SS symmetry
Case Report
Direct Esthetic Composite Restorations in Anterior Teeth:
Managing Symmetry Strategies
Gaetano Paolone 1, *, Salvatore Scolavino 2 , Enrico Gherlone 1 and Gianrico Spagnuolo 3






Citation: Paolone, G.; Scolavino, S.;
Gherlone, E.; Spagnuolo, G. Direct
Esthetic Composite Restorations in
Anterior Teeth: Managing Symmetry
Strategies. Symmetry 2021, 13, 797.
https://doi.org/10.3390/sym13050797
Academic Editor: Rohanah Hussain
Received: 18 April 2021
Accepted: 1 May 2021
Published: 3 May 2021
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in
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iations.
Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Symmetry 2021, 13, 797. https://doi.org/10.3390/sym13050797
1 Department of Dentistry, IRCCS San Raffaele Hospital and Dental School, Vita Salute University,
20132 Milan, Italy; gherlone.enrico@hsr.it
2 Private Practice, 80035 Nola, Italy; dott.scolavino@gmail.com
3 Department of Neuroscience, Reproductive and Odontostomatological Sciences,
University of Naples “Federico II”, 80131 Naples, Italy; gspagnuo@unina.it
* Correspondence: g.paolone@docenti.unisr.it
Abstract: A novel procedure for symmetric and consistent layer thickness management in esthetic
direct restoration of anterior teeth is presented. For the purpose of obtaining a satisfactory final
outcome of an esthetic direct restoration, it is crucial to standardize either margin preparation design
and dentin and enamel layer thickness. Leaving too much space for the final translucent layer may
lead in fact to “low value—gray” restorations if not correctly managed. The most common tool
used to check layer thickness is the sagittal silicone index, which is reliable but involves planning;
therefore, it requires two stages appointments. In this clinical case, a novel procedure is used
to prepare, to model and to check thickness of composite shades in a single appointment, thus
providing a symmetric esthetic outcome. A healthy 21-year-old woman referred to our dental office
for the esthetic rehabilitation of both maxillary central incisors. The correct composite bilateral and
symmetric layer thickness management provided a predictable esthetic outcome of the restorations.
The main objective of this case presentation is to describe a novel technique that is able to save
chair-time and dental laboratory costs during direct restorations in anterior teeth.
Keywords: composite restoration; teeth symmetry; central incisors; esthetic restorations; composite
resin; thickness; color stability
1. Introduction
Most animals, and therefore human beings, are bilaterians [1], they have a bilateral
symmetry [2] with respect to the sagittal plane. Bilateral symmetry (also referred to
as mirror symmetry, mirror-image symmetry and reflection symmetry) find in the two
maxillary central incisors one of its highest expressions. Since these teeth are the most
important part of a smile, every clinician should take particular care to the following
aspects related to symmetry:
• Symmetry and physical attractiveness is strictly related [3];
• Central incisors are often very symmetric, while other teeth, like lateral incisors, may
present huge asymmetries [4,5];
• Central incisors’ asymmetries rarely exceed 0.2 to 0.3 mm in one of the three dimen-
sions (length, width or thickness) [6,7];
• In an appealing smile, symmetry is very relevant near the mid-line. Some asymmetries
can appear pleasant only if far away from it [8].
For all these reasons, clinicians shall try to keep central incisors as symmetric as
possible during the restorative procedures. This is performed easily in indirect restorations
(veneers and crowns) because they are managed in the laboratory [9].
In direct restorations, there are some tools and procedures, which are the subject of this
case presentation, that the clinician can take advantage from in order to provide symmetric
esthetic restorations.
https://www.mdpi.com/journal/symmetry
 In direct restorations, there are some tools and procedures, which ar
2. Case
this Presentation
case presentation, that the clinician can take advantage from in order t
metricAesthetic
healthyrestorations.
21-year-old woman referred to the dental office f
Symmetry 2021, 13, 797 tion of both central maxillary incisors. The patient had a2 ofgood 14 or
2. Case Presentation
plaque score (FMPS) and full mouth bleeding score (FMBS) equa
A healthy 21-year-old woman referred to the dental office for the esth
2.After clinical examination (Figure 1), both restorations resulted
Case Presentation
tion of both central maxillary incisors. The patient had a good oral status, w
shape and
A healthy color.
21-year-old Radiographic
woman referred to the examination
dental office for the (Figure 2) revealed
esthetic rehabilitation
ofplaque score
both central (FMPS)
maxillary and full
incisors. Themouth bleeding
patient had score
a good oral (FMBS)
status, equal
with full mouth to 0 and
treatment.
Afterscore
plaque clinical The
(FMPS) translucent
examination
and full mouth(Figure areas around
1), both
bleeding score (FMBS) the
restorationsinterface
equal to 0 andresulted suggested
in being ai
1, respectively.
of the
After
shape restorative
clinical
and examination material.
(Figure
color. Radiographic 1), bothexamination
restorations resulted
(Figurein being incongruous
2) revealed in
a satisfacto
shape and color. Radiographic examination (Figure 2) revealed a satisfactory endodontic
treatment.
treatment. The The translucent
translucent areas
areas around thearound the interface
interface suggested a poorsuggested a poor inter
internal adaptation
ofofthe
the restorative
restorative material.
material.

