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Lorenzo Vanini 2 PDF Free
Lorenzo Vanini 2 PDF Free
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Conservative Composite
Restorations that Mimic Nature
A Step-by-Step Anatomical Stratification Technique
Lorenzo Vanini, DDS, MD
Learning Objectives:
After reading this article, the participant
posed of five dimensions. These dimen- appear white. They are classified by four substance) and, therefore, restorative
sions are based on the four main hues shape types: spot, small clouds, snow- composite materials should demon-
that present with different tooth shapes flakes, and horizontal bands.1 strate optical properties similar to those
and intensities, depending on age: of dentin and enamel.1,4-6 Enamel is the
yellow-orange, white, blue, and amber. The speed of light most important structure for this rela-
These four hues, also called “chromat- tionship with light, since it covers the
ic chords,” are responsible for the five
through a material dentin structure similar to a fiber-optic
color dimensions, outlined as follows depends on the system. The translucency and refractive
(Fig 5).1 material’s density. index of composites are very important
and also should closely approximate
1. Chromaticity
It is faster through air those of the natural enamel.
Chromaticity is the hue and chroma of than water. The speed of light through a mate-
the dentin body. The composite used rial depends on the material’s density.
in the author’s stratification technique It is faster through air than water. The
requires only one hue, called UD (Uni- 4. Opalescents refractive index is the ratio of the speed
versal Dentine), and different chromas Opalescents are confined to the incisal of light in vacuum compared to a spe-
(0, 0.5, 1, 2, 3, 4, 5, and 6). In anterior third, the interproximal level, and the cific medium; the wavelength of light
teeth, the chromaticity desaturates from margin where free enamel is located. also affects the refractive index. The
the cervical to the incisal and from the These produce the blue and amber hues more optically compact a medium is,
palatal to buccal, and usually is lower in that create the incisal halo and can ex- the slower the speed of light.
young teeth and higher in old teeth.1,3 hibit different shapes: mammelon, split
mammelon, comb-like, window-like, Considerations For Composite Materials
2. Value or Luminosity and stain-like.1 The refractive index (n) of natural
Value or luminosity is strictly related to enamel is 1.62, while the average refrac-
enamel. The more mineralized and thin 5. Characterizations tive index of composite and ceramic re-
the enamel is, the shinier and lower in Characterizations affect both dentin storative materials is 1.50. The refractive
value it appears, such as in the old tooth and enamel. There are five characteriza- index of glass is 1.52, which means that
biotype. The thicker, more porous, and tions: two in the dentin (mammelon composite and ceramic restorative ma-
more poorly demineralized the enamel and band) and three in the enamel terials have optical properties that are
is, the less translucent and higher in (e.g., margin for young teeth, stain, and more similar to glass than to enamel.
value it appears, such as in the young cracks for adult and old teeth).1 This presents problems when managing
tooth biotype.1 the relationship between translucency
Significance of Refractive and value, because increasing material
3. Intensives Index thickness lowers value (i.e., glass effect),
Intensives occur more frequently in while the behavior of natural enamel is
young tooth biotypes and represent Color results from the relationship be- exactly the opposite.4
hypo-mineralized areas of enamel that tween light and an object (i.e., body/
Figure 7: ENA HRi UE2 enamel samples with increasing thickness over a
sample of UD3 dentin. The ENA HRi enamel, with a refraction index of 1.62,
demonstrates optical behavior similar to natural enamel. Increasing the
thickness also increases the value.
