisable to minimize polymerization.
hues, ranging through grey, blue, violet, the time spent manipulating superficial
amber, to milky white. increments to reduce the risk of
incorporating air bubbles, which may affect Shaping
the optical properties and/or be revealed Shape is the most important
Characterizations and during finishing and polishing procedures.2 factor in the final appearance of an aesthetic
intensives16,30 The final layer may be slightly overbuilt and restoration.2 It is therefore essential that
Experienced clinicians are then finished and polished to the correct the primary anatomical features of natural
capable of precisely reproducing a diverse incisal edge thickness. It is recommended teeth are meticulously reinstated using
range of characterizations, including those that the total enamel thickness should be appropriate burs, discs and finishing strips
listed in Table 5.2,3,16,30 a maximum of half of the thickness of the (Figure 18). Initial shaping may be carried
Intensives are used to recreate natural enamel that it replaces (or maximum out using red-stripe (30-40 m) composite
white spots or patches in teeth found thickness of 0.5 mm)3 to prevent restorations finishing burs. When shaping a single central
with hypoplastic and hypomineralization being too translucent, too low in value and incisor, the adjacent tooth should be studied
defects. White features vary in opacity not life-like.2,6 to re-establish symmetry by making the
extent and lack opalescence. A range of reflective face of both teeth equal.3
tinted conventional and flowable materials Repositioning of transition lines
may be applied using suitable instruments Light-curing can change the appearance of poorly shaped
or brushes (Figure 17) or mixed to copy While various alternative teeth, making them appear aesthetically
unusual colourations.2 It is recommended light-curing regimes have been proposed, pleasing even though their outline remains
to use them sparingly to avoid obviously general recommendations include: regular the same.3
unnatural appearances12 and to refer to equipment checks using appropriate Functional surfaces should
an adjacent tooth or a pre-operative light intensity meters; light-curing for be designed and contoured so that both
colour map. a suitable duration (usually at least 60
12 DentalUpdate May 2013
RestorativeDentistry

the restoration and tooth can tolerate the aesthetic/polishable microfill or small particle Fine polishing discs to create the attractive
anticipated occlusal forces.6 In patients with nano-hybrid material. surface lustre seen in natural enamel;
parafunction, more fracture resistant, large The correct shape must be Silicone rubber points and cups to
particle, hybrid composite is recommended, established before refinements are made; if introduce secondary anatomical features such
which may be veneered with a more this is not done the finishing and polishing as developmental grooves (Figure 19b);
process will tend to magnify any errors. Abrasive finishing strips to remove proximal
excess and refine emergence profiles;
Sharp instruments, eg scalpels or scalers to
Finishing and polishing remove unbonded excess;
techniques Tungsten carbide or coarse diamonds (used
Finishing and polishing are at stallout speed7) to create a perikymata
well-researched procedures45,46 and play an effect that increases the restorations value
essential role in the way that light interacts (Figure 19c);
with the restoration.2 The natural secondary Goats hair/chamois/felt wheels and
and tertiary surface texture features may all brushes to develop a high shine after all other
be simulated in direct restorations, using a stages have been completed (Figure 19d, e).
variety of equipment (Figure 19), including:6 Specialized polishing pastes of varying
Finer diamond or tungsten carbide particle size, eg Aluminium oxide;
composite finishing burs (yellow/white/purple A methodical approach is required to
stripe) to refine shape and correct marginal; complete each finishing and polishing
plaque retention factors procedure before moving on to the next.
Medium finishing discs to smooth the Great care should be taken to avoid iatrogenic
restoration and refine line angles/transition damage to tooth surfaces and adjacent
Figure 17. Tinted flowable composite may be lines; periodontal tissues. Copious water spray
applied using suitable instruments to create
natural incisal effects.

Figure 18. Shaping procedure stages: (a) cervical bulge/transition lines; (b) labial face; (c) incisal edge; (d) incisal line angles; (e) refine transition lines; (f)
emergence profile.

May 2013 DentalUpdate 13


RestorativeDentistry

Figure 19. Finishing and polishing stages: (a) highlight surface texture features using silver powder and pencil marks (optional); (b) contour developmental
grooves with a silicone point; (c) introduce perikymata with a coarse diamond bur; (d) polish with goats hair brush and polishing paste; (e) buff with felt disc
and fine polishing paste.

and a light touch should be used as rotary of the restoration.40 For this reason, fine on a daily basis. Direct adhesive procedures
finishing equipment can generate significant finishing and polishing procedures may be have almost limitless potential to restore
heat. This may damage hard and soft dental postponed to a second appointment when function and aesthetics, while preserving
tissues, restorative material, and adhesive shade stabilization has occurred. Clinicians healthy tooth tissue and, as such, anterior
interfaces or destroy finishing burs designed will also be able to reflect on the functional composites are at the very forefront of
for multiple uses.2,15 and aesthetic outcome and carry out any contemporary minimally invasive aesthetic
Restorations should never be necessary adjustments. dentistry.
painted with adhesive agents containing As with all direct and indirect
solvents. Although this will deliver a short- procedures, patients must be informed Acknowledgements
lived shine, surface degradation will rapidly at the outset of the importance of The authors would like to thank
encourage stain formation. The time restoration maintenance and the need for Professor Richard Verdi for reviewing this
taken to shape, finish and polish anterior regular reviews to allow assessment and manuscript and to congratulate Dental
composite restorations accurately will deliver renovation or repair in the longer term. Update on their 40 year anniversary.
reliable, aesthetic, long-lasting restorations
equivalent to those made from ceramic.
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16 DentalUpdate May 2013