Figure
Figure
Figure 1.1.Initial
1. Initial Initial clinical
clinical
clinical situation.
situation.
situation.

Figure 2. Pre-op x-ray.

Figure
Figure 2.Because of the
2. Pre-op
Pre-op X-ray. young
x-ray. age of the patient, a noninvasive treatment with
tionBecause
was proposed. As suggested by several authors, because of the quanti
of the young age of the patient, a noninvasive treatment with direct restoration
ualproposed.
sound tissue,
was Because ofno
As suggested post
the by was planned
several
young authors,
age ofbecausefor the
the of left centralofincisor
the quantity
patient, [10,11]. A
the residual
a noninvasive treat
alyzed the smile-line of the patient (Figure 3), silicone impressions were ta
sound tissue, no post was planned for the left central incisor [10,11]. After having analyzed
tion
the
yether
was
smile-line proposed.
of
material (Impregum
As suggested
the patient (Figure
Penta +
by several
3), silicone impressions
Permadyne
authors,
were taken
Penta
because
with a polyether
L, 3M Espe; St.
of
Pau
material (Impregum Penta + Permadyne Penta L, 3M Espe; St. Paul, MN, USA) in order to
ual sound
order
develop
tissue,
atodiagnostic
develop no post was
a diagnostic
wax-up (Figures 4 wax-up
planned for the left central incisor
and 5) [12].(Figures 4 and 5) [12].
alyzed the smile-line of the patient (Figure 3), silicone impressio
yether material (Impregum Penta + Permadyne Penta L, 3M Esp
order to develop a diagnostic wax-up (Figures 4 and 5) [12].
 Symmetry 2021, 13, 797 3 of 14
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Figure
Figure 3. 3.
TheThe smile
smile of the
of the patient
patient before
before treatment.
treatment.
Figure 3. The smile of the patient before treatment.
Figure 3. The smile of the patient before treatment.

Figure 4. The wax-up developed by the dental lab technician.

Figure4. 4.
Figure TheThe wax-up
wax-up developed
developed bydental
by the the dental lab technician.
lab technician.
Figure 4. The wax-up developed by the dental lab technician.

Figure 5. Palatal aspect of the diagnostic wax-up.

Figure 5. Palatal aspect of the diagnostic wax-up.
Figure
Figure 5. 5. Palatal
Palatal aspect
aspect of diagnostic
of the the diagnostic wax-up.
wax-up.
On the diagnostic wax-up, a palatal silicone index (Elite HD+, Zhermack, Bad
OnOnthethe diagnostic
diagnostic wax-up,
wax-up, a palatal
a palatal silicone
silicone indexHD+,
index (Elite (EliteZhermack,
HD+, Zhermack,
Badia Badi
Polesine,
On the Italy) was created
diagnostic with
wax-up, aa canine-to-canine
palatal silicone extension
index (Elite(Figure
HD+,6). The
Zhermack,palatal sil
Bad
Polesine,
Polesine, Italy)
Italy) was was created
created with with
a a canine-to-canine
canine-to-canine extension
extension (Figure (Figure
6). The 6). The
palatal palatal sil
silicon
con indexItaly)
Polesine, was modified
was createdwithwith
a scalpel in order to remove
a canine-to-canine buccal
extension portions
(Figure andpalatal
6). The in order
silt
con index
index was modified
was modified with ainscalpel
order toinremove
order to remove buccal
andportions
in order toand in order t
have a passive
con index fit with
was modified a scalpel
during restorative
with in order buccal
procedures.
a scalpel portions
to remove buccal portions have
and in order t
ahave a passive
passive fit duringfitrestorative
during restorative
procedures. procedures.
have a passive fit during restorative procedures.
Symmetry
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Figure 6. Palatal silicone index created on the diagnostic wax-up.

Figure6.6.Palatal
Figure Palatal silicone
silicone index
index created
created ondiagnostic
on the the diagnostic wax-up.
wax-up.

Before
Before restorative
restorative procedures,
procedures, the shades
the shades of both
of both the tissue
soundandtissue and the previou
Before restorative procedures, the shades ofthe
bothsound
the sound the previous
tissue and the previou
restorations
restorations were
were recorded,
recorded, using
using commercial
commercial shade
shade references
references tabs
tabs (Figure(Figure 7). In order t
7). In order
restorations were recorded, using commercial shade references tabs (Figure 7). In order t
toselect
selectthe
themain
main dentinal shade,a asmall
dentinal shade, small amount
amount of composite
of composite (“button-try”)
(“button-try”) was placed o
was placed
select the main dentinal shade, a small amount of composite (“button-try”) was placed o
onthe unrestored part of
the unrestored part of the central incisor and cured (Figure 8) [13]. According
central incisor and cured (Figure 8) [13]. According to theto the co
the unrestored
collected
part of
shadeinformation,
the central
information, aacolor
incisor and cured (Figure 8) [13]. According to the co
lected shade colormap
map was
wassketched with
sketched the selection
with of theof
the selection shades to
the shades to b
belected
used shade
to information,
reproduce a colorboth
symmetrically mapmaxillary
was sketched
incisorswith the9).
(Figure selection of the shades to b
used to reproduce symmetrically both maxillary incisors (Figure 9).
used to reproduce symmetrically both maxillary incisors (Figure 9).