When choosing an enamel compos- enamel and composite enamel) with cording to a different application proto-
ite material, the material should func- the same refractive index. As a result, col than previous composites. A slightly
tion like natural enamel, presenting a there is no deviation in optical prop- thinner layer of similar thickness as the
high translucency and demonstrating erties that would otherwise create the enamel being replaced on the tooth,
the same refractive index.4 When the with no visible margin, is necessary.6
proper index is matched, thicker layers
of the enamel composite will appear
All tooth color Determining Tooth Color
whiter, with high value, high luminos- information should Using the Five Dimensions
ity, and low translucency.4 When ap- be recorded in an
plied more thinly, the enamel com- To properly determine tooth color, den-
posite should appear more translucent,
uncomplicated manner. tists should carefully analyze the tooth
with a low value, low luminosity, and structures (e.g., dentin and enamel)
high translucency.4 Unfortunately, as clinical challenge of a gray line appear- and identify the five color dimensions
the thickness of standard enamel com- ing on the margin.4 Furthermore, when and chromatic chords.1,6 To facilitate
posite layers increases, the percentage of placed for incisal edge restorations, the this process, research has demonstrat-
gray or glass-like effect increases in pro- composite is seamlessly integrated, re- ed that a light with a constant color
portion as well.4 placing the full enamel thickness, with temperature of 5500K is ideal for
no need for dentin composites—unlike shade evaluation (Optilume Trueshade,
Composites With Natural Enamel when using other composite materials Optident; Ilkley, UK) (Fig 9).8 Addi-
Properties (Figs 8a & 8b).4 tionally, the use of digital photography
However, a composite system devel- This composite system also includes is fundamental to the analysis of color
oped by the author includes an enamel universal dentin shades (UD) that are dimensions because it quickly enables
composite that demonstrates a re- available in eight chromatic levels, deeper examination of the tooth on a
fractive index of 1.62 and has optical ranging from Bleach C (UD0) to the computer. Underexposing the photo-
properties very close to those of natu- darker High C (UD6), many of which graph and increasing the contrast al-
ral enamel (HRi Universal Enamels, correspond with the Vita Shade Guide lows better visualization of the color
Micerium S.p.A.; Avegno, Italy) (Fig 6). system.6 Although complex restora- dimensions and increases the am-
Increasing the material’s thickness in- tions may require a basic hue and then ber and blue hues of the incisal halo
creases the value (Fig 7). It is possible the next two darker dentin shades to (Figs 10a & 10b).
with this enamel composite to manage achieve final shading, most restorations
the relationship between translucency can be completed with only one shade Recording Tooth Color/Characterization
and value, as well as the esthetic integra- of this dentin composite.6 Information
tion of the margin, because light passes The unique properties of this com- All tooth color information should be
through the two structures (i.e., natural posite material require placement ac- recorded in an uncomplicated manner.
To properly determine
tooth color, dentists
should carefully analyze
the tooth structures...
and identify the five
color dimensions and
chromatic chords.
Figures 10a & 10b: The color dimension and the amber and blue hues of the incisal halo are better visualized by underexposing
the image and increasing the contrast.
Figure 14: Taking a black-and-white photograph can be helpful Figure 15: Intensives are represented by opaque white spots,
when studying the value. stains, or bands.
Figure 16: It is very important to evaluate the shape and size of Figure 17: The mammelon and incisal margin characterizations
the incisal in order to reproduce the incisal third in represent the natural frame of the incisal halo.
a natural way.
Opalescents (Fig 16) in the young tion.1 Stratification, or incremental palatal to buccal, in a harmonious
biotype appear as gray-blue hues of layering, requires a complex under- and modulated way; exhibits contrast
Types 1 (mammelon) and 2 (split mam- standing of the internal structures of in the incisal area between the dentin
melon); in the adult as gray-blue hues the teeth (i.e., enamel, dentin) and their body, free enamel, and darkness of the
of Types 3 (comb-like) and 4 (window- morphology.5,6 mouth; and diffuses light inside the
like); and in the elderly as amber hues The author’s anatomic stratification tooth, imparting a three-dimensional
of Type 5 (stain-like). technique imitates the tooth anatomy, effect to the restoration.
