Q U I N T E S S E N C E I N T E R N AT I O N A L

A direct composite resin stratification technique

for restoration of the smile
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relatively high clinical performance. The aim of this article was to describe an approach to
restore and enhance the esthetic appearance of the anterior dentition through vital tooth
whitening and the direct layering of composite resin during predictable esthetic proce-
dures. (Quintessence Int 2011;42:205–211)

Key words: composite restoration, dental esthetics, layering technique

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The range of composites allows the use of
parameters dictated by society have com-
pelled patients to seek dentofacial harmony
and improve their physical appearance.
Additionally, the evolution of dental materi-
als has increased the indication of esthet-
ic restorative procedures. In this context,
composite resins occupy a paramount posi-
tion among restorative materials for anterior
teeth because they offer good predictabil-
ity, acceptable longevity, and the possibility
of more conservative procedures at a lower
cost than indirect restorations.1–6
In addition, during the replacement of
decayed or missing dental tissue, compos-
ite restorations allow either minimally inva-
sive or no preparation. They also provide
an excellent esthetic outcome, due to the
variety of available colors and effects.7–10
1
Professor, Department of Restorative Dentistry, School of
Dentistry, San Marcos University, Lima, Peru; Professor of
Esthetic Dentistry, Spazio Oral Dental Education, Lima, Peruw.
2
Professor, School of Dentistry, Positivo University, Curitiba,
Brazil.
3
Professor, Department of Restorative Dentistry, Bauru School of
Dentistry, University of São Paulo, Bauru, Brazil.
Correspondence: Dr Juan Carlos Pontons-Melo, Av Alberto
del Campo 452 Dpto 303 San Isidro, Lima 27, Lima, Peru. Email:
drjcpontons@spaziooral.com
different combinations of shade, hue, trans-
lucency, and opacity. Thus, specific details
and aspects that exist in the patient’s
natural dentition may be obtained. This
restorative approach of layering approach
has been called an “anatomic buildup tech-
nique,”11 a “trendy three-layer concept,”12
or a “natural layering concept.”3 The goal
of these methods is to mimic the natural
anatomy of enamel and dentin.13
The application of a layering concept
through the use of separate composite
resin masses that mimic the natural tooth
anatomy presents clear advantages for the
clinician and makes the entire procedure
more efficient and predictable.3 When eval-
uating the polychromatic characteristics
of a tooth, age should also be taken into
account. With increasing age, there is an
increase in chroma, a decrease in value,
and probably a change in hue. Actually,
phenomena such as wear, acquired or dys-
plastic discoloration, and cracks or micro-
fractures will require an individual approach
for the restorative work.7 Thus, as is true of
all art, a heightened sense of observation
is required.14 The excellence in esthetic
dentistry demonstrates further confirmation

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Q U I N T E S S E N C E I N T E R N AT I O N A L
Po n to n s - M e l o e t a l

Fig 1 Preoperative photographs that show an inadequate incisal display and disharmonic relation with the lips.

Fig 2 Initial appearance of the maxillary Fig 3 The in-office tooth bleaching process
incisors. carried out with 35% hydrogen peroxide.

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technology are one and the same.”
In addition to composite resin resto-
rations, vital dental bleaching may be
employed to increase dental esthetics. Two
techniques are currently available: in-office
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may be employed, as the procedure is
considered simple, safe, and incapable of
causing major alterations of enamel and

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dentin structure.15,16
The aim of this article is to describe
an uncomplicated approach with which to
restore and enhance the esthetic appear-

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ance of the anterior dentition via tooth
whitening and direct composite resin resto-
rations with the aid of a layering technique
for predictable esthetic procedures.
CASE REPORT
A 35-year-old woman presented for treat-
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with her smile, especially with the position
of her maxillary central incisors (Fig 1). A
clinical examination revealed worn maxil-
lary incisors and compromised color, as
well as old, defective composite restora-
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casts were taken.
Vital in-office bleaching was proposed
and conducted with 35% hydrogen perox-
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At the 1-week follow-up appointment, the
patient did not report any tooth sensitivity
at any point during the bleaching treatment.
After 3 weeks, which is the recommended