Figure 7. Shade selection of both sound tissue and previous restoration.

Figure7.7.Shade
Figure Shadeselection of both
selection sound
of both tissuetissue
sound and previous restoration.
and previous restoration.

Figure 8. The “button-try” on the cervical portion of the left maxillary central incisor.
Figure8.8.The
Figure The “button-try”
“button-try” on cervical
on the the cervical portion
portion of the of
leftthe left maxillary
maxillary central incisor.
central incisor.
Symmetry 2021,13,
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Figure
Figure9.9.
Figure The
9.The color-chart
Thecolor-chart
color-chartsketch
sketch
sketch prepared
prepared
prepared after shade
after
after analysis.
shade
shade analysis.
analysis.

The
The operatory
Theoperatory
operatory field
field
field was
was
was cleaned
cleaned
cleaned with
with aachlorhexidine
with chlorhexidine
a chlorhexidine andand
and pumice paste
pumice
pumice paste applied
paste withwith
applied
applied with
aaanylon
nylon rotating
rotating brush
brush and
and then
then with
with a a glycine
glycine powder
powder blasting
blasting device
device
nylon rotating brush and then with a glycine powder blasting device (PROPHYflex (PROPHYflex
(PROPHYflex
KaVo
KaVo Dental
KaVoDental
DentalAG,AG,
AG, Biberach,
Biberach,
Biberach, Germany).
Germany).
Germany). The
The upper
upper
The upper arch
arch was
was
arch isolated
isolated
was withwith
with
isolated aarubber
rubber damdam
dam
a rubber
(R&S,
(R&S, Paris,
(R&S,Paris, France)
Paris,France) from
from
France) from second
second
second right
right premolar
premolar
right premolartotosecond
second
to leftpremolar,
left
second premolar,
left using
using
premolar, 2Aclamps
2A
using clamps
2A clamps
(HuFriedy,
(HuFriedy, Chicago,
Chicago, IL,
IL, USA)
USA) (Figure
(Figure 10).
10).
(HuFriedy, Chicago, IL, USA) (Figure 10).

Figure 10. Isolation of the operatory field with rubber dam.

Figure10.
Figure 10.Isolation
Isolation
ofof
thethe operatory
operatory field
field with
with rubber
rubber dam.
dam.
Restorations were carefully removed (Figure 11), using high-speed diamond burs
(FG Restorations
001 G 014, were
Restorations Horico,
were Berlin,
carefully
carefullyGermany)
removed and
(Figure
removed 11),low-speed
(Figure using carbide
11), high-speed
using ones (Excavabur,
diamond
high-speed burs (FG burs
diamond
Dentsply
001 014, Sirona,
(FGG 001 G 014,York,
Horico, PA,
Berlin,
Horico, USA).
Germany) and low-speed
Berlin, Germany) and carbide ones carbide
low-speed (Excavabur,
onesDentsply
(Excavabur,
Sirona, York,
Dentsply PA, USA).
Sirona, York, PA, USA).

Figure 11. Previous restorations are removed.

FigureIn
Figure order
11.
11. to symmetrically
Previous
Previous areprepare
restorations
restorations are the margin (therefore to allow a comparable quan-
removed.
removed.
tity of material on both preparation margins), a calibrated bur (FG 277P021 Horico, Berlin,
In order to symmetrically prepare the margin (therefore to allow a comparable quan-
tity of material on both preparation margins), a calibrated bur (FG 277P021 Horico, Berlin,
Symmetry 2021, 13, 797 6 of 14

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Symmetry 66 of
of 14
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In order to symmetrically prepare the margin (therefore to allow a comparable quantity
of material on both preparation margins), a calibrated bur (FG 277P021 Horico, Berlin,
Germany)
Germany)was
Germany) wasused
was used(Figures
used (Figures
(Figures 1212
and
12 and
and13).
13).
13).Adhesive
Adhesive
Adhesive procedures
procedures
procedureswere then
were
were performed,
then
then performed,
performed,using
us-
us-
Germany) was used (Figures 12 and 13). Adhesive procedures were then performed, us-
aing
3-Step etch-and-rinse
ing aa 3-Step adhesive
3-Step etch-and-rinse
etch-and-rinse adhesive system
adhesive system (Optibond
system (OptibondFL, Kerr,
(Optibond FL, Bioggio,
FL, Kerr, Switzerland)
Kerr, Bioggio, after
Bioggio, Switzerland)
Switzerland)
ing a 3-Step etch-and-rinse adhesive system (Optibond FL, Kerr, Bioggio, Switzerland)
etching
after with a with
after etching
etching 38% phosphoric
with a 38% acid gelacid
38% phosphoric
phosphoric (Ultra-Etch,
acid Ultradent
gel (Ultra-Etch,
(Ultra-Etch, Product,Product,
Ultradent Inc., South
Product, Jordan,
Inc., South
after etching with aa 38% phosphoric acid gel
gel Ultradent
(Ultra-Etch, Ultradent Inc.,
Product, Inc., South
South
UT, USA)
Jordan,
Jordan, UT,and
UT,
UT, USA)light
USA)
USA) and cured
and light
and light for
light cured20
cured s
cured forwith
for 20
for 20 a visible
seconds
20 seconds light-curing
with
seconds with a unit
visible
with aa visible with an
light-curing
visible light-curing intensity
unit
light-curing unit withof
with
unit with an
an
Jordan, 2 (Valo, Ultradent, an
1000 mW/cm
intensity
intensity of
of 1000
1000 mW/cm
mW/cm 22 (Valo,
(Valo,South Jordan,
Ultradent,
Ultradent, UT,
South
South USA).
Jordan,
Jordan, UT,
UT, USA).
USA).
intensity of 1000 mW/cm (Valo, Ultradent, South Jordan, UT, USA).
2