The characterizations mostly pres- restoring enamel and dentin in their
ent (Fig 17) in the young biotype are respective locations and thicknesses Wax-Up and Matrix Guide
the mammelons (Type 1), which can For Class IV restorations, the use of a
appear white or amber, thus creating a silicone matrix/stent is advised to en-
clear-cut boundary with the opalescents; Anatomic stratification sure the correct anatomic position of
and the incisal margin (Type 3), which involves the the palatal/lingual enamel wall, and to
is emphasized by a white or amber line. support the enamel body application.10
In the elderly biotype, the characteriza-
reproduction of dentin The silicone matrix can be provided by
tions seen are one or more horizontal and enamel tissues to a laboratory from the wax-up or created
bands with a whitish or amber tonality the proper thickness directly in the mouth using a medium-
that extend into the interproximal ar- viscosity silicone and temporary restor-
eas (Type 2); amber or brown stain-like
and position. ative, then shaped and adjusted with
characterization (Type 4) at the incisal burs (Figs 19a-20b). Once the silicone
third; and crack of the enamel (Type 5) to achieve a light-composite-color re- has hardened, the stent is removed and
produced by brown pigmented fissures lationship similar to natural tooth adjusted to fit perfectly to the teeth and
or white opaque cracks. structure. This is accomplished by pre- buccal wall corresponding to the affect-
cisely planning the documented resto- ed tooth, then removed.
Anatomic Stratification and ration of the palatal and interproximal
Composites enamel, the dentin body, and the Isolation, Preparation, and Adhesive
buccal enamel. Protocol
Anatomic stratification involves the The composite stratification is guid- Prior to initiating the stratification tech-
reproduction of dentin and enamel ed by the color chart, which must be nique, the area should be cleaned with
tissues to the proper thickness and po- completed with the characteristics of a fluoride-free prophylaxis paste and
sition.1,5,6 During this process, it also is tooth color dimension prior to initiat- isolation achieved with a rubber dam.
necessary to consider the proteinaceous ing restorative procedures (Fig 18). This For interproximal restorations, a trans-
layer between dentin and enamel that will ensure that the anatomic stratifica- parent matrix is required.
is responsible for the internal diffusion tion demonstrates desaturation of the For Class IV restorations, the ideal
of light and luminosity of the restora- hue from cervical to incisal, and from margin preparation includes a 90° butt
Figures 20a & 20b: Impression and silicone stents will be used to build up the palatal wall. The buccal part of the stent is
removed to access the cavity and stratify the enamel.
margin on the palatal and interproxi- A thin coat of adhesive bonding Curing should be completed on all
mal margins, and a short chamfer in agent (ENA Bond) is applied to the sides of the stratification for 40 seconds
the buccal margin. The margin is first preparations, down to the margins, and for each 1 mm to 1.5 mm layer. The
prepared using a coarse-grain diamond then light-cured for 40 seconds. If us- light-curing tip should be kept as close
bur, ball-shaped for the chamfer, and ing ENA Bond, a second coat of mate- to the restoration as possible to ensure
cylindrical for the butt margin. The mar- rial should be applied and cured.11 Care a thorough cure. It also is advisable to
gin is finished using the same burs with should be taken to not contaminate turn off the overhead light or not have
fine grain and, afterwards, polished us- the oxygen-inhibiting layer to ensure a it placed directly overhead to prevent
ing a silicone point, since the smooth strong bond to the composite.12 uncontrolled curing.
surface facilitates flow of the adhesive, Using an acetate matrix and a wedge,
as well as composite adaptation on the Composite Application restore the interproximal walls us-
margin (Figs 21a & 21b). Remove the selected composite from ing the same enamel body compos-
The preparations are etched using the syringe and warm to 39°C with a ite that was placed for the palatal wall
a 35% to 38% phosphoric acid (ENA heating container.5 Place the stent in the (Fig 22). Once these two steps have
Etch, Micerium S.p.A.) for 15 to 30 sec- mouth, and begin the Class IV stratifi- been completed, the complex cavity
onds for enamel and vital dentin. For cation by applying the palatal/lingual is transformed into a simple shell, the
sclerotic dentin, 1 minute is necessary, enamel layer. It should be applied in a shape and thickness of which should be
and root non-vital dentin (for post- thickness that approximates that of the verified and eventually corrected prior
adhesive cementation) requires 1.5 natural enamel being replaced, avoid- to continuing with the restoration. The
minutes. The etched surface should be ing the interproximal areas. The stent is volumes to be filled are now evident,
cleaned and dried with oil-free air, leav- used to verify adaptation, then removed making it easier to check the areas that
ing a white appearance on the enamel. for light curing. need to be restored.
Figure 23: Dentin body and number of composite dentin masses used according to the cavity size.