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 Q U I N T E S S E N C E I N T E R N AT I O N A L
Po n to n s - M e l o e t a l

Fig 4 The palatal silicone guide was fabricated on a study Fig 5 Cosmetic contouring was performed to better align
cast after optimizing the shape and function of the incisors the maxillary central incisors prior to starting definitive
with a wax-up. restorations.

a b c

Fig 6 (a) After prophylaxis, modified rubber dam isolation was established. (b) Restorations were removed with the aid of
abrasive disks and diamond burs. (c) Final preparations before restorative treatment.

a b
Fig 7 (a) Etching with phosphoric acid. (b) After rinsing and blotting with an absorbent paper,
a bonding agent was applied and light cured.

amount of time to wait before creating an
adequate bond after the bleaching pro-
cess,17 new tooth positions and restorations
were planned with the aid of a waxed dental
cast. Enhanced predictability of the treat-
ment can be obtained with a silicone index

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(Fig 4).18
To avoid any interference in the chroma
and opacity evaluations due to tissue dehy-

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dration, tooth shade was determined first.

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rect the alignment of the maxillary central
incisors (Fig 5). After tooth prophylaxis,
modified rubber dam isolation and a retrac-
tion cord were placed. The compromised
old restorations were removed, and circum-
ferential chamfer bevels were created (Fig

seconds of etching with 37% phosphoric
acid, followed by a water rinse, was applied.
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dance with the manufacturer’s guidelines
(Fig 7). Using a composite resin instrument

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Q U I N T E S S E N C E I N T E R N AT I O N A L
Po n to n s - M e l o e t a l

Fig 8 (a) Application of trans-

lucent resin to reproduce the
palatal portion of the teeth with
the aid of the silicone index. (b)
Application of dentin shade to
create mamelons and reproduce
the region that corresponds with
the deepest dentin. Dentin can
be applied and placed precisely
in relation with the future incisal
a b
edge. (c) Application of shades A1
and High Value for the layer that
corresponds to the facial surface.
(d) Artificial enamel of the final
desired shade is applied from the
cervical third to the middle and
incisal thirds.

c d

Fig 9 (left) Completed restorations before

removing rubber dam isolation.

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the artificial enamel, was restored with shade
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contour and new incisal edge. The excess NFEJVN
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material was removed, and the composite for the incisal third (Fig 8). All composites
resin was light cured in position for 20 sec- were carefully applied with a flat spatula and
onds. The artificial dentin (shade A2 dentin, blended with the aid of a no. 4 flat-tipped

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brush (Kota). Increments of composite resin
over the facial portion and sculpted in the were light cured for 20 seconds for each
shape of mamelons. The halo effect (ie, a layer. A Mylar strip was placed interproxi-
thicker volume along the incisal edge) was mally and pulled through to help create a
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tight contact point and the correct facial
To mimic the opalescent effect of natural embrasure forms (Fig 9).
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Finally, both the buccal and palatal sur-
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the region of the incisal third between the polishing, excess material at the margins was
mamelon spaces (Fig 8). removed with a no. 12 surgical scalpel blade

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 Q U I N T E S S E N C E I N T E R N AT I O N A L
Po n to n s - M e l o e t a l

a b c

Fig 10 (a) Lines were drawn along the proximolabial regions to determine the light-reflecting and mamelon areas of the
maxillary anterior teeth. (b) The surface texture was achieved with a tapered diamond bur. (c) In sequence, the polishing was
completed with silicone rubber cups and other finishing materials.

a b

Fig 11 Maxillary bite splint Fig 12 (a) Final outcome after recontouring and restoring the anterior teeth. (b) Patient’s
in position. smile and the new incisal edge position.