Figure 12.
Figure12. A
12.AA symmetric
Asymmetric
symmetric preparation
preparation finishing
finishing line
line among
among both
both incisors
incisors is obtained
is obtained
obtained with
with a cali-
Figure
Figure 12. symmetric preparation
preparation finishing
finishing lineline among
among bothboth incisors
incisors is
is obtained with awith aa cali-
cali- bur.
calibrated
brated
brated bur.
bur.
brated bur.

Figure 13.
Figure13.
Figure Finishing
13.Finishing line
Finishingline preparation
linepreparation completed
preparationcompleted and
completedand adhesive
andadhesive procedures
adhesiveprocedures performed.
proceduresperformed.
performed.
Figure 13. Finishing line preparation completed and adhesive procedures performed.

Composite
Composite was
Compositewas then
wasthen applied
thenapplied on
appliedon the
onthe silicone
thesilicone index
siliconeindex in
indexinin order
inorder to
ordertoto mold
tomold palatal
moldpalatal and
palataland incisal
andincisal
incisal
Composite was then applied on the silicone index order mold palatal and incisal
margin
margin
margin (Figure
(Figure
(Figure 14).
14).
14).
margin (Figure 14).

Figure 14.
Figure 14. Composite
14. Composite is
Composite is placed
is placed on
placed on the
on the silicon
the silicon index.
silicon index.
index.
Figure
Figure 14. Composite is placed on the silicon index.
The silicone
The silicone index,
silicone index, with
index, with the
with the uncured
the uncured composite
uncured composite (Clearfil
composite (Clearfil Majesty
(Clearfil Majesty ES-2
Majesty ES-2 A2E,
ES-2 A2E, A2D,
A2E, A2D, Ku-
A2D, Ku-
Ku-
The
raray
raray Noritake
Noritake Dental,
Dental, Tokyo,
Tokyo, Japan),
Japan), was
was positioned
positioned in
in the
the mouth
mouth of
of the
the patient.
patient. The
The
raray Noritake Dental, Tokyo, Japan), was positioned in the mouth of the patient. The
composite was
composite was cured
was cured from
cured from buccal
from buccal and
buccal and incisal
and incisal area
incisal area for
area for 20″.
for 20″. The
20″. The silicone
The silicone index
silicone index was
index was then
was then
then
composite
Symmetry 2021, 13, 797 7 of 14

Symmetry 2021, 13, 797 The silicone index, with the uncured composite (Clearfil Majesty ES-2 A2E, A2D, 7 of 14
Symmetry 2021, 13, 797 7 of 14
Kuraray Noritake Dental, Tokyo, Japan), was positioned in the mouth of the patient.
The composite was cured from buccal and incisal area for 20”. The silicone index was
then gently
gently removed,
removed, and another
and another 20” light
20″ light curingcuring was performed
was performed from
from the the palatal
palatal side.
side. Distal
gentlyand
Distal removed,
mesialand another
walls were 20″ light with
restored curing was
the performed
help of from the
transparent palatal
convex side.strips
mylar Distal
and mesial walls were restored with the help of transparent convex mylar strips (Hawe
and mesial
(Hawe walls
Adapt, Kerr,were restored
Bioggio, with the and
Switzerland) helpaofwooden
transparent
wedgeconvex mylarKerr,
(Sycamore, strips (Hawe
Bioggio,
Adapt,
Adapt, Kerr,
Kerr, Bioggio,
Bioggio, Switzerland)
Switzerland) and
and aa wooden
wooden wedge
wedge (Sycamore,
(Sycamore, Kerr,
Kerr, Bioggio,
Bioggio, Swit-
Swit-
Switzerland) (Figures
zerland) (Figures 15 and
15 and 16).16).
zerland) (Figures 15 and 16).

Figure 15.Completing
Completing theframe
frame withthe
the helpofofconvex
convex transparentsectional
sectional matrices.
Figure 15. Completingthe
Figure15. the framewith
with thehelp
help of convextransparent
transparent sectionalmatrices.
matrices.

Figure 16. Both frames are completed.

Figure16.
Figure 16.Both
Bothframes
framesare
arecompleted.
completed.

With the aid of the “OUT” tip of a clinical caliper (TNCALIBRA, HuFriedy, Chicago,
With
Withthe
theaid
aidof
ofthe
the“OUT”
“OUT”tiptipof
ofaa clinical
clinical caliper
caliper (TNCALIBRA,
(TNCALIBRA, HuFriedy,
HuFriedy,Chicago,
Chicago,
IL, USA)
IL,USA)
IL, (Figure
USA)(Figure 17),
17),itit
(Figure17), was
itwas possible,
waspossible, during
possible,during
duringallall the
allthe steps
stepsofof
thesteps the
ofthe layering
thelayering procedure,
procedure,toto
layeringprocedure, to
quickly visualize
quicklyvisualize
quickly the
visualizethe volume
thevolume
volumeof of composite
ofcomposite needed
compositeneeded
neededto to restore
torestore either
restoreeither the
eitherthe dentin
thedentin and
dentinand the
andthe
the
enamel ofboth
enamel both centralincisors.
incisors.
enamelofof bothcentral
central incisors.