Figure 26: Margin characterization is created with IW and OA. Figure 27: Opalescent natural OBN is placed in the
interproximal grooves and between the mammelons.
For the dentin body restoration, the el is applied and creates a desaturation composition of the dentin body with
number of dentin shades needed corre- from cervical to incisal, and from pala- different chromas and the balanced de-
lates to the size of the preparation: one tal to buccal. saturation seen in natural teeth.
dentin body for small, two for medium, Therefore, in a large preparation After building up the dentin body,
and three for large (Fig 23). Each tooth area, the dentin body stratification be- characterizations, intensives, and opal-
exhibits three degrees of chromaticity: gins at the most cervical margin by plac- escents are placed before applying the
high in the cervical third, medium in ing a high saturation dentin composite buccal enamel layer. The most impor-
the middle third, and low at the incisal cervically. Continuing this example, tant characterizations are the mam-
level.3 Therefore, one or more compos- UD4 would be placed and cured, after melons and the margin (Figs 25 & 26),
ites with increasing saturation should which UD3 would be applied to com- which are reproduced using white and
be used to reproduce these chromatici- pletely cover UD4, as well as placed on amber (IW and OA). Following mam-
ties, based on the size of the cavity. For the buccal chamfer, pushed more inci- melon and margin characterization,
example, if the basic chromaticity is sally, and cured. These two layers then create the opalescents using a specific
UD2, the required dentin body com- are completely covered with a layer of body composite (OBN) that is placed
posite would be UD2 for a small cavity; UD2, which also is placed on the cham- between the mammelons and the area
UD2 and UD3 for a medium cavity; and fer and extended to the incisal margin, between the incisal margin and the den-
UD2, UD3, and UD4 for a large cavity. and cured. If mammelons are present, tine body (Fig 27) to produce a natural
Such an approach achieves a strong the vertical grooves should be opened halo. Finally, reproduce the intensives
chromatic nucleus that prevents the loss first to create the halo shape (Fig 24). in the shape determined during the col-
of chromaticity when the buccal enam- This enables creation of a chromatic
Figure 28: Small increments of IWS, an opaque white body Figure 29: A 0.6-mm increment of UE2 completes
composite, create small intensive spots. the restoration.
or mapping by using the white opaque surface reduces plaque deposits and ag- and position of the transition lines (i.e.,
body composites (IWS, IM) (Fig 28). ing of the restoration. Finishing defines angles that define the transition from
It is important to remember that the shape, dimension, and contour of the interproximal margin to the buccal
when applying the different composites the restoration (Figs 30a & 30b), while surface) are fundamental to the esthetic
to build up the dentin body, charac- polishing shines the surfaces, maintain- integration of the restoration.
terization, opalescents, and intensives, ing the texture details achieved during After adjusting the shape, finish the
necessary space must be left to apply the finishing (Figs 30c-30f). surface macro-texture using a medium-
buccal enamel layer, which is thinner in grain diamond or multi-bladed bur to
the cervical area and thicker at the inci- create lobes and grooves. The enamel
sal edge, with a natural vertical contour Polishing imparts brilliance growth lines (micro-texture) are created
that creates the natural tooth shape. The to the restoration surfaces. using the point of a green stone to gen-
stratification technique concludes with tly scratch the surface.
the buccal enamel layer, which must
The ideal way to polish Polishing imparts brilliance to the
be applied to reproduce the transition a restoration is by using restoration surfaces. The ideal way to
lines and draft both the macro-texture diamond pastes and a goat polish a restoration is by using dia-
(i.e., lobes, grooves, and depressions) mond pastes and a goat hair brush,
and micro-texture, using a brush to cre-
hair brush, which will not which will not destroy the macro- and
ate the enamel growth lines (Fig 29). destroy the macro- and micro-texture surface details. Begin pol-
Once the last layer of enamel is cured micro-texture surface ishing with a 3-µ diamond paste, then
and prior to initiating finishing and switch to a 1-µ paste with water spray.