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accentuated texture (Fig 10). The final
the primary anatomy and achieve symme- natural gloss was achieved with Astrobrush
try between similar teeth. After the desired (Ivoclar Vivadent), a felt wheel and an alu-
cervicoincisal and mesiodistal lengths were minum oxide polishing paste (Enamelize,
reached, symmetric light-reflection areas and $PTNFEFOU

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light-deflecting zones were outlined with pen- and polishing the interproximal areas.
cil and the distance was checked with a To evaluate the occlusion, the patient
sharp-ended caliper. was placed in an upright position. The
The facial and palatal surfaces were fin- centric occlusion and the protrusive and
ished with a coarse silicone cup (Astropol, lateral movements were examined. Any
Ivoclar Vivadent) to prepare for the macro equilibration that was required to improve
surface texture. Lines along the facial sur- harmony was accomplished with a finish-
face were created with the aid of a fine-grit ing diamond bur, and the final polishing
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procedures were repeated whenever nec-
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indicated for nighttime use (Fig 11). Figure
entire restoration was then buffed with 12 demonstrates the final result.

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Q U I N T E S S E N C E I N T E R N AT I O N A L
Po n to n s - M e l o e t a l

DISCUSSION office bleaching treatment was performed.

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sive restorative treatments, it is important to
the old concepts of indication that lim-
ited their use in several clinical situations
have changed. This transformation may be
attributed to the evolution of the materials’
properties, such as their durability, load
resistance, esthetics, color stability, and
predictability. The clinical performance has
also yielded favorable results. These quali-
ties allow for a greater conservation of tooth
structure compared to indirect restorative
materials.19–22
Frequently, the dental practitioner is
challenged to modify the configuration of
the smile by applying an artificial mate-
rial to replace missing tooth structures or
eventually rearranging the disposition of
the teeth. A good treatment must respect
and simulate the spatial arrangement, rela-
tion, and appearance of natural tissues.7
The success of this procedure, however,
depends on an understanding of the inti-
mate structure of natural teeth.23
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posite resin, there are still some difficulties
in regard to color selection. This aspect
is considered a paramount element for
achieving esthetic success in a restoration,
but if the anatomical shape is not adequate,
the result will not appear natural and harmo-
nious within the dentofacial complex. Often,
it is possible to achieve an esthetic result,
even if the color is slightly different, as long
as the shape, surface texture, and opac-
ity are harmonic.24 The shade of a tooth is
determined by the correlation among enam-
el, dentin, and light during the process
of light refraction and reflection.11
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matching is a problem, especially when
there is a lack of opacity in the dentin shade
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the value of the restoration.25 This problem
is more likely to be noticed than a mistake
in hue.26
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and polishing multiple anterior restorations,
it is recommended that light reflection and
deflection areas be outlined in pencil and
checked with a sharp-ended caliper. This
procedure will enable the restorations to be
as symmetric as possible.27
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When bleaching is indicated prior to adhe-
wait at least 24 hours before bonding to pre-
vent any negative effects of bond strength
of composite resin to the dental structure.16
A modified rubber dam isolation technique
as well as a retraction cord were employed.
This technique allows clinicians to have free
access to the gingival area while keeping
the field free of saliva. Further, only compro-
mised old restorations were removed. Old
restorations that were not compromised by
discoloration, marginal staining, or recur-
rent caries were repaired while seeking
to improve esthetics so that sound dental
structure was not eliminated.
The patient should be aware that the
shade and texture of the material will
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periodic maintenance. Additionally, oral
hygiene protocols should be emphasized.
The color of esthetic restorations can be
maintained for longer periods by introduc-
ing some restrictions on the patient’s dietary
habits.19
CONCLUSION
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potential to reproduce the appearance of a
natural tooth with highly esthetic outcomes.
Additionally, this procedure is a good treat-
ment option that is less costly than other
indirect approaches. Therefore, this simpli-
fied approach has the potential to extend
the benefits of composite resin to a larger
number of clinicians and patients.

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