Figure 17. Buccal overall restoration thickness is checked with the “OUT” tip.
Figure17.
Figure 17.Buccal
Buccaloverall
overallrestoration
restorationthickness
thicknessisischecked
checkedwith
withthe
the“OUT”
“OUT”tip.
tip.
Symmetry 2021, 13, 797 8 of 14
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Symmetry 2021, 13, 797 8 of 14

The tip “IN” of the same instruments was used to model, in a precise way, the internal
The tip “IN” of the same instruments was used to model, in a precise way, the inter-
dentinal
Thebody
nal dentinal
(Figure
tip “IN” of
body of the18).
same
(Figure
This instrument
instruments
18). instruments was
This instrument
allows a asymmetric
used to
allows model, in amodeling
symmetric precise
modeling
and
way,
and
can
the define
inter-
can de-
the
nal The tipmamelons
internal
dentinal “IN”
body thetypical
same
(Figure 18). of
Thisanterior was used toincisors.
maxillary
instrument allows amodel, in a precise
symmetric modelingway,
andthe inter-
can de-
finedentinal
nal the internal
bodymamelons typical
(Figure 18). This of anterior maxillary
instrument incisors. modeling and can de-
allows a symmetric
fine the internal mamelons typical of anterior maxillary incisors.
fine the internal mamelons typical of anterior maxillary incisors.

Figure18.
18. Dentinal body
body is
ismodeled
modeledwith
withthe
the“IN”
“IN”tip.
Figure 18. Dentinal
Figure Dentinal body is modeled with the “IN” tip.
tip.
Figure 18. Dentinal body is modeled with the “IN” tip.
Although central
Although central incisors
incisorsare
aresymmetrical,
symmetrical,little
littlevariations
variationsamong mamelon
among length
mamelon length
and Although
width maycentral
provideincisors
a are
natural symmetrical,
aspect (Figure little
19). variations among mamelon length
and width may
Although provide
central a natural
incisors are aspect (Figure
symmetrical, 19).
little
and width may provide a natural aspect (Figure 19). variations among mamelon length
and width may provide a natural aspect (Figure 19).

Figure 19. Internal anatomy completed.

Figure19.
Figure 19. Internal
Internal anatomy
anatomycompleted.
completed.
Figure 19. Internal anatomy completed.
The superficial enamel layer was then applied on both incisors and excess removed
The
withThe superficial
superficial
the “OUT” enamel
enamel
tip of layer
layerwas
wasthen
the abovementioned thenapplied
applied ononboth incisors
both and
incisors excess
and removed
excess removed
with The
the superficial
“OUT” tip enamel
of the layer was then caliper.
abovementioned applied In
caliper. onorder
In both to
order to
provide
incisors
provideandboth
both
incisors
excess
incisors
with
removed
with
with
a the “OUT”
symmetrical tip ofan
aspect, the abovementioned
opaque white stainingcaliper.
materialIn (Kolor
order to + provide
Plus, Kerr,both incisors
Bioggio, with
Swit-
with
a the “OUT”
symmetrical tip ofan
aspect, theopaque
abovementioned
white caliper.
staining In order
material to provide
(Kolor + Plus, bothBioggio,
Kerr, incisorsSwit-
with
aazerland)
symmetrical
was
symmetrical
aspect,
applied on
aspect, an
antheopaque
opaquebuccal white
aspect
white
staining
of
staining the material
left
material central (Kolor
incisor
(Kolorincisor
+
in
+ Plus,in
Plus,
order
Kerr,
Kerr,
to Bioggio,
replicate
Bioggio, Swit-
zerland)
Switzerland)
the was
whitewas applied
was
spot present on
applied the
onthe
the buccal
on buccal
the aspect
buccal
right of the
aspect
central left left
of the
incisor central
(Figure central incisor
20).incisor order to replicate
in order to replicate
zerland)
the white spotapplied
spot present on
present on the right aspect
central of the
incisor left central
(Figure 20). in order to replicate
the
thewhite
white spot present on the
on theright
rightcentral
centralincisor
incisor(Figure
(Figure 20).
20).

Figure 20. After the external enamel layer was applied, a white opaque stain was applied to im-
Figurethe
prove 20.optical
After the external enamel layer was applied, a white opaque stain was applied to im-
symmetry.
Figure 20. optical
prove the
Figure 20. After the
After external
external enamel
symmetry.
the enamellayer
layerwas
wasapplied,
applied,aawhite
whiteopaque
opaquestain
stainwas
wasapplied to to
applied im-
improve
prove the optical symmetry.
the optical symmetry.
Symmetry 2021, 13, 797 9 of 14
Symmetry 2021, 13, 797 9 of 14
Symmetry 2021, 13, 797 9 of 14