polishing procedures, it is advisable
details. Polish the interproximal walls using
to cover the surface of the restoration abrasive strips with decreasing grain
with a layer of glycerin gel and perform Begin finishing by correcting the and diamond pastes. The final gloss-
an additional cycle of light-curing to shape using medium-grain diamond ing can be achieved using an aluminum
eliminate the oxygen-inhibited lay- burs (e.g., 30 to 40 µ). Finish the verti- oxide paste with a felt disc, working at
er and obtain complete composite cal contour by following the tooth anat- first without water at a very low speed,
polymerization.11 omy, using the bur along three different then increasing the speed but using co-
inclinations, depending on the area of pious water spray and no pressure on
Finishing and Polishing the tooth (e.g., cervical, incisal, or mid- the restoration surface. When the finish-
dle third). Finish the horizontal con- ing and polishing steps are completed,
Finishing and polishing complete the tour by adjusting the shape and length a conservative composite restoration
restoration and are important steps of the incisal edge and corners; finish should be achieved (Fig 31).
in the process because they create the the interproximal internal margin using
ideal relationship between light and abrasive strips; and finish the interprox-
the tooth, which is fundamental to imal external margin using medium-
achieving the desired esthetic result.13 grain diamond burs. This step is very
Furthermore, the finished and polished important because the correct shape
Figures 30a-30f: Images demonstrating the main phases of finishing and polishing.
Figures 32a & 32b: A well-integrated esthetic restoration should reproduce all five color dimensions in a natural way.
Figures 33a & 33b: Another example of an esthetic restoration using the five dimensions of color.
About the Author: Dr. Vanini is 11. D’Arcangelo C, Vanini L, Prosperi GD, Di Bussolo G, De Ange-
Professor of Restorative Dentistry, lis F, D’Amario M, Caputi S. The clinical influence of adhesive
University La Sapienza, in Rome, thickness on the microtensile bond strength of three adhesive
Italy; and Visiting Professor of systems. J Adhes Dent. 2009;10(4):1-7.
Restorative Dentistry, University
De La Mediterranee, in Marseilles,
12. Ghivari S, Chandak M, Manvar N. Role of oxygen inhibited
France. Dr. Vanini can be contacted
layer on shear bond strength of composites. J Conserv Dent.
by e-mail at: dott.vanini@libero.it.
2010 Jan;13(1):39-41.
Author Disclosure: Dr. Vanini
develops products and lectures for
Micerium S.p.A. in Avegno, Italy. 13. Peyton JH. Finishing and polishing techniques: direct com-
posite resin restorations. Pract Proced Aesthet Dent. 2004
May;16(4):293-8. jCD
The 10 multiple-choice questions for this Continuing Education (CE) self-instruction exam are based on the article, “Conservative
Composite Restorations that Mimic Nature: A Step-by-Step Anatomical Stratification Technique” by Lorenzo Vanini, DDS, MD.
This article appears on pages 80-98.
The examination is free of charge and available to AACD members only. AACD members must log onto www.aacd.com to take
the exam. Note that only Questions 1 through 5 appear here in the printed version of the Journal; they are for readers’ infor-
mation only. The complete, official self-instruction exam is available online only—completed exams submitted any other way will
not be accepted or processed. A current web browser is necessary to complete the exam; no special software is needed. The AACD
is a recognized credit provider for the Academy of General Dentistry, American Dental Association, and National Association of
Dental Laboratories. For any questions regarding this self-instruction exam, call the AACD at 800.543.9220 or 608.222.9540.
1. Color matching is considered a challenging task in esthetic 4. Which of the following best describes the esthetic
dentistry due to which of the following? problem that occurs when using standard enamel
composite layers?
a. Typical shade guides represent the body and thickness of
natural tooth structures. a. When the material is applied thinly, the value is lowered
and translucency is increased.
b. Dentists have used stratification techniques that are di-
rectly related to the optical properties of the restorative b. Thicker layers of material appear whiter, higher in value,
materials. and lower in translucency.
c. No single explanation for determining tooth color has c. As the thickness of the material increases, the value of
provided an exact solution. the restoration is lowered.
d. The lack of uniformity of the shade guides available with d. When thicker layers are applied evenly, the value is
the restorative materials. raised and the translucency decreases.
a. Tooth color results from the interaction of dentin To see and take the complete exam, log onto www.aacd.com.
and light.