Great
Greatcare
carewaswas taken
taken inin providing proper light
providing proper light curing
curingto toobtain
obtainthe
thehighest
highestdegree
degreeof
of Great care
conversion, inwas taken
order to in providing
reduce proper
possible light
staining curing
and to
reduce obtain the
potential
conversion, in order to reduce possible staining and reduce potential monomer citotoxi-highest
monomerdegree of
cito-
conversion,
toxicity in
[14–17]. order
Afterto reduce
last lightpossible
curing, staining
finishing and reduce
(Figure 21) potential
and monomer
polishing
city [14–17]. After last light curing, finishing (Figure 21) and polishing (Figure 22) were citotoxi-
(Figure 22)
city
were [14–17].
performed
performed After
with lastburs,
with
burs, lightsilicone
silicone curing,
pointsfinishing
points (Figure
(Enhance,
(Enhance, 21) and
Dentsply
Dentsply polishing
Sirona,Sirona, (Figure
York,York, PA,22)
PA, USA), were
USA),
discs
performed
discs with
(Sof-Lex, 3M burs,
ESPE, silicone
St. points
Paul, MN, (Enhance,
USA) and Dentsply
felts with Sirona,
diamond
(Sof-Lex, 3M ESPE, St. Paul, MN, USA) and felts with diamond paste (Prisma Gloss, York,
paste PA, USA),
(Prisma discs
Gloss,
(Sof-Lex,
Dentsply 3M ESPE,
DentsplySirona,
Sirona, York,
York,St.
PA, Paul,
PA, USA). MN, USA) and felts with diamond paste (Prisma Gloss,
USA).
Dentsply Sirona, York, PA, USA).

Figure21.
Figure 21.Finishing
Finishingprocedures
proceduresare
areperformed
performedwith
withburs
bursand
anddisks.
disks.
Figure 21. Finishing procedures are performed with burs and disks.

Figure 22. Polishing procedure completed.

Figure22.
Figure 22.Polishing
Polishingprocedure
procedurecompleted.
completed.
After rubber dam removal (Figure 23), occlusion and functional movements were
Afterand
After
checked, rubber
rubber damremoval
dam
the patient removal (Figure23),
(Figure
was rescheduled 23), occlusion
forocclusion
post-op andfunctional
and
evaluation functional movements
1 weekmovements
later. At thewerewere
recall
checked,
checked, and
and the
appointment the patient
patient
(Figure was
24),was rescheduled
rescheduled
post-op for post-op
for and
functional post-op evaluation
evaluation
structural 1 week later.
1 week(absence
evaluation At
later. At of the recall
thefracture
recall
appointment
appointment (Figure
(Figure 24),
24), post-op
post-op functional
functional and
and structural
structural evaluation
evaluation
and marginal adaptation), biological evaluation (post-operative sensitivity) and esthetic (absence
(absence of
of fracture
fracture
and
and marginal
marginal
evaluation adaptation),
adaptation),
(gloss, biological
biological
color stability) evaluation
evaluation
were performed (post-operative
(post-operative
and were fully sensitivity)
sensitivity) and
and
satisfactory. As esthetic
esthetic
a final
evaluation
evaluation (gloss,
(gloss, color
color stability)
stability) were
were performed
performed and
and were
were
recommendation, oral hygiene instructions were reviewed, and the patient was resched- fully
fully satisfactory.
satisfactory. As
As aafinal
final
recommendation,
recommendation, oral hygiene
oral hygiene instructions
instructions were
werereviewed,
reviewed,and the
and
uled for a regular 6-month follow-up appointment. After 6 months, function and esthetic patient
the was
patient rescheduled
was resched-
for a regular
uled
were for
checked, 6-month
a regular follow-up
6-month
resulting appointment.
in follow-up
being After 6After
appointment.
fully satisfactory months, function
6 months,
(Figures 25–27). and esthetic
function
Patient were
and esthetic
expectations
checked,
were resulting
checked, resultingin being fully
in being satisfactory
fully (Figures
satisfactory 25–27). Patient
(Figures 25–27). expectations
Patient and
expectations
and post-treatment satisfaction were recorded in questionnaires, using a visual analogue
post-treatment
and satisfaction were recorded in questionnaires, using ausing
visual analogue scale,
scale,post-treatment
and they scored satisfaction were recorded
fully satisfactory. in questionnaires,
Operator also filled a questionnaire a visual analogue
before and
and they
scale, andscored
they fully satisfactory.
scored fully Operator
satisfactory. also filled
Operator also afilled
questionnaire
a before before
questionnaire and after and
after the treatment, recording several variables, such as overall time of treatment, shade
the treatment,
after the recording
treatment, severalseveral
recording variables, such assuch
variables, overall
as time oftime
overall treatment,
of shade used,
treatment, shade
used, adhesive procedures performed, esthetic limitations, esthetic expectations and es-
adhesive
used, procedures performed, estheticesthetic
limitations, esthetic expectations and esthetic
thetic adhesive
outcomesprocedures
[18]. Bilateral performed,
symmetry limitations,
was verified both esthetic
form anexpectations
anatomical and and es-
es-
outcomes
thetic [18].
outcomes Bilateral symmetry
[18].while
Bilateral was
symmetryverified
was both form an anatomical and esthetic point
thetic point of view, the final outcome metverified both form
the previously an anatomical
planned anatomy, and es-
shades,
of view,point
thetic while of the final
view, outcome
while the met
final the previously
outcome met the planned anatomy,
previously planned shades,
anatomy, opacities
shades,
opacities and translucencies.
and translucencies.
opacities and translucencies.
 Symmetry2021,
Symmetry
Symmetry 2021,13,
2021, 13,797
13, 797
797 10of
10
10 of14
of 14
14
Symmetry 2021, 13, 797 10 of 14
Symmetry 2021, 13, 797 10 of 14

Figure
Figure 23.Final
Figure 23.
Figure 23.
23. Finalaspect
Final
Final aspectafter
aspect
aspect afterrubber
after
after rubberdam
rubber
rubber dam
dam
dam removal.
removal.
removal.
removal.
Figure 23. aspect after rubber dam removal.

Figure 24.
Figure 24. The
The smile
smile of
of the
the patient
patient 11 week
week post-op.
post-op.
Figure
Figure
Figure 24.The
24.
24. Thesmile
The smileof
smile ofthe
of thepatient
the patient111week
patient weekpost-op.
week post-op.
post-op.

Figure 25.
Figure 25. Six
Six months
months post-op.
post-op.
Figure25.
Figure
Figure 25.Six
25. Sixmonths
Six monthspost-op.
months post-op.
post-op.

Figure 26.
Figure 26. Six
Six months
months post-op
post-op X-ray.
X-ray.

Figure26.
Figure
Figure 26.Six
26. Sixmonths
Six monthspost-op
months post-opX-ray.
post-op X-ray.
X-ray.
Symmetry 2021, 13, 797 11 of 14
Symmetry 2021, 13, 797 11 of 14

Figure27.
Figure 27.The
Thesmile
smileof
ofthe
thepatient
patient66months
monthspost-op
post-opX-ray.
X-ray.

3.3.Discussion
Discussion
Currently,
Currently,composite
compositeresin is is
resin thethe
first-choice
first-choice material
material forfor
direct restorations
direct restorationsof anterior
of ante-
and
riorposterior teethteeth
and posterior [19,20].
[19,20].
Restorative
Restorativeprocedures
proceduresofofdirect direct anterior
anterior teeth based
teeth based on on
the the
use use
of aofsilicone indexindex
a silicone are
well established since many years
are well established since many years [21–25].[21–25].
Symmetric
Symmetric reproduction
reproduction of of bilateral
bilateralanatomical
anatomicalelements
elementsisis challenging
challenging forfor every
every cli-
clinician. Indirect restorations, while planned in the lab, can be
nician. Indirect restorations, while planned in the lab, can be manufactured precisely re-manufactured precisely
reproducing
producing the thecorrect
correctsymmetry,
symmetry, especially
especially whenwhen working
working in in aa digital
digital workflow.
workflow.In Indirect
direct
restorations,
restorations,dealing
dealingwith withaaspecular
specularsymmetry
symmetryisismore moredifficult
difficultand andsome
someauthors
authorshavehave
proposed strategies to manage this challenging
proposed strategies to manage this challenging situation [21]. situation [21].
AAcorrect
correctmanagement
managementfor foraapredictable
predictablesymmetric
symmetricoutcome
outcomeinvolves
involveseveryeveryaspect
aspectofof
the
the restorative procedure. First of all, margins should be prepared with the samedesign
restorative procedure. First of all, margins should be prepared with the same design
and
andgeometry,
geometry,whilewhiledifferent
differentmaterial,
material,different
differentthickness
thicknessand anddifferent
differentsubstrate
substratemay may
provide
providedifferent
differentesthetic
estheticoutcomes
outcomes[26,27].
[26,27]. Using
Using aa calibrated
calibrated bur, bur, as asseen
seenin inthis
thiscase
case
report,
report, can help the clinician in creating a consistent margin design though reducingthe
can help the clinician in creating a consistent margin design though reducing the
risk of color mismatch on the finishing line. Furthermore, the use of the same rotative
risk of color mismatch on the finishing line. Furthermore, the use of the same rotative
instruments on a daily basis, while easily providing a reproducible margin definition,
instruments on a daily basis, while easily providing a reproducible margin definition, al-
allows the clinicians to focus more on other more complex aspects of the restorative
lows the clinicians to focus more on other more complex aspects of the restorative proce-
procedure. Besides preparation, composite layering plays a fundamental role in the final
dure. Besides preparation, composite layering plays a fundamental role in the final es-
esthetic outcome. One of the most common procedure is to use a silicone index created
thetic outcome. One of the most common procedure is to use a silicone index created in
in the lab. With this technique [22], it is possible to mold either the palatal and the incisal
the lab. With this technique [22], it is possible to mold either the palatal and the incisal
margin, replicating the planned anatomy. Several authors have tried to mold the buccal
margin, replicating the planned anatomy. Several authors have tried to mold the buccal
surface, but it is a very difficult task to achieve in a predictable way [28]. Several issues in
surface, but it is a very difficult task to achieve in a predictable way [28]. Several issues in
fact have to be managed during a molding procedure from a buccal aspect: (1) any kind
fact have to be managed during a molding procedure from a buccal aspect: (1) any kind
of imprecision on the previous restorative steps could cause the misalignment though the
of imprecision on the previous restorative steps could cause the misalignment though the
correct positioning of the buccal silicone; (2) interproximal excesses can be troublesome
tocorrect
managepositioning of the buccal
and can result silicone;whose
in overhangs (2) interproximal
removal could excesses
be very candifficult
be troublesome
and timeto
manage and can result in overhangs whose removal could be very
consuming; (3) when a finishing margin line is available, it is difficult to manage correctly difficult and time con-
suming; (3) when a finishing margin line is available, it is difficult
the quantity of restorative material—voids or excesses are difficult to manage even when to manage correctly the
quantity of restorative material—voids or excesses are difficult to
vent holes are planned in advance. Therefore, the current approach in direct restorations in manage even when vent
holes are
anterior planned
teeth consistsin generally
advance. of Therefore,
three steps, the ascurrent approach
described by severalin direct
authorsrestorations
[21–25]: in
anterior teeth consists generally of three steps, as described by several authors [21–25]:
1. Molding palatal wall and incisal margin;
2.1. Building
Molding interproximal
palatal wall and incisal
walls withmargin;
matrices;
3.2. Building interproximal walls
Layering free-hand buccal surface. with matrices;
3. Layering free-hand buccal surface.
The palatal silicone index can easily provide a symmetric outcome based on a pre-
The palatal
operative mock-up. silicone index can walls
Interproximal easily canprovide a symmetric
be restored through outcome
the help based on a pre-
of sectional
operative mock-up. Interproximal walls can be restored through
convex matrices rather than straight mylar matrix strips [29]. Providing a symmetric the help of sectional con-
vex matrices rather
interproximal outlinethancan straight
be achieved mylar bymatrix
twisting strips [29]. Providing
the matrices until the a symmetric inter-
desired outline
isproximal
achieved.outline can be achieved by twisting the matrices until the desired outline is
achieved.
Symmetry 2021, 13, 797 12 of 14

Once the frame (palatal, incisal and interproximal) is completed, it is possible to add
internal dentinal shades according to the initial color chart [30]. Internal anatomy influences
esthetic outcomes of a multi-layered restoration [31]. The choice of correct opaque and
translucent shades can provide a natural aspect to the restoration and should be carefully
performed. In the coronoapical direction, the incisal third of anterior maxillary teeth is
generally characterized by a thin opaque incisal shade, then by a translucent area and then
by the opaque dentinal body, often characterized by mamelons. Commercially available
shades generally suggest enamel and dentin to be used with an anatomical criterion, but
they are often used to reproduce more opaque areas (with dentinal shades) and more
translucent ones (with enamel shades) [12,22–24,31,32].
While buccal surface, especially the outer layer, has to be managed free hand, an
esthetic and symmetric outcome may be challenging. A correct and uniform thickness of
the enamel layer is generally difficult to achieve. This depends first of all on the design
and thickness of the underlying dentin. As reported by Friebel M. et al., the influence
of the cover layer on the color impression depends on the layer thickness [33]. This
finding was also corroborated by Vichi A. et al., who confirmed that layer thickness greatly
influences the final aspect of a multi-layer composite restoration [34]. It is well-known, in
fact, that exceeding in enamel thickness could provide a gray final outcome (low value). In
order to check thickness during the layering procedures, clinicians have generally relied
on sagittal silicon index [21,25,31,32]. This tool is reliable but has some drawbacks: it
generally requires an additional appointment to take impressions in order to manufacture
it; furthermore, it is “static”, as it only shows thickness around the cut of the silicone. This
limit could be overcome by performing more cuts although this results in small silicone
portions generally not stable and not rigid. Both tips of the caliper described in this case
presentation have the characteristic to be anatomic while they follow an average convex
shape typical of anterior teeth. Furthermore, they have the capability to be ready-to-use
and can be moved mesially and distally in order to “dynamically” check the thickness
along all the portions of the restoration. Another important aspect to take in consideration
in order to obtain a mimetic restoration is the surface and texture. In the presented case,
a step-by-step procedure was followed in order to provide a surface close to the adjacent
teeth either for an esthetic purpose and to reduce biofilm formation which can cause
discoloration and secondary caries [35–38].
Within the limitation of this single case presentation, it can be concluded that the
described procedure may allow the practitioner a practical solution for symmetrical thick-
ness management in anterior composite restorations. Further research is needed in the
form of well-designed, randomized controlled trials with long-term follow-ups, in order to
establish the reliability of the proposed technique.

4. Conclusions
A symmetric restoration of both central incisors is a challenging procedure. Clinicians
can take advantage of several tools and procedures. The technique presented allows the
clinician to easily prepare, model and check the thickness of multi-layered composite
restorations. Thickness management is historically performed with a sagittal silicone index
that requires two appointments. The proposed technique could be therefore considered
a contribution to the well-known silicone index technique, while providing predictable
symmetric multi-layered restorations in a single stage appointment, therefore allowing
chair-time and laboratory costs savings.

Author Contributions: All authors contributed equally to this work. All authors have read and
agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not Applicable.
Symmetry 2021, 13, 797 13 of 14

Informed Consent Statement: Written informed consent has been obtained from the patient to
publish this paper.
Data Availability Statement: Not applicable.
Acknowledgments: The authors would like to thank Roberto Kaitsas for the endodontic treatment
and Francesco Napolitano for the lab wax-up.
Conflicts of Interest: The authors declare no conflict of interest.

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